Splenic trauma can occur after blunt or penetrating trauma or secondary to medical intervention (i.e. iatrogenic). The spleen is the most frequently injured organ after blunt trauma.
Patients may present with left upper quadrant/left chest pain, left shoulder tip pain (referred from diaphragmatic irritation) and signs of hypotension or shock.
In blunt trauma, the spleen can account for up to 49% of abdominal organ injuries 2.
The spleen may be injured after blunt or penetrating trauma, or may be iatrogenic (e.g. colonoscopy).
- haematoma: subcapsular (more common) or intraparenchymal
- active haemorrhage
- pseudoaneurysm or AV fistulas (in ~15% of splenic trauma 4)
- splenic infarct (rare) 7
Splenic trauma is associated with injuries to other intra-abdominal organs 1:
In penetrating trauma, the spleen is more likely to be injured than bowel 6.
- FAST scanning may be performed to determine the presence of free fluid - absence of free fluid does not rule out splenic injury 1
- disruption to the splenic echotexture indicating laceration or hypoechoic regions representing haematoma may be present 1
CT is the modality of choice for assessing splenic trauma:
- splenic parenchyma should be assessed in portal venous phase as the inhomogeneous splenic enhancement (zebra or psychedelic spleen) seen on arterial phase can mimic splenic laceration/contusion; arterial phase scanning can be useful in detecting vascular injuries such as pseudoaneurysm and AV fistula 3-5
- lacerations appears as linear or branching hypodensities 3
- subcapsular haematomas can be seen as low-density fluid adjacent to the spleen that distorts the splenic architecture 2
- active haemorrhage appears as a high-density (80-95HU) material due to the extravasation of contrast media that increases in size on delayed imaging 2-3
- pseudoaneurysms and AV fistulas have a similar appearance to active haemorrhage on initial scanning but do not increase in size on delayed phases 3
- splenic clefts may be mistaken for a laceration 9
- these are due to persistent lobulation of the splenic after development
- in contrast to a laceration, a cleft is usually smooth with a rounded edge and are not associated with an adjacent subcapsular haematoma or perisplenic fluid
- some larger clefts may contain fat
Treatment and prognosis
Most splenic injuries in haemodynamically stable patients are treated non-surgically. Splenic artery embolisation plays a major role in treating high-grade splenic injuries (both in haemodynamically stable and unstable patients; practice varies from institution-to-institution).
Complications of splenic trauma include 2:
- delayed rupture (~ 5% in non-surgically treated patients)
- pseudocysts (< 1%)
- splenic abscess formation
- splenic artery pseudoaneurysm
- normal appearance of the spleen
- pseudolesion of the spleen: inhomogeneous splenic enhancement
splenic lesions and anomalies
- congenital anomalies
- mass lesions
- infiltrative processes
- incidental splenic lesion (approach)
- 1. Emergency Radiology of the Abdomen: Imaging Features and Differential Diagnosis for a Timely Management Approach (Medical Radiology / Diagnostic Imaging). Springer. ISBN:B00A9YG6JG. Read it at Google Books - Find it at Amazon
- 2. Hassan R, Abd Aziz A, Md Ralib AR et-al. Computed tomography of blunt spleen injury: a pictorial review. Malays J Med Sci. 2012;18 (1): 60-7. Free text at pubmed - Pubmed citation
- 3. Mandell J. Core Radiology: A Visual Approach to Diagnostic Imaging. Cambridge University Press. ISBN:1107679680. Read it at Google Books - Find it at Amazon
- 4. Uyeda J, LeBedis C, Penn D et-al. Radiology. 2013; . doi:10.1148/radiology.13121242
- 5. Boscak AR, Shanmuganathan K, Mirvis SE et-al. Optimizing trauma multidetector CT protocol for blunt splenic injury: need for arterial and portal venous phase scans. Radiology. 2013;268 (1): 79-88. doi:10.1148/radiol.13121370 - Pubmed citation
- 6. Lozano JD, Munera F, Anderson SW et-al. Penetrating wounds to the torso: evaluation with triple-contrast multidetector CT. Radiographics. 2013;33 (2): 341-59. doi:10.1148/rg.332125006 - Pubmed citation
- 7. Miller LA, Mirvis SE, Shanmuganathan K et-al. CT diagnosis of splenic infarction in blunt trauma: imaging features, clinical significance and complications. Clin Radiol. 2004;59 (4): 342-8. doi:10.1016/j.crad.2003.09.005 - Pubmed citation
- 8. Shankar S, Rowe S. Splenic injury after colonoscopy: case report and review of literature. Ochsner J. 2011;11 (3): 276-81. Free text at pubmed - Pubmed citation
- 9. Freeman JL, Jafri SZ, Roberts JL, Mezwa DG, Shirkhoda A. CT of congenital and acquired abnormalities of the spleen. Radiographics : a review publication of the Radiological Society of North America, Inc. 13 (3): 597-610. doi:10.1148/radiographics.13.3.8316667 - Pubmed