What is Splenic Injury?
The spleen is a key organ located inside your abdomen. It’s often prone to injuries, which can result in dangerous bleeding. In the event of abdominal injuries, it’s paramount for medical practitioners to quickly identify any damage to the spleen. The care required in the situation where the spleen is hurt mandates a well-coordinated team of healthcare professionals who understand the possible changes in the body, particularly those that involve the immune system. The spleen is one of the most blood-rich organs in the body, meaning injuries can result in lots of bleeding or blood in the abdomen, which is known as hemoperitoneum.
The spleen has a crucial role in a variety of bodily functions, like immune responses. Having a good understanding of spleen injuries is essential as ignoring them may result in unnecessary injury-related deaths.
The spleen’s unique structure contributes to the seriousness of the injuries, with excessive bleeding often leading to substantial hemoperitoneum. It should be noted that the bleeding in such cases mainly happens inside the abdomen, further complicating the injury and treatment. Traditionally, doctors use the spleen’s role in immune functions to guide their decisions regarding spleen injuries, favoring saving the spleen over removing it wherever possible.
However, thanks to advancements in technology, especially the use of CT scans, doctors can now respond to spleen injuries in a more conservative manner and try to save the spleen whenever possible.
For children, who often need surgery for spleen injuries, doctors must be on high alert for signs of life-threatening complications. Dealing with spleen injuries requires a thorough understanding of the body’s blood circulation and immune systems. Using diagnostic tools and treatment strategies is vital to improving patient outcomes and minimizing the chance of avoidable sickness and death relating to spleen trauma.
What Causes Splenic Injury?
Splenic injuries, or damage to the spleen, often occur as a result of motor vehicle accidents. Other common causes include direct blunt force and falling from a height. Abdominal gunshot injuries also significantly contribute to spleen damage, making up 7% to 9% of all penetrating injuries.
Less often, injuries to the spleen can occur indirectly, like when the outer covering of the spleen tears during a colonoscopy, or if too much force is used on the ligament connecting the spleen and the colon during surgery.
Risk Factors and Frequency for Splenic Injury
In the US, injuries to the spleen are fairly common and typically caused by accidents or other forms of trauma. Major causes include car accidents, injuries from blunt force, falls, and wounds from objects that penetrate the body like bullets. Safety practices, enhanced care for trauma patients, and advancements in technology that help doctors see inside the body have all played a role in changing the frequency and outcomes of spleen injuries in the US. On average, about a quarter of all admissions due to blunt force trauma to the spleen occur each year, equating to 800-1200 cases. Furthermore, 25% to 30% of children that endure trauma to the abdomen experience injuries to the spleen.
Signs and Symptoms of Splenic Injury
In emergencies, doctors need to check for internal injuries in the belly, even if the patient seems stable and doesn’t complain of belly pain. If the patient isn’t stable, immediate action to stabilize them and evaluate the situation is necessary.
Ask the patient about their past surgeries, especially removal of the spleen, and whether they take blood thinners or anti-inflammatory medicines. Look for physical signs of injury like scratches, cuts, bruises, or seatbelt marks when examining the belly. But remember, even if these signs are missing, that doesn’t mean the patient does not have an internal injury. As many as 10-20% of patients with internal injuries might not show these signs. Even if the belly doesn’t feel tender, tight, or bloated when first checked, it could still be injured. So, it’s crucial to check all patients with trauma for internal bleeding.
A review of 12 studies including almost 11,000 patients showed that certain signs are most commonly seen with internal belly injuries after blunt trauma. These are seatbelt signs, belly tenderness, low blood pressure (less than 90 mm Hg), a bloated belly, tensing of the belly muscles, and a broken thigh bone. A seatbelt sign also indicates an internal injury. Broken thigh bones are especially concerning as they suggest the patient was hit by a car while walking. However, the absence of these signs does not assure that the patient is free of injury.
Injuries to the spleen might not seem obvious right away. A patient may present with symptoms of shock due to blood loss, such as a fast heartbeat and low blood pressure. Other symptoms could be tenderness in the upper left part of the belly, whole-body inflammation, or even rare symptoms, such as pain in the left shoulder (also known as Kehr’s Sign). Some patients might complain of left-sided chest pain that worsens with deep breathing. However, a physical examination might be challenging if the patient’s mental status is altered or has other distracting injuries. Elevated concern for injury to the spleen should be maintained if there are fractures of the lower left ribs, especially below the sixth rib. Interestingly, up to 20% of adults with such fractures might have an associated spleen injury. On the other hand, in children, a severe spleen injury can occur even without rib fractures due to the rib cage’s flexibility. Additionally, doctors should be aware of possible bowel injuries if the patient has a trauma directly to the spleen as it occurs in less than 5% of the time with initially suspected isolated organ injury.
Testing for Splenic Injury
If you’ve had a trauma to the abdomen, your doctor may use imaging tests to check for injuries to your spleen. Two major tests are used: the ‘focused assessment with sonography for trauma’ (or FAST) and CT scans.
The FAST test is a quick way for doctors to look for fluid build-up – a sign of injury – within the abdomen. They do this by examining four different areas around the heart, the liver, the spleen and the pelvis. The test is often used if a patient is unstable and has likely had a severe injury. If they find fluid around the spleen, this suggests a tear or cut (laceration) into the spleen. Sometimes, even if the spleen is injured, there may not be any fluid build-up, especially if the outer layer (or capsule) of the spleen hasn’t been broken. In these cases, it’s important to know that up to 1 in 4 spleen injuries won’t show any fluid on the FAST test. If you are found to have fluid in the abdomen and are in a critical condition, you may need immediate surgery to prevent losing your spleen or to save your life.
Another test used to find spleen injuries is a CT scan. This can show any disruption to the spleen’s normal texture, blood collecting around the spleen (hematoma), or other fluid in the abdomen. If they use a special dye (contrast), the CT scan can show more details and help doctors find any additional injuries. The quality of the image taken by the CT scanner is vital. Inadequate images could mean missing a minor spleen injury. CT scans provide a fast and correct diagnosis. Good quality scans are significant to improving your chances of getting better.
At the same time, your doctor may order some blood tests, although these may not always be useful in the immediate management of your injuries. One of these tests is a urinalysis, where they look at a sample of your urine under a microscope. This is because the presence of more than 25 red blood cells in a single field of view indicates that there could be a major injury inside the abdomen, including the spleen.
Another blood test looks at your hematocrit levels, which measures the proportion of red cells in your blood. If your hematocrit level is below 30%, you may be at a higher risk of internal injury following blunt damage to your abdomen. Even if a patient with low blood pressure keeps a normal hematocrit level after a trauma, doctors should not rule out the possibility of internal bleeding.
Sometimes, your doctor may also check your white blood cell (WBC) count. However, both high and normal white blood cell counts don’t provide a clear indication of injury. After a trauma, natural chemicals (catecholamines) are released in the body which can temporarily increase the white blood cells count. An elevated white blood cell count can be seen in injuries to the solid organs like the spleen, or injuries to the hollow organs like the stomach or intestine.
Treatment Options for Splenic Injury
When a person suffers from a splenic injury, there are three main types of treatment: non-surgical therapy, surgery, and a method called embolization. The goal of treating a splenic injury is to save the spleen through non-surgical treatments and avoid spleen removal, or splenectomy, if possible. Up to 80% of blunt splenic injuries can be successfully treated without surgery. This non-operative management has become more widely used in recent years, with no particular effect of age on the results. Injuries in which the bleeding has has stopped often don’t require surgery, but these patients remain at risk for delayed bleeding, which can occur up to 10 days after initial injury. The risk is determined by the severity of the splenic injury.
Non-surgical treatment is suitable for stable patients, meaning those whose blood flow and blood pressure levels are in within normal limits, and they do not have signs of peritonitis, a serious complication where the abdominal lining becomes inflamed. In children with severe injuries, non-surgical approaches may be tried with close observation if the child remains stable and does not show sign of active bleeding. It’s crucial to keep these children in hospitals with pediatric surgical expertise, as surgical intervention must always be quickly available if the situation changes.
If nonoperative management is not successful, surgical intervention and splenectomy can be lifesaving measures for many patients. The decision to perform surgery depends on the patient’s clinical status, blood flow and pressure, and imaging results. In general, if a patient does not respond to efforts to stabilize them, or has fluid in their abdomen detected through a type of ultrasound called a FAST examination, surgery should be considered. Other signs that might suggest surgery include the need for more than two units of blood transfused or ongoing bleeding.
Certain situations may be clear indications for splenectomy. These include if the patient has unstable blood pressure and pulse, inflammation of the abdominal lining, forming of a pseudoaneurysm (a false aneurysm), and other intra-abdominal injuries that require surgical exploration, like injuries to the bowel.
In selected stable patients that require ongoing blood transfusions, embolization may provide an alternative to surgery. Embolization is a procedure that blocks the blood flow to the spleen and requires specialized imaging and a vascular expert. The commonly accepted guidelines for embolization in patients with spleen trauma include a severity grade of III or higher, moderate blood in the abdominal cavity, and signs of continuing bleeding.
In recent years, non-surgical management using a method called splenic arteriography and embolization has seen increased usage. This method is frequently used to treat blood vessel injuries to the liver and spleen in adults. The latest guidelines suggest embolization is the primary intervention for stable patients showing active bleeding from arteries on CT imaging, regardless of the severity of the injury. Unfortunately, the use of these techniques in children is mostly restricted to isolated incidents and case studies. But, limited evidence does hint that angiography may be a possible alternative to surgery in children with serious liver or spleen injuries.
No universal guidelines exist for when surgical intervention is necessary in cases of blunt (caused by an impact) splenic trauma. Some experts suggest that if over 50% of the estimated blood volume has to be replaced, this could indicate the need for surgical intervention. Often, children’s splenic injuries are treated in hospitals where surgeons who primarily care for adults manage their care. This approach is associated with a higher risk of spleen removal compared to when pediatric trauma surgeons manage their care. While making decisions about treatment, it’s important to consider the patient’s overall injury severity and physiological status, including factors like coagulopathy, a condition where the blood does not clot normally. Any decisions should largely be guided by the patient’s clinical condition.
What else can Splenic Injury be?
When doctors are trying to diagnose an injury to the spleen, they also have to consider these conditions which might display similar symptoms:
- Liver laceration (damage to the liver)
- Retroperitoneal bleeding (bleeding behind the abdominal cavity)
- Diaphragmatic injury (damages to the diaphragm)
- Pancreas injury
What to expect with Splenic Injury
In general, how stable a patient’s bodily functions are can greatly impact the success of non-surgery treatments. A CT scan-based grading system helps doctors to effectively assess patients with blunt force injuries to the spleen. Usually, patients with mild spleen injuries who are managed without surgery typically have good outcomes.
However, people who have to have their spleen removed (a procedure known as a splenectomy) are more susceptible to getting infections. To lessen these risks, it’s important to give the right post-splenectomy vaccinations. Moreover, people with associated injuries, like a traumatic brain injury along with a spleen one and then needing a splenectomy, tend to have a higher risk of dying while in the hospital compared to those who didn’t have their spleens removed.
Possible Complications When Diagnosed with Splenic Injury
After a spleen injury, some potential complications might include:
- A delayed rupture of the spleen, which although rare, can happen within ten days following the injury. This commonly happens with small spleen injuries that could go undetected in scans.
- Re-hospitalization due to bleeding
- Development of a pseudoaneurysm in the splenic artery
- An increase in the risk of infection after spleen removal, particularly within the first two years, but it can happen at any time
- Formation of an abscess in the spleen
- Development of pancreatitis
- Death
Some common complications after embolism include:
- Infarction of the spleen, which means that more than 25% of the spleen loses its blood supply. This can happen in up to 20% of patients after embolization.
- Rebleeding
- Formation of an abscess
Losing spleen tissue can also compromise the immune system, making it harder for the body to fight off bacteria in the bloodstream.
Effects of spleen removal include,
- Poor immune response to antigens, which are substances that trigger the immune system
- Reduced levels of phagocytosis, where cells in the immune system engulf and destroy harmful particles
- Lower levels of Immunoglobulin M (IgM), an type of antibody that plays a crucial role in the primary immune response
- Reduced levels of properdin, a protein involved in the immune response
Recovery from Splenic Injury
People who have had their spleen removed should get vaccines against a type of bacteria, known as encapsulated bacteria, before they leave the hospital. These vaccines protect against various diseases including pneumonia, Hib (Haemophilus influenza type B), and meningitis. It’s best to get these vaccines by the 14th day after surgery or before discharge from the hospital. The meningococcal vaccine needs to be given in follow-up doses every two months.
Doctors also recommend taking preventive antibiotics to further protect from infections. For children, this usually means taking an antibiotic called penicillin V (250 mg per day) for at least two years. For patients at high risk of getting infections, doctors may suggest that they stay on antibiotics for life.
Preventing Splenic Injury
If you’ve had a minor injury, it’s possible to have a delayed rupture or break in your spleen. This could cause pain on the left side of your abdomen. If you experience this, contact your doctor right away. Persons who’ve had their spleen removed are more susceptible to infections, and can face a lifetime risk of a serious infection known as sepsis. This is primarily because the spleen normally protects against certain types of harmful bacteria like Streptococcus pneumoniae, Neisseria meningitidis, and Hemophilus influenzae type B. Sometimes, other bacteria like E. coli can also be involved.
To prevent infections after spleen removal, your doctor might prescribe preventive antibiotics, and give you vaccinations against these types of bacteria. Additionally, getting a yearly flu shot is also recommended. It’s really important for individuals and their families to understand, if you’ve had your spleen removed, high fevers are considered a medical emergency and need immediate attention by a medical professional.
Patients should also be aware about travel-related diseases, like malaria and babesiosis, and risks associated with dog bites, such as an infection caused by bacteria known as Capnocytophaga canimorsus. After your spleen removal surgery, it’s a good idea to carry a laminated information card or medical alert bracelet stating you have no spleen. This is useful in emergency situations so that healthcare providers know of your condition and can provide appropriate care.