Splenic Rupture

Splenic rupture is disruption of splenic parenchyma, capsule or hilar vasculature causing haemorrhage into the peritoneal cavity.

Most cases follow blunt abdominal trauma, particularly:

• Road traffic collision
• Fall
• Direct left upper quadrant impact
• Lower left rib fracture

Rupture can also occur after penetrating trauma or without major trauma in a pathologically enlarged or diseased spleen.

Important causes of atraumatic rupture include:

• Haematological malignancy
• Infectious mononucleosis
• Malaria
• Myeloproliferative disease
• Lymphoma
• Portal hypertension
• Splenic tumour
• Inflammatory disease
• Anticoagulation

The major immediate danger is intra abdominal haemorrhage and haemorrhagic shock.

Management is determined primarily by:

• Haemodynamic status
• Response to resuscitation
• Presence of peritonitis
• Active vascular bleeding
• Associated injuries
• Ability to provide continuous monitoring and interventional radiology

The CT injury grade alone should never override physiology.

A haemodynamically unstable patient with active splenic haemorrhage requires operative haemorrhage control regardless of a nominal anatomical grade.

Presentation can range from mild left upper quadrant pain to profound shock.

Typical findings include:

• Left upper quadrant tenderness
• Generalised abdominal tenderness when haemoperitoneum is large
• Abdominal guarding or rigidity
• Tachycardia
• Hypotension
• Pallor
• Diaphoresis
• Reduced consciousness with severe haemorrhage

Kehr sign

Pain referred to the left shoulder from diaphragmatic irritation by intraperitoneal blood.

It is suggestive but neither sufficiently sensitive nor specific to exclude or establish splenic injury.

Lower left rib fractures should increase suspicion because the spleen lies beneath approximately ribs 9 to 11.

A patient can initially maintain normal blood pressure despite substantial internal bleeding, particularly when young.

Serial observations are therefore critical.

Delayed rupture

Delayed splenic rupture can occur after an initially contained injury when:

• Subcapsular haematoma ruptures
• Splenic pseudoaneurysm bleeds
• Clot dislodges
• Injured parenchyma breaks down

Presentation can occur days or occasionally considerably later after trauma.

New:

• Severe abdominal pain
• Shoulder pain
• Syncope
• Tachycardia
• Hypotension

after recent splenic trauma should be treated as recurrent haemorrhage until excluded. Delayed rupture remains a recognised complication of nonoperative care.

Unstable patient

Use bedside trauma ultrasound to identify free intraperitoneal fluid rapidly.

A positive FAST examination in a persistently unstable patient with no better explanation for shock should accelerate operative haemorrhage control.

Do not transfer a profoundly unstable bleeding patient repeatedly between imaging departments merely to establish an exact splenic injury grade.

Haemodynamically stable patient

Contrast enhanced CT abdomen and pelvis: definitive acute investigation.

The most important CT features are:

• Splenic parenchymal disruption
• Haemoperitoneum
• Active contrast extravasation
• Pseudoaneurysm
• Arteriovenous fistula
• Major devascularisation
• Associated abdominal injuries

CT angiographic phase imaging is particularly useful when arterial injury is suspected.

Check serial:

• Haemoglobin
• Haematocrit
• Lactate
• Base deficit
• Coagulation profile
• Platelets
• Renal function

A normal initial haemoglobin does not exclude major acute haemorrhage because equilibration has not yet occurred.

Haemodynamic instability

Begin haemorrhage control resuscitation immediately.

Establish large bore IV or rapid intraosseous access.

Use warmed blood components early in significant haemorrhage.

When massive transfusion is required, a balanced strategy approximating:

Packed red cells : plasma : platelets = 1 : 1 : 1

is a reasonable initial framework until laboratory or viscoelastic guided replacement becomes available.

Correct:

• Hypothermia
• Hypocalcaemia
• Acidosis
• Coagulopathy

Immediate operative indications

Proceed to emergency laparotomy when there is:

• Persistent haemodynamic instability despite appropriate resuscitation
• Transient response followed by recurrent shock with ongoing intra abdominal bleeding
• Generalised peritonitis
• Associated intra abdominal injury requiring laparotomy
• Failure of nonoperative management
• Inability to safely monitor or provide rescue intervention in a patient with ongoing haemorrhage

Laparotomy

Use rapid abdominal entry.

Pack the left upper quadrant initially while other major bleeding sources are assessed.

The operative choice is between:

• Splenic preservation
• Splenectomy

Splenectomy

Splenectomy is appropriate when:

• Spleen is shattered
• Hilar pedicle is severely disrupted
• Bleeding cannot be controlled rapidly by splenic preserving techniques
• Patient physiology requires the fastest definitive haemorrhage control
• Major associated injuries make prolonged splenic reconstruction unsafe

Control the splenic vascular pedicle carefully.

Protect:

• Tail of pancreas
• Greater curvature of stomach
• Short gastric vessels
• Left colonic flexure

An unrecognised pancreatic tail injury can produce a postoperative pancreatic fistula.

Splenic salvage

In a stable operative field, selected focal injuries can be treated with:

• Direct haemostatic sutures
• Topical haemostatic agents
• Partial splenectomy
• Selective vascular ligation

Do not spend prolonged time attempting organ preservation in a shocked patient with ongoing major haemorrhage.

Stable patient

Haemodynamically stable patients can usually undergo nonoperative management regardless of anatomical grade, provided there is:

• Appropriate monitoring
• Immediate access to blood products
• Surgical rescue capability
• Interventional radiology where high grade injuries are managed nonoperatively

Nonoperative treatment includes:

• Serial abdominal examination
• Frequent vital signs
• Serial haemoglobin assessment
• Analgesia
• Early recognition of recurrent bleeding

Splenic artery embolisation

In a haemodynamically stable patient, perform early angiography and splenic artery embolisation when CT demonstrates:

• Active arterial contrast extravasation
• Splenic pseudoaneurysm
• Arteriovenous fistula

The presence of an arterial blush is an important indication regardless of anatomical grade.

For stable grade IV or V injuries, angiography with consideration of embolisation is appropriate even when a clear contrast blush is absent, particularly where rescue interventional radiology is readily available.

Proximal embolisation

Reduces overall splenic arterial pressure while collateral circulation maintains splenic viability.

Useful for:

• Multifocal injury
• Diffuse bleeding
• High grade injury

Distal embolisation

Targets a specific injured segmental branch.

Useful for:

• Focal pseudoaneurysm
• Localised bleeding

Distal embolisation creates more segmental infarction, while both approaches can successfully preserve splenic tissue.

Failure of nonoperative management

Escalate immediately with:

• Haemodynamic deterioration
• Increasing transfusion requirement
• Falling haemoglobin with clinical evidence of ongoing bleeding
• Increasing abdominal tenderness
• Expanding haemoperitoneum
• Persistent or new vascular lesion
• Recurrent haemorrhage after initial stabilisation

A stable patient with recurrent arterial bleeding can undergo embolisation.

An unstable patient requires surgery.