Diagnosis

Splenic injury

Etiology

Cause [ahm][5rz]

• Trauma: Blunt force usually from motor vehicle collisions (94%) or penetrating trauma

• Iatrogen laceration during surgery or colonoscopy

• Infection (mononucleosis)

• Infarction

• Neoplasm

Pathophysiology [5rz]

1. The spleen is a highly vascular organ and plays a vital role in:

   • Innate and adaptive immunity

   • Hematopoiesis

   • The clearance of cellular debris

2. A relative small injury --> susceptible to serious bleeding --> significant hemoperitoneum --> hemodynamic compromise

3. Even smaller injuries require strict observation and/or treatment

   • Small capsular tears (splenomegaly weakens the capsule)

   • Focal vascular injuries ( pseudoaneurysms and arteriovenous fistula)

   • High-grade fractures with profuse parenchymal bleeding

Complications [5rz]

• Splenic rupture

• Splenic artery pseudoaneurysm

• Splenic infarction --> Abscess formation

• Pancreatitis

• Hemodynamic shock

• Multi organ failure

• Complication to treatment

  • Postsplenectomy sepsis

  • Splenic infarction --> Abscess formation

  • Arterial dissection

  • Coil migration

Epidemiology

Incidence per 100.000 [chf][msv][wmr][svz]

Approach

• CT abdomen

• Ultrasound abdomen

• Diagnostic laparoscopy

The American Association for the Surgery of Trauma splenic injury scale [nnw]

• Grade I

  • Subcapsular hematoma <10% of surface area

  • Parenchymal laceration <1 cm depth

  • Capsular tear

• Grade II

  • Subcapsular hematoma 10-50% of surface area

  • Intraparenchymal hematoma <5 cm

  • Parenchymal laceration 1-3 cm in depth

• Grade III

  • Subcapsular hematoma >50% of surface area

  • Intraparenchymal hematoma ≥5 cm

  • Parenchymal laceration >3 cm in depth

  • Ruptured subcapsular or intraparenchymal hematoma

• Grade IV

  • Any injury in the presence of a splenic vascular injury (pseudoaneurysm, AV fistula) or active bleeding confined within splenic capsule

  • Parenchymal laceration involving segmental or hilar vessels producing >25% devascularisation

• Grade V

  • Shattered spleen

  • Any injury in the presence of splenic vascular injury (pseudoaneurysm, AV fistula) with active bleeding extending beyond the spleen into the peritoneum

Treatment

1. Hemodynamic stable: [aqh][ahm]

   • Grade I and II: Conservative treatment

   • Grade III and IV: Catheter embolization, partial resection or mesh splenorrhaphy

   • Grade V: Angiography or splenectomy

2. Hemodynamic unstable --> Splenectomy [5rz]

   • Postsplenectomy sepsis:

     • Encapsulated pathogens and parasites that reside within erythrocytes

     • 50% mortality

Differential diagnoses

Abdominal compartment syndrome, Diaphragmatic rupture, Liver injury, Pancreatic fistula, Pelvic fracture, Renal hemorrhage, Retroperitoneal hemorrhage, Splenic abscess