The spleen is an organ located in the left-upper quarter of the abdomen, beneath the ribs. It is about the size of a clenched fist and plays a vital role in fighting infection and filtering blood. A spleen can split open, or rupture, during a traumatic injury.
This important organ has a number of functions, including the production of immune cells and antibodies. It is also responsible for removing abnormal or old blood cells and foreign bodies, such as bacteria and viruses, from the blood.
The spleen also recycles hemoglobin, the component in blood that carries oxygen, and stores platelets to help blood clot.
A tough, elastic outer layer containing muscle fibers covers the spleen. Blunt injury to the spleen can cause this layer to rupture.
The symptoms of a ruptured spleen are often accompanied by other signs of injury caused by blunt trauma to the abdomen.
Examples of these other injuries include rib fractures, pelvic fracture, and spinal cord injury.
The location of the spleen means that injury to this organ can cause pain in the upper-left part of the abdomen. However, after a rupture, pain can occur in other locations, such as the left chest wall and shoulder.
Pain felt in the left shoulder as a result of a ruptured spleen is known as Kehr’s sign. This feels worse when the individual breathes in. A ruptured spleen can cause pain in the left shoulder because bleeding from the spleen may irritate the phrenic nerve, a nerve that originates in the neck and extends through the diaphragm.
Abdominal tenderness is the most common sign of an injury inside the abdomen but is not specific to spleen injury.
Other symptoms include:
- blurred vision
- signs of shock, including restlessness, anxiety, nausea, and paleness
These symptoms result from loss of blood and a drop in blood pressure.
There are two main types of treatment for a ruptured spleen: Surgical intervention and observation.
Many people with a ruptured spleen experience serious bleeding that requires immediate surgery on the abdomen. The surgeon will cut open the abdomen and operate with a procedure called a laparotomy.
For people with less severe splenic rupture, doctors will often use observation instead of surgery. However, these individuals still require active treatment and usually need a blood transfusion.
People that have a low-grade splenic rupture and no signs of other injuries in the abdomen will generally be hemodynamically stable. This means that blood pressure will be close to normal.
Up until fairly recently, treatment for a spleen injury usually involved complete removal of the spleen, or splenectomy.
A non-operative approach to managing a splenic rupture is a modern development in adult trauma surgery and was adopted following its success in treating children without surgery. Trauma surgeons used to routinely remove spleens when there was evidence of splenic rupture.
Surgery is now avoided in 95 percent of children and 60 percent of adults that have a splenic rupture.
When surgery is performed, it is still common practice to remove the entire spleen, although less severe cases may allow a surgeon to repair a tear and put pressure on the spleen until the bleeding stops.
People who remain stable under observation will often undergo further scans for monitoring purposes, including CT scans.
Those in a stable condition may also undergo a procedure called splenic embolization. The procedure aims to stop any bleeding from the spleen. This procedure usually needs to be performed quickly and can help avoid the need to remove the spleen.
Splenic embolization requires specialized facilities and staff, including a vascular surgeon or interventional radiologist. They need to be experienced in carrying out a certain type of artery catheterization and in performing embolization techniques.
Surgical removal of the spleen
This is known as a splenectomy. It is normally performed during an emergency laparotomy on a person in an unstable condition.
In some cases of less severe spleen damage, the organ may be salvaged during surgery. Instead of being completely removed, it may be repaired with partial removal, patches, repairs, or staples. There are, however, very limited opportunities for these options.
After a spleen is either repaired or removed, recovery can take a few weeks.
It is important for a person to rest and allow the body time to heal, and only to resume normal activity after receiving the go-ahead from their treating doctor. People who play sports are advised that they can resume mild physical exertion for three months before resuming their usual training or exercise regimen.
A person can live without a spleen, but its role in the immune system means that spleen removal or injury can seriously affect the body’s ability to fight infection. This means that all individuals who have undergone a splenectomy should get vaccinated against Pneumococcus. High-risk patients should be vaccinated against Meningococcus and Haemophilus influenzae type B.
These vaccinations are typically given 14 days before an elective splenectomy or 14 days after surgery in emergency cases.
Children who have undergone a splenectomy may need to take antibiotics daily to help prevent infection. This can also be important for people who also have autoimmune conditions, such as HIV, and for the 2 years following removal of the spleen.
Even after recovery, it is important to inform medical professionals that you no longer have a spleen as this can affect future treatments.
The main complication of a ruptured spleen is bleeding and the problems that can come from it, such as cysts and blood clots.
Delayed bleeding and spleen death may also result from a ruptured spleen. It is often these serious complications that result in surgery.
The decrease in immune activity following a splenectomy can lead to an increased risk of infection, so extra precautions should be taken to prevent infections.
The most common cause of a ruptured spleen is blunt trauma to the abdomen, usually as the result of a road traffic collision. However, splenic rupture can occur due to sports injuries and physical assault.
The spleen is the abdominal organ to which it is most likely an injury will occur during physical trauma.
In addition to blunt trauma, rupture can result from impalement, such as from a knife wound. The location of the spleen under the ribs means that it is, however, better protected against penetrating trauma.
Medical interventions can sometimes cause a ruptured spleen as an unintended complication. Injury to the spleen during medical treatment is most commonly caused by abdominal surgery or endoscopic manipulation and can take any of the following forms:
- tear of the capsule of the spleen
- laceration from the use of retraction devices
- tension in the spleen during colon manipulation
In rare cases, a splenic rupture is not caused by injury. This type is known as non-traumatic rupture and usually results from a disease of the spleen. Sometimes, a normal, healthy spleen may rupture, although this is extremely rare.
Other causes that can potentially lead to rupture include:
Emergency doctors are trained to suspect a ruptured spleen in any person involved in an accident that might have caused injury to their left-lower chest or left-upper abdomen.
They will also look for possible injuries to the diaphragm, pancreas, and bowel.
A doctor who has reason to suspect a ruptured spleen will first examine the abdomen to look for tenderness or enlargement as a result of fluid buildup, usually blood. The doctor will apply gentle pressure on the abdomen during this examination.
It is important to note that a person who is in hospital as a result of trauma may still have a ruptured spleen even if their abdominal examination is unremarkable.
The heart rate and blood pressure will confirm which further investigations to carry out.
Internal bleeding is confirmed by low blood pressure, a high heart rate, and a positive FAST ultrasound scan. If these results indicate splenic rupture, urgent abdominal surgery is needed to determine the source of the bleeding.
An ultrasound scan is the most sensitive diagnostic method for injuries to the abdomen, although a normal scan may not rule out splenic rupture.
In people who are hemodynamically stable, a CT scan is typically used to help determine the grade of injury.
In the emergency trauma setting, an ultrasound scan is performed while other monitoring and management continue uninterrupted. This scan is done according to the focused assessment with sonography for trauma (FAST) protocol, which forms part of the advanced trauma life support (ATLS) protocol developed by the American College of Surgeons.
A FAST ultrasound enables clinicians to scan for fluid in four areas of the abdomen, including the space around the spleen.
Diagnostic peritoneal aspiration (DPA) or lavage (DPL) is another diagnostic test that may be used. The doctor draws fluid from the abdominal cavity. Nowadays, this is rarely performed. A ruptured spleen is often identified by a CT scan.
In some cases, such as where a patient has kidney stones or is allergic to the contrast substance used in a CT scan, a stable individual with a suspected ruptured spleen may undergo an MRI scan. This can also show problems with the soft tissues of the body.
Splenic injury is classified by severity, taking into account the level of laceration, injury to the veins and arteries, and clotting. The American Association for the Surgery of Trauma grading system for spleen injury is as follows:
- Grade 1: This stage involves a tear in the capsule that goes less than 1 centimeter (cm) deep into the spleen, or a buildup of clotted blood, known as a hematoma, under the capsule. The hematoma covers less than 10 percent of the surface area of the spleen.
- Grade 2: At this stage, a 1-to-3-cm tear occurs that does not involve the arterial branches of the spleen. Alternatively, a hematoma may occur under the capsule that covers between 10 and 50 percent of the surface area. This stage can also involve a hematoma less than 5 cm in diameter in the tissue of the organ.
- Grade 3: This mid-stage rupture is a tear more than 3 cm deep. It can also involve the splenic artery or a hematoma that covers over half of the surface area. A grade 3 rupture can also mean that a hematoma is present in the organ tissue that is greater than 5 cm or expanding.
- Grade 4: This is a tear that lacerates the segmental or hilar blood vessels and causes the loss of more than 25 percent of the organ’s blood supply.
- Grade 5: This is an extremely severe tear that lacerates certain blood vessels and causes a total loss of blood supply to the organ. This stage can also mean that a hematoma has completely shattered the spleen.
The grading of a ruptured spleen helps doctors determine whether surgical or non-operative management is indicated for treatment.