Splenic Haematoma

A splenic haematoma is a collection of blood within or immediately beneath the splenic capsule after traumatic vascular or parenchymal injury.

It can be:

Subcapsular

Blood accumulates between splenic capsule and parenchyma.

Intraparenchymal

Blood collects within the splenic substance.

The key danger is that a contained haematoma can:

• Expand
• Rupture into the peritoneum
• Develop a pseudoaneurysm
• Become secondarily infected, rarely

Injury grading

For isolated haematoma:

Grade I

Subcapsular haematoma involving less than 10% of surface.

Grade II

Subcapsular 10% to 50%, or intraparenchymal haematoma less than 5 cm.

Grade III

Subcapsular greater than 50%, ruptured subcapsular haematoma, or intraparenchymal haematoma at least 5 cm.

The presence of pseudoaneurysm or active vascular bleeding upgrades the injury beyond a simple haematoma category.

A contained haematoma may produce:

• Mild left upper quadrant pain
• Local tenderness
• No haemodynamic abnormality

Expansion or rupture produces:

• Increasing abdominal pain
• Shoulder pain
• Tachycardia
• Falling haemoglobin
• Syncope
• Hypotension
• Peritonism

Delayed haemodynamic deterioration after apparently uncomplicated blunt trauma should prompt reassessment even when the initial CT demonstrated only a contained haematoma.

Contrast enhanced CT: establishes:

• Location
• Size
• Associated laceration
• Active extravasation
• Pseudoaneurysm
• Devitalised splenic tissue

Ultrasound can demonstrate fluid but is less reliable than contrast CT for defining vascular complications.

Stable contained haematoma

Treat nonoperatively with:

• Clinical observation
• Serial haemoglobin
• Serial examination
• Appropriate analgesia
• Progressive mobilisation once stable

A large haematoma does not automatically require splenectomy if physiology remains stable and no uncontrolled vascular injury exists.

Vascular complication

Perform splenic artery embolisation when the haematoma is associated with:

• Active arterial extravasation
• Pseudoaneurysm
• Arteriovenous fistula
• Evidence of ongoing haemorrhage in a stable patient.

Expanding haematoma with instability

Proceed to emergency operative haemorrhage control.

At laparotomy, treatment depends on actual injury:

• Splenic salvage if focal and rapidly controllable
• Splenectomy for extensive disruption or unstable physiology

Delayed pseudoaneurysm

A pseudoaneurysm can develop after the initial CT.

This is one reason high grade splenic injuries benefit from repeat vascular phase imaging during the first several days.

An identified clinically important pseudoaneurysm should generally undergo embolisation before rupture.

Delayed rupture

Educate patients managed nonoperatively to return immediately for:

• Sudden worsening abdominal pain
• Left shoulder pain
• Dizziness
• Collapse
• New profound weakness
• Syncope

Delayed splenic rupture is uncommon but can be catastrophic.