Splenic Rupture Workup
- Author: H Scott Bjerke, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
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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.
See the list below:
- 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.
- Multidetector CT scanners have improved diagnostic capabilities but may still miss some vascular injuries.
- 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.
See the list below:
- 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.
See the list below:
- 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.
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).
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.
Harbrecht BG, Franklin GA, Miller FB, Richardson JD. Is splenectomy after trauma an endangered species?. Am Surg. 2008 May. 74(5):410-2. [Medline].
Fishback SJ, Pickhardt PJ, Bhalla S, Menias CO, Congdon RG, Macari M. Delayed presentation of splenic rupture following colonoscopy: clinical and CT findings. Emerg Radiol. 2011 Dec. 18(6):539-44. [Medline].
Ha JF, Minchin D. Splenic injury in colonoscopy: a review. Int J Surg. 2009 Jul 26. epub ahead of print. [Medline].
Rozycki GS, Knudson MM, Shackford SR. Surgeon-performed bedside organ assessment with sonography after trauma (BOAST): a pilot study from the WTA Multicenter Group. J Trauma. 2005 Dec. 59(6):1356-64.
Sirlin CB, Casola G, Brown MA. Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury. J Ultrasound Med. 2001 Apr. 20(4):351-7.
Hedrick TL, Sawyer RG, Young JS. MRI for the diagnosis of blunt abdominal trauma: a case report. Emerg Radiol. 2005 Jul. 11(5):309-11.
Lin WC, Chen YF, Lin CH, Tzeng YH, Chiang HJ, Ho YJ. Emergent transcatheter arterial embolization in hemodynamically unstable patients with blunt splenic injury. Acad Radiol. 2008 Feb. 15(2):201-8. [Medline].
Willmann JK, Roos JE, Platz A. Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma. AJR Am J Roentgenol. 2002 Aug. 179(2):437-44. [Medline].
Nwomeh BC, Nadler EP, Meza MP. Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma. J Trauma. 2004 Mar. 56(3):537-41.
Marmery H, Shanmuganathan K, Mirvis SE, Richard H 3rd, Sliker C, Miller LA, et al. Correlation of multidetector CT findings with splenic arteriography and surgery: prospective study in 392 patients. J Am Coll Surg. 2008 Apr. 206(4):685-93. [Medline].
Vick LR, Islam S. Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children. J Pediatr Surg. 2008 Jan. 43(1):195-8; discussion 198-9. [Medline].
Sims CA, Wiebe DJ, Nance ML. Blunt solid organ injury: do adult and pediatric surgeons treat children differently?. J Trauma. 2008 Sep. 65(3):698-703. [Medline].
Shatz DV, Schinsky MF, Pais LB, et al. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma. 1998 May. 44(5):760-5; discussion 765-6. [Medline].
Shatz DV, Romero-Steiner S, Elie CM, Holder PF, Carlone GM. Antibody responses in postsplenectomy trauma patients receiving the 23-valent pneumococcal polysaccharide vaccine at 14 versus 28 days postoperatively. J Trauma. 2002 Dec. 53(6):1037-42. [Medline].
Killeen KL, Shanmuganathan K, Boyd-Kranis R. CT findings after embolization for blunt splenic trauma. J Vasc Interv Radiol. 2001 Feb. 12(2):209-14. [Medline].
Ekeh AP, McCarthy MC, Woods RJ. Complications arising from splenic embolization after blunt splenic trauma. Am J Surg. 2005 Mar. 189(3):335-9.
Wu HM, Kortbeek JB. Management of splenic pseudocysts following trauma: a retrospective case series. Am J Surg. 2006 May. 191(5):631-4.
Runyan BL, Smith RS, Osland JS. Progressive splenomegaly following splenic artery embolization. Am Surg. 2008 May. 74(5):437-9. [Medline].
Hamers RL, Van Den Berg FG, Groeneveld AB. Acute necrotizing pancreatitis following inadvertent extensive splenic artery embolisation for trauma. Br J Radiol. 2009 Jan. 82(973):e11-4. [Medline].
Bjerke S, Pohlman T, Saywell RM. Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience. Am J Surg. 2006 Mar. 191(3):413-7.
Harbrecht BG, Zenati MS, Ochoa JB. Management of adult blunt splenic injuries: comparison between level I and level II trauma centers. J Am Coll Surg. 2004 Feb. 198(2):232-9.
Carlin AM, Tyburski JG, Wilson RF. Factors affecting the outcome of patients with splenic trauma. Am Surg. 2002 Mar. 68(3):232-9.
Amonkar SJ, Kumar EN. Spontaneous rupture of the spleen: three case reports and causative processes for the radiologist to consider. Br J Radiol. 2009 Jun. 82(978):e111-3. [Medline].
Bain IM, Kirby RM. 10 year experience of splenic injury: an increasing place for conservative management after blunt trauma. Injury. 1998 Apr. 29(3):177-82. [Medline].
Bain IM, Kirby RM, Cook AL. Role of the general surgeon in a British trauma centre. Br J Surg. 1996 Sep. 83(9):1248-51. [Medline].
Barone JE, Burns G, Svehlak SA. Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee. J Trauma. 1999 Jan. 46(1):87-90. [Medline].
Bianchi JD, Collin GR. Management of splenic trauma at a rural, Level I trauma center. Am Surg. 1997 Jun. 63(6):490-5. [Medline].
Caplan ES, Boltansky H, Snyder MJ. Response of traumatized splenectomized patients to immediate vaccination with polyvalent pneumococcal vaccine. J Trauma. 1983 Sep. 23(9):801-5. [Medline].
Cathey KL, Brady WJ Jr, Butler K. Blunt splenic trauma: characteristics of patients requiring urgent laparotomy. Am Surg. 1998 May. 64(5):450-4. [Medline].
Clancy TV, Ramshaw DG, Maxwell JG. Management outcomes in splenic injury: a statewide trauma center review. Ann Surg. 1997 Jul. 226(1):17-24. [Medline].
Clancy TV, Weintritt DC, Ramshaw DG. Splenic salvage in adults at a level II community hospital trauma center. Am Surg. 1996 Dec. 62(12):1045-9. [Medline].
Coburn MC, Pfeifer J, DeLuca FG. Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Arch Surg. 1995 Mar. 130(3):332-8. [Medline].
Cocanour CS, Moore FA, Ware DN. Age should not be a consideration for nonoperative management of blunt splenic injury. J Trauma. 2000 Apr. 48(4):606-10; discussion 610-2. [Medline].
Cocanour CS, Moore FA, Ware DN. Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg. 1998 Jun. 133(6):619-24; discussion 624-5. [Medline].
Cochran A, Mann NC, Dean JM. Resource utilization and its management in splenic trauma. Am J Surg. 2004 Jun. 187(6):713-9.
Cohn SM, Arango JI, Myers JG, Lopez PP, Jonas RB, Waite LL, et al. Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries. Am Surg. 2009 Feb. 75(2):133-9. [Medline].
Daoud RA, Taghizadeh AK, Pickford RB. Conservative management of splenic trauma. J R Army Med Corps. 1999 Jun. 145(2):69-72. [Medline].
Ekeh AP, Izu B, Ryan M, McCarthy MC. The impact of splenic artery embolization on the management of splenic trauma: an 8-year review. Am J Surg. 2009 Mar. 197(3):337-41. [Medline].
Garber BG, Yelle JD, Fairfull-Smith R. Management of splenic injuries in a Canadian trauma centre. Can J Surg. 1996 Dec. 39(6):474-80. [Medline].
Gaunt WT, McCarthy MC, Lambert CS. Traditional criteria for observation of splenic trauma should be challenged. Am Surg. 1999 Jul. 65(7):689-91; discussion 691-2. [Medline].
Guth AA, Pachter HL, Jacobowitz GR. Rupture of the pathologic spleen: is there a role for nonoperative therapy?. J Trauma. 1996 Aug. 41(2):214-8. [Medline].
Harbrecht BG, Peitzman AB, Rivera L, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. J Trauma. 2001 Nov. 51(5):887-95.
Harbrecht BG, Zenati MS, Alarcon LH. Is outcome after blunt splenic injury in adults better in high-volume trauma centers?. Am Surg. 2005 Nov. 71(11):942-8; discussion 948-9.
Ivatury RR, Simon RJ, Guignard J. The spleen at risk after penetrating trauma. J Trauma. 1993 Sep. 35(3):409-14. [Medline].
Keller MS, Vane DW. Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons. J Pediatr Surg. 1995 Feb. 30(2):221-4; discussion 224-5. [Medline].
Kilic N, Gurpinar A, Kiristioglu I. Ruptured spleen due to blunt trauma in children: analysis of blood transfusion requirements. Eur J Emerg Med. 1999 Jun. 6(2):135-9. [Medline].
Krause KR, Howells GA, Bair HA. Nonoperative management of blunt splenic injury in adults 55 years and older: a twenty-year experience. Am Surg. 2000 Jul. 66(7):636-40. [Medline].
Krupnick AS, Teitelbaum DH, Geiger JD. Use of abdominal ultrasonography to assess pediatric splenic trauma. Potential pitfalls in the diagnosis. Ann Surg. 1997 Apr. 225(4):408-14. [Medline].
Lawson DE, Jacobson JA, Spizarny DL. Splenic trauma: value of follow-up CT. Radiology. 1995 Jan. 194(1):97-100. [Medline].
Lucas CE. Splenic trauma. Choice of management. Ann Surg. 1991 Feb. 213(2):98-112. [Medline].
Morrell DG, Chang FC, Helmer SD. Changing trends in the management of splenic injury. Am J Surg. 1995 Dec. 170(6):686-9; discussion 690. [Medline].
Myers JG, Dent DL, Stewart RM. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. J Trauma. 2000 May. 48(5):801-5; discussion 805-6. [Medline].
Novelline RA, Rhea JT, Bell T. Helical CT of abdominal trauma. Radiol Clin North Am. 1999 May. 37(3):591-612, vi-vii. [Medline].
Pachter HL, Guth AA, Hofstetter SR. Changing patterns in the management of splenic trauma: the impact of nonoperative management. Ann Surg. 1998 May. 227(5):708-17; discussion 717-9. [Medline].
Peitzman AB, Heil B, Rivera L. Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000 Aug. 49(2):177-87; discussion 187-9. [Medline].
Pisters PW, Pachter HL. Autologous splenic transplantation for splenic trauma. Ann Surg. 1994 Mar. 219(3):225-35. [Medline].
Poulin EC, Thibault C, DesCoteaux JG. Partial laparoscopic splenectomy for trauma: technique and case report. Surg Laparosc Endosc. 1995 Aug. 5(4):306-10. [Medline].
Ransom KJ, Kavic MS. Laparoscopic splenectomy for blunt trauma: a safe operation following embolization. Surg Endosc. 2009 Feb. 23(2):352-5. [Medline].
Rappaport WD, McIntyre KE, Stanton C. The effect of alcohol in isolated blunt splenic trauma. J Trauma. 1990 Dec. 30(12):1518-20. [Medline].
Rose AT, Newman MI, Debelak J. The incidence of splenectomy is decreasing: lessons learned from trauma experience. Am Surg. 2000 May. 66(5):481-6. [Medline].
Rutherford EJ, Livengood J, Higginbotham M. Efficacy and safety of pneumococcal revaccination after splenectomy for trauma. J Trauma. 1995 Sep. 39(3):448-52. [Medline].
Rutledge R, Hunt JP, Lentz CW. A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury. Ann Surg. 1995 Sep. 222(3):311-22; discussion 322-6. [Medline].
Schurr MJ, Fabian TC, Gavant M. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J Trauma. 1995 Sep. 39(3):507-12; discussion 512-3. [Medline].
Shatz DV. Vaccination practices among North American trauma surgeons in splenectomy for trauma. J Trauma. 2002 Nov. 53(5):950-6. [Medline].
Smith J, Armen S, Cook CH, Martin LC. Blunt splenic injuries: have we watched long enough?. J Trauma. 2008 Mar. 64(3):656-63; discussion 663-5. [Medline].
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Wasvary H, Howells G, Villalba M. Nonoperative management of adult blunt splenic trauma: a 15-year experience. Am Surg. 1997 Aug. 63(8):694-9. [Medline].
Williams RA, Black JJ, Sinow RM. Computed tomography-assisted management of splenic trauma. Am J Surg. 1997 Sep. 174(3):276-9. [Medline].
Wu Y, Wan L, Li P, Zhang Y, Li M, Gong J, et al. Application of radiofrequency ablation for splenic preservation. J Surg Res. 2014 Jul 22. [Medline].