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Splenic Rupture

Rupture of the spleen occurs due to the penetrating or non-penetrating especially blunt trauma (gun shots, missile explosions etc.). most commonly we have combined penetrating trauma, which includes left lower rib fractures, gross muscular injuries, diaphragm injury, injury of tail of pancreas, left colonic flexure etc. spontaneous may rarely occur in huge spleen e.g. after malaria or infectious mononucleosis. Spleen is the first organ which has largest incidence of damages due to blunt trauma, which affects the organs after the spleen as follows:
Rib fractures
Kidneys
Spinal cord
Liver
Lungs
Cranial cerebral structures
Small intestine
Stomach
Large intestine
Pancreas

Usual type or the acute rupture:
Following the initial shock features of intra-abdominal catastrophe set in. the suggestive features are:
  • Profound shock associated with rapidly progressive rapid fall of blood pressure and quickly deteriorating pulse
  • Severe pain in the upper left quadrant, which usually radiates to the left shoulder (Kehr’s sign) where sometimes a hyperaesthesia may also be elicited. This is due to the irritation of the left dome of diaphragm by blood clots and is particularly raised if the foot end of the bed is raised (Trendenelburg’s position)
  • Tenderness and rigidity is seen over abdomen and well marked over left hypochondrium
  • Shifting dullness on the flanks because of blood in the peritoneal cavity (Balance’s sign)
  • Intestinal sounds are absent because of paralytic ileus, which also causes abdominal distension
  • Rarely Cullen sign may be positive
  • Rectal examination may elicit tenderness and soft swelling due to blood clots in the rectovesical pouch of Douglas
The Hurricane type:
The patient never recovers from the initial shock and succumbs before any treatment is given. This may happen:
  • If there is avulsion of spleen from its pedicles
  • If the splenic vessels are torn
  • If a big vascular spleen rupture
The Delayed type:
Following an initial shock there is a quick recovery but after variable intervals, usually two weeks, suddenly the features of splenic rupture appear. This may be due to:
  • A haematoma under capsule (subcapsular) gradually increases in size and ruptures later
  • A small ruptured area, plugged by omentum for time being, which later detaches
  • A small ruptured area sealed by blood clots temporarily the clot after being digested by ferments released from lacerated pancreatic tail
Classification of splenic rupture based on the morphological changes in the organ

Class I: includes
  • Non-expanding sub-capsular haematomas which take less than 10% of the surface area
  • Non bleeding capsular laceration with less than 1cm of depth of parenchymal invasions

    • Class II: includes
  • Includes non-expanding subcapsular haematomas in 10-15% of area
  • Non-expanding intraparenchymal haematomas, less than 2 cm in diameter
  • Bleeding capsular lesion or parenchymal laceration without any damage of trabecular vessels

    • Class III: includes
  • The expanding subcapsular or intraparenchymal haematomas
  • Bleeding h\haematomas which cover more than 50% surface area
  • Intraparenchymal lacerations less than 3 cm in depth

    • Class IV: includes
  • Ruptured interparenchymal haematomas with bleeding (acute)
  • Laceration involving segmental or hilar vessels producing major devascularization

    • Class V: includes
  • Completely shuttered avulsed organ
  • Total devascularization of hilar region


    • X-Ray investigation:
    Though no confirmatory signs following points are suggestive:
    • Obliteration of splenic outline
    • Obliteration of left psoas shadow
    • Indentation in the normal gas shadow of gastric fundus
    • Fractured lower ribs on left side
    • Elevation of left dome of diaphragm
    Treatment:
    Shock treatment:
    • Rest
    • Sedation (morphine or pethidine injections)
    • Fluid transfusion
    • Blood transfusion
    Surgical:
    First do the splenectomy followed by the auto transfusion (blood sucked from the peritoneal cavity and then rein fused in the same person)

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    This article has been written by Dr. M. Javed Abbas.
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    21:07 21/12/2002