What is Splenic Rupture?
The spleen is an organ responsible for producing and removing blood cells, contained in a protective covering. It’s located at the back of the top left part of your abdomen, fairly close to ribs number 9, 10, and 11, the left kidney, the stomach, parts of the large intestine called the transverse and descending colon, the left side of the diaphragm, and the pancreas. The spleen is the organ in the body most likely to get injured in a situation of blunt abdominal trauma, like a car accident. It’s also the organ most likely to rupture, or break open, from such trauma. If a person’s spleen ruptures and it wasn’t caused by trauma, it’s generally because of disease or health conditions – this happens in about 93% of these cases. In about 7% of these cases, doctors cannot pinpoint a cause behind the spontaneous rupture of the spleen.
What Causes Splenic Rupture?
Damage to the spleen can happen in two main ways: due to a traumatic event or for non-traumatic reasons. Trauma, like car accidents, is the most common cause, accounting for 50% to 75% of all spleen injuries. Other common traumatic causes include getting a direct hit in the abdomen or falling. It’s also worth noting that spleen injuries due to trauma might show up right away or develop over time.
On the other hand, spontaneous spleen injuries, where the spleen gets damaged without any known injury, are quite rare. But, they usually happen due to some underlying disease or sometimes occur for no identifiable reason. Despite being rare, these spontaneous injuries can be serious when they happen and have around 12% mortality rate.
One classic example often mentioned is spleen rupture that can happen to just 0.1 percent of people with the infection mononucleosis. Mononucleosis is a contagious disease caused by the Epstein-Barr virus.
Risk Factors and Frequency for Splenic Rupture
Splenic ruptures, or tears in the spleen, don’t have a lot of data reported about how common they are. Typically, they can occur from car accidents or direct hits to the belly. Activities like football, hockey, and cycling may also increase the risk of getting a splenic injury. Studies have shown that splenic ruptures due to trauma are more likely to happen in males and in people from the ages of 18 to 34.
However, there are also non-trauma related reasons for a spleen to rupture. These include:
- Cancer (neoplasm) or infection, which both account for 30% of cases
- Inflammatory disease, which makes up 15% of cases
- Use of certain medications and medical treatments, causing 10% of these ruptures
- Mechanical causes and unknown reasons (idiopathic), each responsible for about 7% of ruptures.
Signs and Symptoms of Splenic Rupture
Trauma or injury is often the main cause of a splenic rupture. Particularly, any blunt force trauma to the upper left region of the abdomen or left side of the ribs should concern medical professionals for potential injury to the spleen. However, even if there hasn’t been a major traumatic event, a splenic injury can’t be ruled out. This is especially true for those with a medical history of an enlarged spleen, who may be more prone to this rupture with less force.
Medical professionals should also ask patients about their previous surgical history, any liver disease, recent infections, and their use of blood thinners, aspirin, or inflammation-reducing medication. They should also check for bleeding disorders. Even if there are no apparent signs of trauma such as cuts, bruises, or other injuries, up to 20% of patients with internal injuries may not show these external signs initially. The physical exam may not also always reveal severe tenderness, stiffness, or bloating despite a rupture. This is particularly pertinent if the patient’s mental state is altered or they are suffering from other distracting injuries. Therefore, a physical exam alone may not be always enough to evaluate a ruptured spleen.
Critically sick patients may come in with symptoms of shock due to loss of blood, such as fast heart rate, low blood pressure, and paleness. They may also experience pain in the upper left quadrant of their abdomen, an inflamed peritoneum, or referred pain to the left shoulder (known as Kehr sign). Some patients might also report sharp pains on the left side of their chest. It’s important to be cautious in the early evaluation of patients since few symptoms may initially be present.
If fractures in the left lower ribs are identified, an evaluation for a splenic injury is necessary, as up to 20% of adults with this type of fracture may sustain subsequent splenic injuries. In children, the pliable nature of their rib cage puts their spleen at risk for serious injury, even without the presence of a rib fracture.
Testing for Splenic Rupture
It’s possible to get a splenic injury, or an injury to the spleen, without realizing it, even from relatively minor or seemingly harmless incidents. This could mean that the spleen ruptures unexpectedly, causing a lot of damage with a little impact.
To diagnose a spleen injury, an ultrasound scan can be very informative and precise. However, it has its limitations and might not catch things like active bleeding, a pseudoaneurysm, or if the blood loss from the injury is still minimal. Ultrasound working at the bedside in the emergency department can often detect as little as 100 mL of free fluid in the abdomen with 90% sensitivity. Computed tomography, commonly known as a CT scan, is usually the main method for checking a stable patient. It can provide details about the severity of a spleen injury and check for injuries in other organs in the abdomen. It’s also more effective in identifying something known as an intraparenchymal or subcapsular hematoma, which is a collection of blood inside the spleen or underneath the protective covering of the spleen. This may be linked with a delayed rupture of the spleen.
The severity of splenic injuries is classified based on the findings from the CT scan. The American Association for the Surgery of Trauma (AAST) has an Organ Injury Scale that helps categorize these injuries. It ranges from Grade 1, which involves minor injuries such as a small hematoma (a solid swelling of clotted blood) involving less than 10% of the surface area of the spleen or a tiny tear in the spleen, to Grade 5, which could mean that the spleen is completely shattered or that the splenic artery, the main blood vessel of the spleen, is injured to the point of cutting off blood supply to the spleen. However, the AAST Organ Injury Scale is not designed to predict whether or not surgery will be needed to treat the injury.
Treatment Options for Splenic Rupture
The treatment approach for a ruptured spleen depends on how severe the rupture is, what caused the rupture, and how stable the patient’s vital signs (like heart rate and blood pressure) are.
In an attempt to maintain the spleen’s vital role in the body, 60% to 90% of patients with ruptured spleens caused by blunt trauma (like a car accident or a fall) are treated without surgery. This approach was recommended following a key study in 1968 which indicated that children with isolated spleen injuries could be safely treated without surgery. Following this, several other studies have shown similar results, particularly for children. Non-surgical treatment is currently successful in 90% of cases in children.
In some hospitals, interventional radiology (a type of medical imaging) can be used to stop bleeding from damaged vessels in stable patients with a ruptured spleen. This procedure can also be considered for patients who do not respond well to non-surgical treatment methods.
However, surgery may be necessary if a patient remains unstable and/or needs more than four units of blood over two days. The surgeon will initially try to repair any damage to the spleen (a procedure known as splenorrhaphy). If the injury is too severe or if there is uncontrolled bleeding, the spleen may need to be removed (a procedure known as a splenectomy). After spleen removal, vaccines are given to protect against certain bacteria which include Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitides. For children who have their spleen removed, it’s typically recommended to take antibiotics until they’re five years old to protect against infection, although the recommended length of this treatment can vary.
What else can Splenic Rupture be?
These are various types of injuries or conditions that can occur in the abdominal and pelvic areas:
- Abdominal Compartment Syndrome
- Acetabular Pelvic Fractures
- Diaphragm Injury
- Genitourinary Trauma
- Liver Trauma
- Open Book Pelvic Fracture
- Retroperitoneal Hemorrhage
- Straddle Pelvic Fracture
- Ureter Trauma
