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Splenic Rupture Workup

  • Author: H Scott Bjerke, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Nov 24, 2014
 

Laboratory Studies

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  • While frequently obtained, a complete blood cell count or hemoglobin level is rarely helpful in the initial workup of the suspected splenic injury. These are helpful in providing baseline values and, when performed serially, in diagnosing ongoing blood loss or hemodilution due to volume resuscitation.
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Imaging Studies

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  • Focused abdominal sonographic technique
    • FAST, observing for the presence or absence of fluid in the peritoneal cavity, may be performed rapidly and safely in trauma patients.
    • FAST is poor for delineating organ-specific anatomy with any reliability in the emergency setting. In addition, the learning and interpretation curve is rather steep when compared to DPL.
    • In experienced hands, visualization of fluid in the right upper quadrant, the left upper quadrant, and the pelvis suggests solid organ injury (or mesenteric injury) and the possibility of splenic injury.
  • CT scanning
    • In the stable patient, CT scanning provides structural evaluation of the spleen and surrounding organs.
    • Intravenous contrast injected at the time of scan improves the clinician's ability to determine the severity of injury. Active bleeding from the splenic parenchyma can be missed with a noncontrast CT scan.
    • A splenic contrast blush noted by a helical CT scanner has a greater propensity to require splenic exploration in most series.[8, 9] See the image below.
      Intra-parenchymal blush observed on helical CT scaIntra-parenchymal blush observed on helical CT scan.
    • Multidetector CT scanners have improved diagnostic capabilities but may still miss some vascular injuries.[10]
  • Angiography
    • Angiography is rarely the first choice for evaluation of the patient with a splenic injury, but it is being used more frequently for primary therapeutic management of splenic injuries.
    • Angiography is usually performed after CT scanning images are obtained showing an arterial contrast blush or active extravasation. Angiography is less of a diagnostic modality and more of a preparation for therapeutic angioembolization of active bleeding sites.
  • MRI has been reported as an option in the patient with renal failure or significant contrast allergy.
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Other Tests

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  • Radioisotope studies
    • These are rarely helpful in this day of rapid, detailed, high-resolution CT scanners.
    • These studies should probably be eschewed as a diagnostic option in the trauma patient unless no other confirmatory tests are available.
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Diagnostic Procedures

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  • Diagnostic peritoneal lavage
    • DPL is a method of rapidly determining if free intraperitoneal blood is present. This test is especially useful in the hypotensive patient.
    • DPL is fast and inexpensive. It has a low complication rate in experienced hands.
    • FAST has replaced DPL in many institutions because it is less invasive, but it has not yet been shown to be more sensitive or specific than DPL in most published studies.
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Histologic Findings

Histologic findings may help to explain why a minor trauma resulted in a major splenic injury. Splenic rupture may follow after a seemingly minor transfer of kinetic energy because of organ expansion with capsular thinning or an abnormal internal architecture with reduced elasticity to the parenchyma. Such events may happen with splenomegaly due to hematologic abnormalities (eg, hereditary spherocytosis), infectious diseases (eg, malaria), and liver disease (eg, portal and splenic hypertension).

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Staging

Splenic injury is graded using the standards published by the Organ Injury Scaling Committee of the AAST. Categories range from grade I (minor) to grade V (major) and correlate to the need for laparotomy. These grades are used in conjunction with nonoperative assessment (eg, CT scanning, angiography), operative intervention by laparotomy, or postmortem by autopsy. Some studies comparing CT staging with operative staging indicate that CT scanning overestimates the injury by as much as 10%. However, CT scan findings correlate well with the need for operative intervention.

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Contributor Information and Disclosures
Author

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Midwest Surgical Association, Royal Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Janet S Bjerke, RN, MBA, CCRC Research Coordinator, Trauma Services, Methodist Hospital of Indianapolis

Janet S Bjerke, RN, MBA, CCRC is a member of the following medical societies: Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Lewis J Kaplan, MD, FACS, FCCM, FCCP Associate Professor of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania; Section Chief, Surgical Critical Care, Philadelphia Veterans Affairs Medical Center

Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, Surgical Infection Society

Disclosure: Nothing to disclose.

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Hemisplenectomy (splenorrhaphy) with preservation of greater than 50% of splenic parenchyma.
Intra-parenchymal blush observed on helical CT scan.
Physical findings in postsplenectomy sepsis with peripheral thrombosis and disseminated intravascular coagulation (DIC).
Grade 4-5 splenic laceration on helical CT scan.
 
 
 
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