Treatment of a ruptured spleen: Splenic trauma and conservative managment

Hello my fellow medical students and everyone reading this post. Today we will talk about the treatment of splenic traumas (rupture spleen) and what are the possible approaches to manage this condition. The spleen is the most common organ to be injured and until 1971, splenic traumas were treated surgically by splenectomy. After 1971, surgeons have researched the condition more and more and since then there has been an increasing trend towards conservative management and spleen salvage, specially in children, more on this later.

First let's see how such case is presented, what are the symptoms and signs of ruptured spleen?
It differs according to the severity of the damage. The classical cases will present with signs and symptoms of internal hemorrhage :

• A history of trauma to the left upper abdomen.
• Severe pain that maybe referred to the left shoulder.
• Rapid weak pulse, hypotension and collapse, pallor and subnormal temperature.
• Abdominal examination may reveal a wound, bruises, tenderness and guarding, shifting dullness and Cullen's sign. The last two signs results from the free blood in the peritoneum.
  

Another presentation in case of a very severe trauma leading to deep tears may lead to fatal hemorrhage and shock with rapid death. Sometimes, the effect is delayed and the symptoms appear 10-14 days after the trauma when a subcapsular hematoma rupture or a blood clot gets dislodged.

Diagnosis of a ruptured spleen:

Mainly using imaging studies:

1. -FAST (Focused Abdominal Sonographic Technique) to detect the free fluid in the abdomen.
2. -CT (helical CT with contrast) shows the injury, a blush of blood and it can determine the grade of the injury.
3. -MRI can also be used.
4. -DPL can be performed to determine wether the fluid in the peritone is blood or not, FAST is now used instead as it is less invasive.

Treatment of splenic trauma:
Due to the immunologic functions of the spleen, the philosophy nowadays is to try to save the spleen, specially in children as long as the patient is haemodynamically stable.

If the patient is in shock or haemodynamically unstable, immediate resuscitaion must be performed followed rapidly by exploratory laparotomy through a midline incision with partial or total splenectomy.

If the case is hemodynamically stable or not a serious emergency, the surgeon should try to preserve spleen by performing splenorrhaphy, splenic mesh wrap or embolisation of the splenic artery by interventional radiology.

After the operation, children should be vaccinated against Pneumococcus ,Haemophilus and Meningococcus as pert of post-operative management.