Ruptured Spleen

Definition/Description 

The spleen is an organ of the lymphatic system located on the left side of your stomach (abdomen) under the rib cage and diaphragm in a region that is referred to as the left upper quadrant. In humans the spleen is about the size of a fist and its primary roles are filtering the body’s blood and helps to fight infection. It also serves a role in storing and releasing certain types of immune cells that mediate tissue inflammation. [1]

Rupturing a spleen describes an emergency situation in which your spleen has developed a disruption in its surface or blood supply. This is serious condition that can occur during a direct blow or trauma and without emergency treatment a ruptured spleen can cause life threatening internal bleeding. [2]


Prevalence

The prevalence of splenic ruptures are poorly documented but one study suggest that traumatic splenic ruptures are more likely to occur in males (2:1 male to female) with ages ranging from 18-34 years.[3]

Infectious Mononucleosis: Annually in the United States there are appropriately 345 – 671 cases per 100,000. Typically involving school age children aged 13-19 years. Approximately 0.1% to 0.2% of the 345 – 671 cases in the United States will suffer from splenic ruptures. “Based on this figure, approximately 100 cases of ruptures may occur yearly in the US, only a few of which are reported.” [4]

Characteristics/Clinical Presentation

Signs and symptoms of a ruptured spleen include: [5]

  • Pain (usually severe but not always) in the upper left portion of the stomach (abdomen) or under rib cage
  • Tenderness when you touch the upper left portion of the stomach (abdomen)
  • Left shoulder pain (Kehr’s Sign)

Kehr's sign:

  • Pain in the left shoulder caused by irritation of the undersurface of the diaphragm by blood leaking from a ruptured spleen. The pain impulses are referred along the phrenic nerve supplying the diaphragm C3-C5 nerve distribution. [6]
  • Video of Kehr’s Sign:

https://www.youtube.com/watch?v=UkXghZn2WJ8 [7]


Internal Bleeding: occurs secondary to a ruptured spleen and can cause blood pressure to drop (hypotension). This can lead to: [8]

  • Blurred vision
  • Confusion 
  • Light-headedness
  • Fainting
  • Signs of shock (cold clammy skin, pallor, nausea, vomiting, and weak and/or rapid pulse)


Castell’s Percussion Test: Clinical Screen for the presence of splenic inflammation.

  •  Patient Supine
  •  Clinician palpates the left costal margin near the anterior axillary line.
  •  Clinician then instructs the patient to breathe normally while they apply percussion at both full inspiration as well as at rest.
  •  Findings: Positive test if dull sound is present upon full inspiration and expiration. (Indicates spleen descending)
  •  Normal it is only dull at full inspiration and should be tympanic at rest.
  •  Important: If spleen is found to be inflamed, DO NOT continue to palpate as it can lead to a rupture. [9]

Clinical Pearl:
It is strongly advised to seek immediate medical care if an injury is sustained coupled with pain in the left upper stomach (abdomen) region along with any of the above listed signs and symptoms. If severe injuries are untreated a ruptured spleen can be fatal.

Associated Co-morbidities

Common co-morbidities for traumatic splenic ruptures are hypertension, type II diabetes, and asthma. In a study involving 538 subjects, 25% suffered from one or more of the co-morbitities listed above. [10]

Non-traumatic splenic ruptures can be associated with numerous conditions and diseases. Some of the most common include, lymphoma, cirrhosis of the liver, liver disease, pancreatic pathology, bone marrow disorders such as leukemia, and blood clotting disorders.

Viral diseases that can lead to splenic rupture include mononucleosis, malaria, and in rare cases HIV.

Other conditions that can lead to splenic include drug addiction, sickle cell disease, and prolonged use of blood thinners.

Correlation with infectious mononucleosis:

  • Splenomegaly can often be a primary symptom of Epstein Barr Virus (EBV).
  • Splenic enlargement from the virus is associated with adenopathy as the virus places stresses on the immune system of which the spleen plays an important role.
  • Incidence of trauma in the presence of a diagnosis of infectious mononucleosis places one with an increased risk of a ruptured spleen. [11]
  • Signs and symptoms of infectious mononucleosis are:

         -Extreme fatigue
         -Fever
         -Sore throat
         -Head and body aches
         -Adenopathy
         -Splenomegaly
         -Dermatitis rash [12]

  • Clinicians should be aware of associated signs and symptoms of EBV infectious mononucleosis in order to refer out and provide the patient with proper medical treatment before a potential splenic rupture.

Medications

No medications are prescribed to heal severe splenic ruptures, there are medications and vaccines recommended post-surgical removal of the spleen (splenectomy) in severe injuries.

The Advisory Committee on Immunization Practices for the Centers for Disease Control and Prevention (CDC) and the Society of Surgery for the Alimentary Tract recommends all patients that undergo splenectomy receive: [13]

• the pneumococcal polysaccharide vaccine
• meningococcal vaccination
• considered for the Hib vaccine
• annual influenza vaccine in addition to the pneumococcal, meningococcal, and Hib vaccines, because secondary bacterial infections can lead to severe disease in this patient population
• boosters for all the bacterial vaccines every 5 years

Diagnostic Tests/Lab Tests/Lab Values

Blood tests such as a complete blood count to check the number of red blood cells, white blood cells and platelets in your system.
Ultrasound or computerized tomography (CT) scan to help determine the size of your spleen and whether it's crowding other organs. This is the most common test used to diagnose a splenic rupture and can be supplemented by an x-ray.
Magnetic resonance imaging (MRI) to trace blood flow through the spleen [14]


Grades of Splenic Injury:

Grades Extent of Splenic Injury
Grade 1

Hematoma; subcapular, non expanding, <10% of surface area

Laceration: capsular tear, non bleeding, <1 cm of parenchymal depth

Grade 2

Hematoma, subcapular, non expanding, 10-50% of surace area, intraparenchyma, non expanding, <2 cm in diameter

Laceration: capsular tear, active bleeding, 1-3 cm of parenchymal depth that does not involve a trabecular vessel

Grade 3            

Hematoma: subcapular >50% of surface area or expanding, ruptured subscapuar hematoma with active bleeding, intraparenchymal hematoma, >2 cm or expanding

Lacertation > 3 cm of parenchymal depth or involving trabecular vessels

Grade 4

Hematoma: ruptured intraparenchymal hematoma with active bleeding

Laceration: laceration involving segmental or hilar vessel producing major devascularization (>25% of spleen)

Grade 5

Hematoma: completely ruptured spleen

Laceration: hilar vascular injury that devacularizes spleen

Table Reference[15]


Grade I.jpg

Spleen, trauma. Chest radiograph shows a peripherally calcified mass in the left upper quadrant under the diaphragm. The mass represents a calcified splenic hematoma.[16]


Grade II.jpg

Spleen, trauma. Contrast-enhanced CT scan shows a localized area of dense contrast collection in the splenic hilum, with a massive amount of surrounding fluid/blood. Findings here are indicative of active extravasation of contrast in a patient with traumatic autosplenectomy. This is a grade V injury.[16]


Grade III.jpg

Grade I - Subcapsular hematoma of less than 10% of surface area. Capsular tear of less than 1 cm in depth.[17]


Grade IV.jpg

Grade III - Subcapsular hematoma of greater than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma. Intraparenchymal hematoma of greater than 5 cm or expanding. Laceration of greater than 3 cm in depth or involving trabecular vessels. [17]


Grade V.jpg

Grade V - Shattered spleen or hilar vascular injury [17]

Etiology/Causes

Traumatic (common) [5]
• Injury or blow to left side of the body (left upper abdomen or left lower chest)
• Sports Related
• Fights/Assaults/Domestic Violence
• Motor Vehicle Accidents
• Falls

Video demonstrating traumatic force required to rupture a spleen:
https://www.youtube.com/results?search_query=ruptured+spleen [18]

Atraumatic (uncommon and diagnosis is often missed due to absence of any history of trauma)

Table 12.png


[3]

http://www.rcsed.ac.uk/journal/vol47_1/47100010.html

Atraumatic Schematic.png

[3]

http://www.rcsed.ac.uk/journal/vol47_1/47100010.html

Systemic Involvement

Rupture of the spleen can lead to life threatening bleeding into the abdominal cavity, which will lead to low blood pressure and decreased oxygen supply to the heart and brain. It is a medical emergency and should be referred to the emergency room immediately.

Medical Management (current best evidence)

First case control study on operative vs. non-operative management by Upadhyaya and Simpson in 1968 suggested that isolated splenic injuries could be safely treated without surgery in children. Pediatric surgeons led the way during the following decades, and non-operative management is now reported to be successful in more than 90 percent of children with isolated blunt injuries.[19]


Non-Operative Management (NOM)

  • Non-operative management may require: [20]

• Significant Blood Transfusions

• Repeated CT Scans

• Hematocrits (a centrifuge for separating blood cells from plasma)

• Close observation for up to 2 weeks, including an initial period of observation in an intensive care unit (ICU). 


• Non-Operative treatment is attempted in 60-90% of patients with blunt traumatic splenic injuries with intent to preserve splenic function. [19]

• Spleen preserving surgery gained popularity in 1960’s due to the discovery of the spleens role in immune function. [19]

Predictors and other risk factors associated with failure of non-operative management: [19]

•Hemodynamic instability:
o Systolic Blood Pressure less than 100 mm Hg.
o Heart rate greater than 120 beats per minute. 
o Lack of response to a fluid challenge of 2 L of a crystalloid solution.

Contrast Extravasation:
o A leakage of contrast material into the fatty tissue around a vein. Contrast is a dye that allows your veins and arteries to show up more clearly on the CT/MRI scan. [21]

•Arteriovenous Fistula:
o Abnormal connection between an artery and a vein. [5]

•Pseudoaneurysm:
o False Aneurysm

o Large Volume of Blood in Peritoneal Cavity
o Age Over 55 years 
o Multiples Injuries

• Angioembolization is an adjunct to non-operative management and generally reported to increase the success rate of non-operative management approaching 95 percent.  [19]

Angioembolism Pics.docx.png

http://onlinelibrary.wiley.com/doi/10.1002/bjs.7764/abstract [19]


• In angiographic embolization, coils or pledgets are used to reduce splenic hemorrhage, by occlusion either of the proximal splenic artery or of more distal branches (Fig.2a,b). Proximal splenic artery embolization is thought to reduce the perfusion pressure in the spleen, thereby stopping bleeding and the risk of delayed rupture or rebleeding. Peripheral embolization stops bleeding more selectively and occludes pseudoaneurysms or arteriovenous fistulas [19]


Operative Management (OM)

  • Splenectomy:

• Performed with most splenic injuries up to 1950
• Complete removal of spleen
• Most appropriate procedure for unstable patients [19]


  • Laparoscopic and Open Procedures: 

• Prone to infections




  • Splenorrhaphy
  • Suturing the spleen and non-removal:• Performed approximately 6% of the time (anything new in adult splenic ruptures)
    • Grade 3 spleen injury - mesh splenorrhaphy


Splenorrhaphy.png

[22]

http://www.trauma.org/index.php/main/images_keyword/laparotomy/

Physical Therapy Management (current best evidence)

Physical therapist must be able to recognize the signs and symptoms of spleen rupture.  In sports, splenic rupture is the most common cause of death due to abdominal trauma, it is vital that clinicians perform a through exam of the patient.[23]

Palpation: The spleen is located in the left upper quadrant and covered by the 9th - 11th ribs. Clinicians should check this area for pain and tenderness.  Abdominal palpation should also be performed in the hook-lying position checking for tenderness, distension, guarding, and rebound tenderness. "To palpate the spleen, lift the left flank with your non-dominant hand; keeping your other hand flat, depress the palpating digits just below and anterior to the 11th  and 12 ribs and ask the patient to take a deep breath.  A normal healthy spleen should not be palpable." [23]

Patient Education: Most splenic ruptures can be rapidly progressing, while others can delay hemmorrhage for hours, days, or even weeks after injury, until a suffient enough force causes rupture.  It is vital that we education patients about the signs and symptoms so they can seek medical care immediately.

Post-operation: encourage ROM, ambulation, and coughing techniques (splinted coughing). Most traumatic splenic ruptures will not be seen in physical therapy.

Video Link of Physical therapy management:

https://www.youtube.com/watch?v=gip3fDb5O3E

Differential Diagnosis

-Left kidney trauma/pathology

-Rib fracture

-Intestinal pathology

-Musculoskeletal Involvement

-Non-Hodgkin's Lymphoma 

-Infectious Mononucleosis 


Case Reports/ Case Studies


Spontaneous rupture of the spleen – a fatal complication of pregnancy

http://www.ncbi.nlm.nih.gov/pubmed/7572867


Case Report

Philippe E. Fait, Richard DeMont. Third-degree spleen laceration
in a male varsity athlete. Athletic Therapy Today. 2003; 8; 32-33


Patient:
-23 year old male university hockey player "Eric"
-Collided with another player and then got up and skated to the bench but had extreme difficulty breathing
-They performed a bench and concussion evaluation and the player was deemed “winded” and cleared to play
-Not long after getting back out there he complained of general body pain
-They took him into the locker room where he immediately began vomiting

Physician Evaluation and Dx:
-No rib fractures
-Kehr’s Sign= suspected spleen damage yet not 100% certain b/c he had prior shoulder surgery the previous year

Tests:
-X-ray and then sent home

Next Day:
-Felt worse so parents took him back to hospital
-Admitted to intensive care department
-CT revealed a 3rd degree spleen laceration

Care and Treatment:
-Usual conservative (nonsurgical) trx - 1 week hospitalization
-Prescribed a 6 month recovery before returning to hockey
-At 2 months-light to medium physical activity and a CT scan
-At 4 months- follow up assessment, intense physical noncontact training began
-At 6 months- full contact was permitted

Prognosis:
-At 5 months postinjury-
-engaged in regular gym workouts
-returned to a normal diet
-lost considerable weight

Player continued a conservative approach to return to sport in that he decided to not to play varsity hockey the following season, taking at least 1 year off.

Case Report #2

  • Patient:

- Patient is a 40 year old female middle school teacher who was recently involved in an automobile accident in which she was T-boned in an intersection three days ago.
- She reports no major injuries but comes to physical therapy for L shoulder pain and difficulty breathing since the accident.

  • Clinical impression:
  • Pt reports following subjective symptoms:

- Blurred vision
- Lightheadedness
- Increased sweating
- Feeling of "racing heart"
- Pain in L shoulder
- Difficulty breathing


  • Objective findings

- Negative ER lag
- Negative drop arm test
- Negative Neer's impingement test
- Positve Castell's Percussion Test
- Positive Kehr's Sign
- 5/5 MMT Bilaterally of UE
- Sensation is WNL Bilaterally
- AROM: WNL other than Lumbar FB 75% with pain, Lumbar SB Bil 75% with pain

  • Interventions:

- Referral to Emergency department for signs and symptoms consistent of splenic rupture secondary to MVA

  •  Outcomes:

- After X-ray and CT scan confirmation of ruptured spleen and peritoneal hemorrhaging, surgical correction was performed to stop abdominal bleeding and splenic rupture.

  • Discussion:

- Patient returned to full function after recovery from the surgery, all shoulder symptoms were alleviated after surgical intervention
- Physical therapist demonstrated excellent clinical judgement in the situation when deciding to refer the patient which resulted in a life saving scenario.

Resources

1. Mayo Clinic
http://www.mayoclinic.com/health/ruptured-spleen/DS00872

2. Medscape
http://emedicine.medscape.com/article/432823-treatment

3. Discussion Board Spleen Rupture
http://www.medhelp.org/tags/show/148977/rupture-spleen

http://www.healthboards.com/boards/general-health/698344-rib-cage-injury-ruptured-spleen.html


References

  1. 1
  2. 2
  3. 3.0 3.1 3.2 Debnath D, Valerio D. Education- Atraumatic rupture of the spleen in adults. J.R. Coll.Surg.Edinb. 2002;47;437-445. http://www.rcsed.ac.uk/journal/vol47_1/47100010.html (accessed 28 Mar 2012)
  4. Foreman B, Mackler L. Can we prevent splenic rupture for patients with infectious mononucleosis? Journal of Family Practice 2005; 54: 547
  5. 5.0 5.1 5.2 Cite error: Invalid <ref> tag; no text was provided for refs named Mayo_Clinic
  6. A Dictionary of Nursing. 2008. Kehr’s Sign. 29 Mar. 2012 Available at: http://www.encyclopedia.com/doc/1O62-Kehrssign.html.
  7. https://www.youtube.com/watch?v=UkXghZn2WJ8
  8. WebMD. 2005-2012. Ruptured Spleen. [Internet] [reviewed 2009 Aug 19; cited 2012 Mar 30]. Available from: http://www.webmd.com/digestive-disorders/ruptured-spleen
  9. Examination of the Spleen. Examination of the Spleen | Stanford Medicine 25 | Stanford Medicine. http://stanfordmedicine25.stanford.edu/the25/spleen.html. Accessed April 4, 2017.
  10. Clancy A, Tiruta C, Ashman D, Ball C, Kirkpatrick A. The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007. Journal of Trauma Management & Outcomes 2012; ISSN 1752-2897
  11. About Infectious Mononucleosis. Centers for Disease Control and Prevention. https://www.cdc.gov/epstein-barr/about-mono.html. Published September 14, 2016. Accessed April 5, 2017
  12. Infectious Mononucleosis Differential Diagnoses. Infectious Mononucleosis DifferentialfckLRDiagnoses. http://emedicine.medscape.com/article/222040-differential. Published January 6,fckLR2017. Accessed April 4, 2017.
  13. Webb C, Crowell K. Which vaccinations are indicated after splenectomy? Journal of Family Practice 2006;55:8. http://www.jfponline.com/Pages.asp?AID=4327&issue=August%202006&UID= (accessed 26 Marc 2012)
  14. Mayo Clinic Staff Print. Diagnosis. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/enlarged-spleen/diagnosis-treatment/diagnosis/dxc-20214826. Published August 3, 2016. Accessed April 4, 2017.
  15. EB Medicine, Splenic Injuries: http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=132&seg_id=2728
  16. 16.0 16.1 Klepac S. Spleen Trauma Imaging. Medscape.http://emedicine.medscape.com/article/373694-overview (accessed 22 March 2012).
  17. 17.0 17.1 17.2 Johnson J, Splenic Injury AAST Grading System. UVMRads. UVMRads. http://uvmrads.org/sections/bodyct/87-splenic-injury-aast-grading-system?start=1 (accessed 23 March 2012
  18. YDS. How Much Force to Rupture a Spleen: Sport Science. YouTube. https://www.youtube.com/watch?v=uQp9iwVzN5Q. Published July 15, 2014. Accessed April 4, 2017.
  19. 19.0 19.1 19.2 19.3 19.4 19.5 19.6 19.7 Skattum J, Naess P, Gaarder C. Non-operative management and immune function after splenic injury. BJS 2011;99:1;59-65. http://onlinelibrary.wiley.com/doi/10.1002/bjs.7764/abstract (accessed 28 Mar 2012)
  20. MD Guidlelines, Rupture of Spleen Traumatic. fckLRhttp://www.mdguidelines.com/rupture-of-spleen-traumatic (accessed 20 Mar 2012)
  21. University of Washington, Radiology and Imaging Services. http://uwmedicine.washington.edu/Patient-Care/Our-Services/Medical-Services/Radiology-Imaging-Services/Pages/Contrast-Extravasation.aspx (accessed 21 Mar 2012)
  22. Trauma.org. Care for the Injured- Massotto H. Grade 3 spleen prevention-mesh splenorrhaphy. Available: http://www.trauma.org/index.php/main/images_keyword/laparotomy (assessed 30 Mar 2012)
  23. 23.0 23.1 Shultz SJ, Houglum PA, Perrin DH. Examination of Musculoskeletal Injuries, 2nd ed. Champaign, IL, 2005. p. 570-571