Splenic rupture is a potentially life-threatening tear of the spleen that can result in severe bleeding and usually results from blunt abdominal trauma. The various degrees of severity of splenic rupture are treated differently. In the most severe degree of rupture, the spleen is surgically removed.
What is a splenic rupture?
Humans do not necessarily depend on the spleen. However, a so-called splenic rupture, in the sense of a ruptured spleen, can have life-threatening consequences. In splenic rupture, a tear forms in the splenic capsule made of connective tissue. Clinically, different degrees of severity of the disease are distinguished.
- The first severity corresponds to an isolated capsular tear in the form of a subcapsular, non-expanding hematoma.
- Type 2 splenic rupture is an injury to the capsule and parenchyma. The splenic hilus and segmental arteries are not injured.
- In type 3, in addition to injuries to the splenic capsule and parenchyma, hemorrhages of the segmental arteries are also present.
- Type 4 exists with injury to the capsule, parenchyma, and segmental and hilar vessels associated with avulsion of the vascular pedicles.
- In the most severe form of splenic rupture, the spleen breaks apart, so to speak. The organ ruptures out of the splenic hilus and the vascular supply is completely cut off.
The clinical symptoms of splenic rupture may be unilateral or bilateral. A single-stage splenic rupture results in hemorrhagic hypovolemia immediately after the rupture event. In a two-stage rupture, hypovolemia does not develop until several hours or even days after the event.
Causes
In most cases, rupture of the spleen occurs in the setting of an accident and then has a traumatic cause. In this context, splenic rupture is considered a consequence of blunt abdominal trauma, often associated with work accidents, but also traffic accidents and sports accidents. When the patient is a polytrauma patient, splenic rupture often represents the most threatening of all trauma components. In some circumstances, in addition to blunt trauma, sharp trauma can also cause splenic rupture, such as knife wounds or rib impalements. Less commonly, the traumatic cause of splenic rupture is considered to be intraoperative injury. In addition to traumatic causes, a number of nontraumatic phenomena can cause splenic rupture. Such an association is considered to be far less common than splenic rupture after trauma. Nevertheless, the possibility of splenic rupture exists in the context of viral infections such as EBV infection. The same is true for malaria. In isolated cases, splenic tumors or lymphomas cause the spleen to rupture. Portal vein thrombosis is also among the conceivable causes of rupture, but occurs rather rarely.
Symptoms, complaints, and signs
The clinical symptoms of splenic rupture depend primarily on the severity of the precipitating cause. Thus, the clinical picture may be marked by significant differences from case to case. The spectrum of injury begins with a mild splenic contusion including water retention and edema formation and may progress to complete splenic rupture with substantial hemorrhage within the abdominal cavity. Almost invariably, patients with splenic rupture complain of more or less severe abdominal pain located primarily in the upper left quadrant, often radiating to the left arm. In the upper left quadrant of the abdomen, patients are tender to pressure and have guarding. Often, a hematoma also forms. If severe bleeding occurs, hemorrhagic hypovolemic shock may result. Such shock is usually recognized by tachycardia and hypotension. Because splenic rupture sometimes also irritates the diaphragm and phrenic nerve, severe hemorrhage or capsular hematoma also causes pain in the left side of the neck, also known as Saegesser’s sign.
Diagnosis and course of the disease
Timely diagnosis largely determines the patient’s prognosis in cases of splenic rupture. In acute cases, the diagnosis can be made by abdominal sonography, as this allows detection of free fluid around the renal poles. If the sonographic findings are unremarkable, although the patient continues to show symptoms of rupture on palpation, the examination is repeated closely.A two-stage rupture and increase in any capsular hematomas cannot be missed in this manner. An abdominal CT is always the safest diagnostic tool for a splenic rupture. However, the patient’s circulatory status may prevent obtaining this imaging.
Complications
Due to splenic rupture, most patients suffer from relatively severe pain in the lower abdomen. It is not uncommon for these to spread to other regions of the body, resulting in very uncomfortable discomfort throughout the body. Not infrequently, the arms are also affected by the pain. In some cases, the pain can also lead to loss of consciousness. In most cases, the diagnosis of splenic rupture is relatively simple and quick, so that early treatment can be initiated. In an acute emergency, the spleen must be completely removed in the worst case. Since the spleen is not a vital organ, the affected person can survive without it. However, the affected person without a spleen is more susceptible to various infections and inflammations, so this can lead to various complications or a reduced life expectancy. Splenic rupture can be treated with the help of medications and surgical interventions as well. In most cases there are no particular complications. It cannot be predicted whether there will be a decreased life expectancy as a result of treatment or removal of the spleen.
When should you go to the doctor?
The spleen is not a vital organ, so life without a spleen is entirely possible. However, a rupture is still a medical condition that requires mandatory medical and drug treatment. A rupture of the spleen is usually caused by external force. Since the spleen is responsible for the filtration of blood, the cells there are abundantly filled with blood. If a tear occurs, internal bleeding may result, which must be stopped and staunched immediately. Otherwise, there is a risk that the affected person will bleed to death. Even the formation of an abscess is possible if the wound becomes infected in the spleen. In this case, there is an unpleasant feeling of tension, as the pressure inside increases. In case of such signs, the visit to the doctor should not be delayed. Thus, as a rule, a ruptured spleen should always be treated medically and with medication. Otherwise, there is a risk of serious and dangerous complications that can be avoided by a visit to the doctor. In the worst case, there is even a risk of life-threatening complications or permanent consequential damage that cannot be treated afterwards.
Treatment and therapy
Treatment of patients with splenic rupture depends on the clinical severity in each individual case. Primarily, the extent of hemorrhage and its hemodynamic relevance determined the therapy. If the capsule of the spleen is still intact, conservative therapy can often be given depending on the extent of bleeding. Fluid administration and blood transfusions improve the hemodynamic situation. Patients on conservative therapy must be monitored closely. If the situation worsens, invasive procedures must be performed. This invasive procedure consists of surgery aimed at preserving the organ, especially in children or adolescents. Type 2 or 3 splenic rupture are treated surgically by local measures to stop bleeding, such as infrared coagulation, electrocoagulation or intervention with fibrin glue. Once hemostasis is achieved, mesh compression can take place. For this purpose, the physician usually uses an absorbable plastic net. If there is severity 4 or even 5, the organ usually has to be removed in parts. In individual cases, a total splenectomy is required. The timing of diagnosis has a major impact on prognosis. If a splenic rupture is detected early, the prognosis is favorable. If a ruptured spleen is discovered late, life-threatening consequences may result. Not only the time of diagnosis, but also the age of the person with the disease must be taken into account when making a prognosis. Children, who can often be treated without surgery, have a very good prognosis. The prognosis is worse in the elderly or sick individuals. If the spleen is partially removed, the affected person can lead a normal life. The reason for this is that the spleen grows back and therefore resumes its functions to the full extent.Rarely, people who have the entire spleen removed experience serious consequences, such as sepsis. Sepsis is associated with high mortality. On average, 80 out of 100 people who have a ruptured spleen are completely cured. The prospect of recovery is highest if the individual is treated within 72 hours. Physical rest until healing also has a positive effect on the prognosis of a ruptured spleen. Healing is usually achieved within two to three months.
Prevention
Splenic rupture can be prevented only to the extent that blunt abdominal trauma can be prevented.
Follow-up care
A splenic rupture is a medical emergency and therefore requires prompt medical attention. Once the life-threatening condition is overcome, follow-up care is aimed at strengthening the patient. After a surgical procedure to treat splenic rupture, a high standard of hygiene must be maintained to be sure that the splenic bed does not become infected and inflamed with germs. Therefore, in the aftermath of the surgery, affected individuals must take it easy so as not to further stress the weakened immune system. For these reasons, persons with ruptured spleens must be comprehensively observed and monitored as inpatients. This is the best way to detect possible complications so that early interventions can be made. If inadequately monitored and cared for, splenic rupture poses the threat of numerous serious sequelae. Since treatment is protracted even after the acute phase, affected individuals should try to build a positive attitude toward the situation to make it easier to cope with the condition. In this regard, meditative relaxation exercises can help calm the mind and focus on recovery.
Here’s what you can do yourself
A ruptured spleen requires medical evaluation and treatment. However, medical therapy can be supported by various measures. First and foremost, it is important to make an appointment for surgery as soon as possible to avoid further damage. After surgery – usually a so-called laparoscopy is performed, in which the rupture is closed with a tissue adhesive – the patient should take it easy. Depending on the size of the rupture and the constitution after the procedure, at least one to two weeks of bed rest apply. If the entire organ was removed, longer-term rest is necessary. A personalized diet and moderate exercise will help speed recovery and reduce the risk of complications. Only limited prevention of further splenic rupture is possible. Efforts should be made to reduce the risk of abdominal trauma, for example, by ensuring better protective clothing during sports. Accompanying regular check-ups are indicated. The physician must check the rupture or the site of the procedure (if the spleen has been removed) and ensure that the wound heals without complications. If a mesh was used to hold the splenic parts together, regular checks must be made to ensure that it has been properly absorbed by the body.
