Introduction:
An injury to the spleen is one of the most common injuries in abdominal trauma. If the injury remains unrecognized, it can lead to preventable traumatic death. Spleen is the body's most vascular (rich in blood vessels) organ. Thus the injuries affecting the organ generally affect the arteries and lead to hemoperitoneum. The splenic injuries are recognizable because the bleeding is mostly intraperitoneal (inside the peritoneum). The treatment of choice in cases of injuries is salvaging the spleen instead of removing it because of its immunological functions. The injuries of the spleen are traced easily with a computed tomography scan.
What Are the Functions of the Spleen?
The spleen is a small organ inside the left rib cage above the stomach. The size of the spleen is similar to an avocado in an adult. The spleen is a major part of the lymphatic system, which is an important part of the body's immune system. The functions of the spleen include storage of blood, formation of white blood cells and antibodies, which helps to strengthen the immune system, maintenance of fluid levels in the body, filtration of blood by removing the cellular waste (dead cells) and production of antibodies for the protection of the body from infections.
What Causes Splenic Injury?
The spleen is generally injured when the trauma involves the upper left abdomen or the lower left chest region. It is most commonly affected by trauma because of its juxtaposition in the upper left abdomen to the 9th, 10th, and 11th rib.
Some of the conditions which can lead to splenic injury are:
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Blunt trauma is like a blow to the left upper quadrant of the abdomen.
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Indirect trauma generally occurs while treating any organ besides the spleen or performing an endoscopy or colonoscopy. This type of injury can damage the outer splenic capsule.
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Penetrating trauma in which there is direct injury to the spleen. One example is gunshot wounds, which comprise almost 7 to 9% of penetrating traumas of the abdomen.
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Road Accidents: These are the most common changes of splenic injury, which may involve a blunt blow to the spleen.
How Common Are Splenic Injuries?
Splenic injuries are the most common abdominal traumas, with almost 25 % of cases every year. It has no specific gender prevalence; it can affect anyone. However, out of all the causes, blunt trauma is the most common cause of splenic injury.
What Are the Symptoms of Splenic Injury?
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The most common reason to inquire is trauma to the left rib cage or upper left abdomen region. Although in every case, there doesn't need to be a history of trauma.
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The symptoms include abdominal pain (especially in the upper left region), abdominal distension, reduced blood pressure or hypotension, and tenderness of the abdominal region.
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In some rare cases, there can be pain in the left shoulder region due to diaphragmatic irritation. This phenomenon is known as Kehr's sign.
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In trauma cases, there are external signs such as lacerations, abrasions, or contusions.
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Some of the cases also witness pleuritic left-sided pain in the chest.
What Are the Points Important for Physical Examination in Splenic Injury Cases?
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The most common reason behind splenic injuries is trauma. However, it is not the only reason in all cases. Suppose there is trauma in the left upper chest region. In that case, it is advised to look for external injuries such as lacerations, abrasions, or contusions, which can help evaluate the trauma's intensity.
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It is important to ask for a history of splenectomy or any surgery around the spleen. The doctors also investigate other liver or portal vein diseases with the help of anticoagulants.
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It is important to inquire if there are fractures in the lower rib region on the left side, as splenic injury can occur. In adults with lower rib fractures, approximately 20% of cases have associated splenic injury.
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In children, even with a history of blown-out trauma, there might be no fractures as the chest wall has plasticity characteristics, but there might be a chance of internal injuries, which could be splenic.
How to Evaluate Splenic Injuries?
Some of the adjuncts which can be used to locate the splenic injury are:
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Focused Assessment with Sonography for Trauma (FAST): This examination can quickly identify the presence of free intraperitoneal fluid in cases of blunt abdominal trauma. This test is useful in cases of hemodynamically unstable patients. There are four acoustic windows in the examination, perihepatic, pericardiac, pelvic, and perisplenic. The test is positive when there is a black rim or anechoic band around the spleen. This test is advised in cases of intraperitoneal bleeding, which is not always necessary for splenic injury. In approximately 25% of cases of spleen injuries, there is no intraperitoneal hemorrhage.
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Computed Tomography: The CT scan (computed tomography) helps to diagnose disruption in solid organs, such as it helps to trace abnormal splenic parenchyma, free intra-abdominal blood, and hematoma. A contrast-enhanced CT scan is used to evaluate the density difference between the splenic parenchyma and hematoma.
What Is the Spleen Organ Injury Scale?
Based on the computed tomography findings, the splenic injuries are classified into different grades:
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Grade 1: Laceration involving less than 1 cm of parenchymal depth with hematoma is less than 10% surface area.
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Grade 2: Presence of hematoma and subcapsular in about 10% to 50% of surface area, with lacerations in 1 to 3 cm of parenchymal depth that does not involve trabecular vessels.
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Grade 3: Hematoma in more than 50% of surface area with subcapsular, intraparenchymal hematoma with more than 5 cm diameter and lacerations greater than 3 cm in depth.
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Grade 4: Lacerations that involve segmental or hilar vessels that produce major devascularization up to 25%.
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Grade 5: Laceration, which completely shattered the spleen, and major devascularization.
What Is the Treatment for Splenic Injuries?
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The initial step in managing splenic injury includes following the trauma's ABCs (airway, breathing, and circulation). The assessment of circulation is done by checking the possibility of bleeding in patients with blunt trauma.
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Injuries in which the bleeding has stopped can be managed without splenectomy (spleen removal). However, there are chances of delayed hemorrhages in such cases.
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Nonoperative Treatment of Splenic Injury: The aim of the treatment of splenic injuries is maximizing salvage therapy. In children, it is the treatment of choice in most cases. Approximately 80 % of cases can be treated by nonoperative technique, but the patient's condition should be hemodynamically stable without any sign of peritonitis.
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Operative Management: The cases of ongoing bleeding or the ones which require more than two units of blood are considered for the operative approach. The conditions which are indications for an operative approach are hemodynamic instability, peritonitis, intra-abdominal injuries associated with the spleen, and pseudoaneurysm formation.
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Embolization: It requires a vascular interventionist and splenic embolization. It is advised in cases of grade 3 or splenic injuries. However, some embolization complications include devascularization of about 25 % of the spleen and recurrence of hemorrhage or abscess.
Conclusion:
Splenic injuries are considered one of the most common abdominal injuries, as trauma can easily affect them. Spleen is the most vascularized organ of the body, and the basic symptom of splenic injury is bleeding. The injuries are divided into five grades depending on the intensity of damage caused to the spleen. The causes vary from different types of trauma to surgical accidents. The treatment is necessary because the spleen is an important part of the lymphatic system (which is a part of the immune system).
