[29] Splenic Rupture

Question 1

What is the consequence of the spleen being an extremely vascular organ?

Answer 1

Splenic rupture can cause a large intraperitoneal haemorrhage, rapidly leading to fatal haemorrhagic shock

Question 2

What is splenic rupture secondary to in the majority of cases?

Answer 2

Abdominal trauma, particularly blunt trauma

Question 3

What are the common situations in which the spleen is ruptured?

Answer 3

Seat-belt injuries in RTAs

Falls onto the left side

Question 4

What is the cause of the minority of cases of splenic rupture?

Answer 4

Iatrogenic, or secondary to underlying splenomegaly

Question 5

What can cause underlying splenomegaly?

Answer 5

Haemotological malignancy

Infective causes e.g. EBV

Question 6

How does splenomegaly increase the risk of splenic rupture?

Answer 6

The spleen grows in size, and the capsule stretches and thins, becoming more fragile. This puts it at an increased risk of rupture

Question 7

How is a diagnosis of splenic rupture most commonly made?

Answer 7

From investigations of abdominal pain following a history of trauma

Question 8

What symptoms might splenic rupture present with?

Answer 8

Abdominal pain

Clinical features of hypovolaemic shock

Question 9

What is required to confirm the diagnosis of ruptured spleen?

Answer 9

Imaging

Question 10

What may be found on examination in splenic rupture?

Answer 10

Left upper quadrant tenderness and/or peritonism

Kehr’s sign

Question 11

What can happen to the peritonism as splenic rupture progresses?

Answer 11

It can become more generalised as the blood loss increases

Question 12

What is Kehr’s sign?

Answer 12

Radiating left shoulder pain

Question 13

How can splenic rupture cause Kehr’s sign?

Answer 13

Free blood irritates the diaphragm

Question 14

When is an immediate laparotomy required in splenic rupture?

Answer 14

In patients who are haemodynamically unstable with peritonism following trauma, unless proven otherwise

Question 15

What investigation is required in those who are haemodynamically stable with suspected abdominal injury?

Answer 15

Urgent CT chest-abdo-pelvis with IV contrast

Question 16

What does CT scan allow for in suspected splenic rupture?

Answer 16

Identification and assessment of splenic injury, alongside any other abdominal viscera involvement
Also allows for grading of splenic injury

Question 17

What is the importance of grading of splenic injury?

Answer 17

It guides further management

Question 18

What can FAST scans in the emergency department reveal in splenic rupture?

Answer 18

Free peritoneal fluid

Fluid in the pericardium

Question 19

What needs to be considered when ordering a FAST scan in A&E?

Answer 19

It should not delay CT imaging and/or surgical intervention

Question 20

What is the most commonly used system for grading splenic trauma?

Answer 20

The American Association for the Surgery of Trauma (AAST) splenic injury scale

Question 21

What is the purpose of the AAST splenic injury scale?

Answer 21

It can be used to help guide which patients are likely to benefit from conservative management, and which need surgery

Question 22

What is a grade 1 AAST splenic injury?

Answer 22

Capsular tear <1cm parenchymal depth

Subcapsular haematoma <10% surface area

Question 23

What is a grade 2 AAST splenic injury?

Answer 23

Capsular tear 1-3 cm parenchymal depth

Subcapsular haematoma 10-50% surface area, or intraparenchymal haematoma <5cm

Question 24

What is a grade 3 AAST splenic injury?

Answer 24

Capsular tear >3cm parenchymal depth, or any tear involving trabecular vessels
Subcapsular haematoma >50% surface area, or intraparenchymal haematoma >5cm, or any expanding or ruptured haematoma

Question 25

What is a grade 4 AAST splenic injury?

Answer 25

Laceration involving segmental or hilar vessels, devascularising >25% of spleen

Question 26

What is a grade 5 AAST splenic injury?

Answer 26

Completely shattered spleen or hilar vascular injury, devascularising the entire spleen

Question 27

How should all patients with a suspected splenic injury be managed initially?

Answer 27

They should be assessed, resuscitated, and treated according to ATLS principles

Question 28

Which splenic rupture patients will require an emergency laparotomy?

Answer 28

Patients who are haemodynamically unstable, or with a grade 5 injury (a shattered spleen or major hilar vascular injury)

Question 29

What should be done if there is evidence of active extravasation of the contrast during the arterial phase of a CT scan?

Answer 29

The patient should undergo embolisation (if locally available) or laparotomy with splenectomy

Question 30

Which patients with splenic rupture can be treated conservatively?

Answer 30

Haemodynamically stable patients with grade 1-3 injuries

Question 31

What is involved in the conservative management of splenic rupture?

Answer 31

Resuscitation as appropriate Admitted to high dependancy area for observation Serial abdominal examinations for evidence of deterioration Prophylactic vaccinations at discharge

Question 32

What should be done with any evidence of increasing tenderness or peritonitis in splenic ruptures being monitored?

Answer 32

There should be a low-threshold for re-imaging and/or laparotomy

Question 33

Why should there be a low threshold for re-imaging and/or laparotomy in patients with splenic rupture and increasing tenderness or peritonitis?

Answer 33

As associated injuries such as small bowel injuries are easily missed on initial CT imaging

Question 34

What prophylactic examinations should be given in patients with splenic rupture who are being managed conservatively?

Answer 34

Strep Pneumoniae Haemophilus influenzae B Meningococcus

Question 35

What are the main complications of conservative treatment or embolisation in splenic rupture?

Answer 35

Ongoing bleeding Splenic necrosis Splenic abscess formation Splenic cyst formation

Question 36

What is the pathophysiology behind overwhelming post-splenectomy infection (OPSI)?

Answer 36

The spleen is an immunologically active organ, with an active role in destroying encapsulated organisms. Asplenic patients are therefore unable to mount a normal immunological response against these organisms, and infection can lead to overwhelming sepsis

Question 37

Give three examples of encapsulated organisms

Answer 37

Pneumooccus Meningococcus H. Influenzae

Question 38

How can OPSI be prevented?

Answer 38

Any asplenic patient should receive vaccinations against pneumococcus, meningococcus, and H. influenzae. Prophylactic Penicillin V should be considered

Question 39

When might lifelong prophylactic pencillin V not be required?

Answer 39

In low risk patients