Brief overview
- Symptoms: pain or tenderness in the left upper abdomen, sometimes radiating to the left flank or shoulder; hard abdominal wall; possible dyspnea and shock
- Treatment: after circulatory stabilization, either observation in hospital or surgery to stop bleeding or remove part to all of the spleen
- Diagnosis: Medical history, physical examination and blood test; also imaging procedures (ultrasound, computer tomography), if necessary supported by contrast medium.
- Course of disease and prognosis: Usually recovery within a few weeks; complications possible especially after complete removal of the spleen (asplenia)
What is a ruptured spleen?
A distinction is made between a one-stage and a two-stage splenic rupture: In a one-stage splenic rupture, the capsule and the tissue of the spleen tear at the same time. In a two-stage splenic rupture, on the other hand, only the splenic tissue is injured initially, and the capsule does not rupture until hours or even weeks later.
Spleen: anatomy and function
The spleen has various tasks: On the one hand, it forms and stores a certain type of white blood cells – the so-called lymphocytes. At the same time, it breaks down used red blood cells (erythrocytes) and platelets (thrombocytes). Because of these tasks, the special blood vessels of the spleen are always abundantly filled with blood.
Ruptured spleen: What are the symptoms?
If the splenic laceration is due to trauma, bruise marks or broken ribs in the left upper abdomen will be noticeable. In a traffic accident, sometimes a bruise along the seat belt in the left upper abdomen indicates severe trauma to the spleen.
If it is a so-called two-stage splenic rupture, the initial pain may subside at first, only to return more severely after a break (“silent interval”).
Splenic rupture: How is it treated?
After the initial examination, the doctor makes the decision whether emergency surgery is necessary or whether to wait for the time being. In that case, the injured person is carefully monitored medically. The more severe the injury, the more likely the medical professionals will decide to operate immediately. This is true, for example, if they suspect bleeding in the abdomen and the circulation is unstable.
Conservative treatment
Surgery
There are many different techniques to operate on a ruptured spleen. Whereas in the past doctors often directly removed the spleen completely (splenectomy), today they mostly try to preserve the organ as completely as possible. This is especially true for a ruptured spleen in children, since for them the spleen still plays a fairly important role in the immune system.
In special cases, it is possible to occlude individual vessels of the spleen with a catheter inserted into the inguinal vessels (embolization) in order to stop active bleeding.
After spleen surgery, the individual usually remains in the hospital for monitoring for one to two weeks, depending on the severity of the injury, the type of surgery and the risk of bleeding.
Complications of the surgery
Regular follow-up visits are crucial to the outcome after surgery. Abdominal pain for up to several weeks after abdominal surgery is possible.
In addition, every operation in the abdominal cavity entails general risks. These include injury to other abdominal organs, bleeding, infections and allergic reactions. In addition, pancreatitis or thrombosis of the portal vein sometimes occur after splenectomy.
Other possible complications include pseudocysts, abscesses, and so-called arteriovenous shorts (unwanted connections between an artery and a vein).
Asplenia
A severe complication in asplenia is the so-called “OPSI” (overwhelming post splenectomy infection), which leads to severe blood poisoning (sepsis). Infants and toddlers without a spleen are particularly at risk of a severe infection.
In addition, the removal of platelets (thrombocytes) by the spleen is omitted. As a result, the number of platelets increases in the first three months after spleen removal until the body has adapted. Thus, there is a temporary increased risk of thrombosis, but this can be reduced by treatment with acetylsalicylic acid and, if necessary, heparin.
Causes and risk factors
In children, the ribs are even softer and the abdominal muscles weaker than in adults, making them more susceptible to a ruptured spleen. In particular, the seat belt in the car sometimes triggers a splenic rupture due to the firm pull during a traffic accident.
In rarer cases, overt force is the cause of a splenic rupture, such as a gunshot or stab wound.
Rarely, there are splenic ruptures that are not due to an injury. Usually, an underlying disease then initially leads to an enlargement of the spleen (splenomegaly), which increases the tension of the splenic capsule. This in turn increases the risk of spontaneous splenic rupture.
Infections
Other infections with an increased risk of splenic rupture include malaria and typhoid fever.
Inflammation
Severe or prolonged inflammation also sometimes causes the immune system to be upregulated and the spleen to enlarge as a result. These include chronic pancreatitis, liver inflammation, autoimmune diseases, and amyloidosis. These are usually deposits of abnormally altered proteins affecting the entire body.
Tumor
Diseases of the blood
Congenital and structural causes
Disturbances in the structure of the spleen, for example, leading to a backlog of blood, also increase the risk of splenomegaly and rupture of the spleen. These often include congenital tumors of the blood vessels (hemangiomas) or cysts of the spleen. Such tumors sometimes cause massive bleeding and thus rupture of the spleen.
Abdominal operations
During abdominal surgery, there is a risk of injury to the spleen or its vessels. How high the risk is for a ruptured spleen during surgery depends on many factors. Chief among these are the individual’s anatomy, how close the surgical area is to the spleen, and how experienced the surgeon is.
Examinations and diagnosis
- Have you recently suffered an abdominal injury (such as a blow or fall)?
- Do you feel any pain in your abdomen?
- Have you had a fever or do you feel sick?
- Do you have any pre-existing conditions?
- What medications are you taking?
Ultrasound
Ultrasound examination is the fastest and easiest method to exclude acute bleeding in the abdominal cavity in case of emergency (FAST-Sono). In case of doubt, it is repeated regularly. A contrast agent during the ultrasound examination improves the accuracy of the diagnosis.
Computed tomography
Laboratory tests
If a splenic rupture is suspected, the physician will draw blood for a blood test. Among other things, parameters for assessing blood loss (hemoglobin, hematocrit, blood count) can be determined in the laboratory. If the blood samples are repeated during the course, the values also serve as progression parameters.
Splenic rupture: severity
- Local rupture of the capsule or hematoma under the capsule
- Capsular or tissue tears (large splenic vessels excluded).
- Deep tears also involving the large splenic vessels
- Complete splenic rupture
There are a number of other systems for assessing a splenic laceration, some of which involve close evaluation of the CT image.
Splenic laceration: disease course and prognosis
If only part of the spleen is removed, there is even the possibility that the remaining spleen will “grow back” and the organ will become fully functional again.
In up to four percent of patients whose spleen has been removed, so-called blood poisoning (sepsis) occurs with a high mortality rate.
