Splenic trauma

Changed by Amit Chacko, 23 Nov 2017
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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.

Clinical presentation

Patients may present with left upper quadrant/left chest pain, left shoulder tip pain (referred from diaphragmatic irritation) and signs of hypotension or shock.

Epidemiology

In blunt trauma, the spleen can account for up to 49% of abdominal organ injuries 2.

Pathology

The spleen may be injured after blunt or penetrating trauma or may be iatrogenic (e.g. colonoscopy).

Types
Grading
Associations

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.

Radiographic features

Ultrasound
  • 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

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 and follow the blood pool
  • 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:

  • -<a title="Splenic artery pseudoaneurysm" href="/articles/splenic-artery-pseudoaneurysm">pseudoaneurysms</a> and AV fistulas have a similar appearance to active haemorrhage on initial scanning but do not increase in size on delayed phases <sup>3 </sup>and follow the blood pool</li>
  • +<a href="/articles/splenic-artery-pseudoaneurysm">pseudoaneurysms</a> and AV fistulas have a similar appearance to active haemorrhage on initial scanning but do not increase in size on delayed phases <sup>3 </sup>and follow the blood pool</li>
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