1. Dr. Raheel Anis

2. INTRODUCTION
 Spleen is one of the most commonly injured intra-abdominal
organs
 In up to 60 percent of patients, the spleen is the only organ
injured
 Diagnosis and prompt management of potentially life-
threatening hemorrhage is the primary goal
 Any attempt to salvage the spleen is abandoned in the face of
ongoing hemorrhage or other life-threatening injuries
 Emergent and urgent splenectomy remains a life-saving
measure for many patients

3. Anatomy

4. Anatomy
 Spleen lies in posterior portion of left upper quadrant, deep to
9, 10 and 11 ribs
 Convex surface lies under lt hemidiaphargm
 Concavities on medial side due to impression by neighbouring
structures
 Average length 7-11cm
 Weight 150 grams (70-250)
 Tail of pancreas lies incontact with spleen in 30% and within 1cm
in 70%

5.  Situated
Posteriorly
left
upper
abdomen
 Covered by peritoneum except at the
hilum
 Posterior and lateral surface related
to
left
hemidiaphragm
posterolateral lower ribs
and
 Lateral surface attached through
splenophrenic ligament

6.  Posteriorly
related to left
iliopsoas muscle & left adrenal
glands
 Posterior medial surface related
to body & tail of pancreas
 Anteriomedially related to great
curvature of stomach

7.  Inferiorly
related to distal
transverse colon & splenic flexure
 Lower pole attached to colon
through splenicocolic ligament
 These
attachments
require
devision during mobilisation

8. ARTERIAL SUPPLY
Receives blood supply from celiac axis
1.Spleenic artery
2.Short gastric vessels that connect left gastroepiploic artery.
& splenic circulation along greater curvature of stomach

9. VENOUS DRAINAGE
 Through splenic vein
 Joins superior mesenteric vein to form portal vein

11. PHYSIOLOGIC FUNCTIONS
A. Filtering – splenic blood flow – 350 ml/day
1. Removal of abnormal red blood cells approximately 20 ml
of aged RBC are removed daily
2.Removal of abnormal WBC , Plateletes
B. Immunologic Function
1. Opsonin production
2. Antibody synthesis (IgM)
3. Protection from infection
C. Storage Function
1. Plateletes – 1/3 are stored in the spleen
2. In splenomegaly, up to 80% of the plateletes may be stored in the spleen 
thrombocytopenia

12. MECHANISM OF INJURY
 Splenic injury most commonly occurs following blunt trauma
due to motor vehicle collisions
 Penetrating splenic trauma is less common than blunt injury
 Iatrogenic traumatic injuries to the spleen can result from
surgical or endoscopic manipulation
 colon,
 stomach,
 pancreas,
 Kidney
 primary mechanism is capsular tear, laceration from
retraction devices, or tension on the spleen during
manipulation of the colon

13. HISTORY AND PHYSICAL EXAMINATION
 History of trauma,
 Left-upper quadrant, left rib cage, or left flank
 Negative history does not reliably exclude splenic injury
 Penetrating object can injure the spleen even if the entrance
wound is not in proximity to the spleen

14. SIGN & SYMPTOMS
 Complain of left upper abdominal, left chest wall, or left
shoulder pain (ie, Kehr's sign).
 (Kehr's sign) is pain referred to the left shoulder that worsens
with inspiration and is due to irritation of the phrenic nerve
from blood adjacent to the left hemidiaphragm
 Abdominal tenderness and peritoneal signs
 Abdominal wall contusion or hematoma (eg, seat belt sign),
 Associated injuries
 With blunt abdominal trauma, lower rib fractures, pelvic fracture, and
spinal cord injury may also be present

16. ON EXAMINATION
 Vitals are most important
 r/o left lower rib tenderness



14% patients with left lower rib
tenderness have splenic injury
In children plasticity of chest
will have splenic injury
without rib #
Ecchymoses or abration over LUQ

17. Diagnostic evaluation
 Focused assessment with sonography in trauma (FAST
exam),
 FAST exam is more useful in hemodynamically
unstable patients
 Computerized tomography (CT scan).
 Diagnostic peritoneal aspiration/lavage (DPA/DPL) is
less common

18. SPECIFIC DIAGNOSTIC FINDINGS
 FAST findings
o
Signs of splenic injury observed with FAST examination
include a finding of hypoechoic (ie, black) rim of
subcapsular fluid or intraperitoneal fluid usually found
around the spleen or in Morrison’s pouch (hepatorenal
space).

19.  CT findings
 In non-injured patients

CT scan is typically performed with both oral (PO) and
intravenous (IV) contrast

For obvious reasons, non-intravenous contrast CT scan cannot
establish the presence of active bleeding (ie, contrast
blush, active extravasation).

20. CT scan findings that indicate splenic
injury include
 Hemoperitoneum – Localized fluid collections around the spleen
(especially those with an elevated Hounsfield unit measurement) are highly
suggestive of hemoperitoneum. Briskly bleeding splenic lacerations may
establish blood density fluid throughout the abdomen.
 Hypodensity – Hypodense regions represent areas of parenchymal
disruption, intraparenchymal hematoma or subcapsular hematoma.
 Contrast blush or extravasation – Contrast blush describes hyperdense
areas within the splenic parenchyma that represent traumatic disruption or
pseudoaneurysm of the splenic vasculature. Active extravasation of
contrast implies ongoing bleeding and the need for urgent intervention

21. SPLENIC INJURY WITH EXTRAVASATION
OF CONTRAST

22. MINOR BLUNT SPLENIC INJURY

23. MODERATELY SEVERE BLUNT SPLENIC
INJURY

24. OTHER IMAGINGS
 Plain films, organ-based ultrasound imaging, and magnetic resonance
imaging (MRI) are of limited value in the acute diagnosis of splenic injury
 Plain films are generally nonspecific but may demonstrate rib fracture, or
medial displacement of the gastric air bubble (ie, Balance sign) raising
suspicion for a splenic injury.
 MRI and organ-based ultrasound examination may be time-consuming to
perform, and may put the patient in a location of the hospital remote from
ready access and intervention. However, MRI may be applicable in a subset
of hemodynamically stable patients who cannot undergo CT scan
(eg, allergic to IV contrast)

25. SPLENIC INJURY GRADING
 The AAST criteria for hematoma and laceration for each splenic injury grade are as
follows
Grade I — Hematoma: subcapsular, <10 percent of surface area. Laceration: capsular
tear <1 cm in depth into the parenchyma
Grade II — Hematoma: subcapsular, 10 to 50 percent of surface area. Laceration:
capsular tear, 1 to 3 cm in depth, but not involving a trabecular vessel.
Grade III — Hematoma: subcapsular, >50 percent of surface area OR
expanding, ruptured subcapsular or parenchymal hematoma OR intraparenchymal
hematoma >5 cm or expanding. Laceration: >3 cm in depth or involving a trabecular
vessel.
Grade IV — Laceration involving segmental or hilar vessels with major devascularization
(ie, >25 percent of spleen)
Grade V — Hematoma: shattered spleen. Laceration: hilar vascular injury which
devascularizes spleen.

27. MANAGEMENT APPROACH
 Splenic injury can be initially managed with..
 Observation
 Angiographic embolization
 Surgery depending upon the hemodynamic status
 Grade of splenic injury
 Presence of other injuries and medical comorbidities.

28. HEMODYNAMICALLY UNSTABLE
Based upon ATLS principles, the hemodynamically
unstable trauma patient with a positive
FAST scan or DPA/DPL requires emergent abdominal
exploration to determine the source
of intraperitoneal hemorrhage

29. HEMODYNAMICALLY STABLE
Hemodynamically stable patients with
low-grade (I to III) blunt or penetrating splenic injuries
without any evidence for other intra-abdominal injuries,
active contrast extravasation, or a blush on CT, may be
initially observed safely.

30.  CT scan findings of contrast extravasation or vascular blush
have higher failure rates for observational management
 Patients may benefit from initial splenic embolization
followed by continued observation
 Another indication for embolization is intraparenchymal
pseudoaneurysm formation
 Splenic embolization is controversial for higher grade (IV, V)
injuries and in patients older than 55

31. NONOPERATIVE MANAGEMENT
 Nonoperative management, encompassing both
observation and embolization techniques, is used to
manage 50 to 70 percent of cases
 Typically for patients with lower grade injuries

32. Rationale for nonoperative management is based
upon the assumption that salvaging functional splenic
tissue avoids the surgical and anesthetic risks
and complications associated with laparotomy and
abrogates the risk of postsplenectomy sepsis.

33. CONTRAINDICATIONS TO NONOPERATIVE
MANAGEMENT
 Nonoperative management is not appropriate in patients with
 Hemodynamic instability,
 Generalized peritonitis,
 Other intra-abdominal injuries requiring surgical exploration
 Portal hypertension is a relative contraindication
 Higher-grade splenic injury (>Grade III), J

34. RELATIVE CONTRAINDICATIONS
 Portal hypertension
 Higher-grade splenic injury (>Grade III),
 Active contrast extravasation
 Large volume hemoperitoneum (though difficult to accurately
quantify),
 Refusal of blood transfusion
 Altered neurologic status precluding adequate serial abdominal
examination

35.  The optimal management of hemodynamically stable
patients with higher-grade (IV, V) injuries remains
controversial
 Though grade V injuries are generally unsuitable for
embolization due to vascular disruption
 Grade IV injuries to be a relative contraindication
to splenic embolization

36. ONE SMALL RETROSPECTIVE REVIEW
 60 percent of patients with higher grade injuries were
taken directly to the operating room
 remaining patients were managed nonoperatively with 55
percent of these patients ultimately requiring surgery
 prefer to initially manage hemodynamically stable patients
with Grade III or IV splenic injury with angiographic
embolization
as
part
of
their
nonoperative
management, provided that they do not have large volume
hemoperitoneum or other injuries that require abdominal
exploration or medical comorbidities providing a
contraindication.

37.  Embolization is also relatively contraindicated in
patients older than 55 due to higher failure rates in
these patients
 Retrospective
reviews suggest, however, that
carefully selected individuals over 55 who are
hemodynamically stable, and have no significant
medical comorbidities, can also be safely managed
with observation, with or without embolization

38. OBSERVATION
 Successful
observation
during
non-operative
management for splenic trauma depends upon
 Proper patient selection
 Availability of adequate resources
 Closely monitored by nursing and medical staff

39.  Initially place the patient on bed rest,
 Serial hemoglobin levels every six hours in the first
24 hours.
 NPO for at least the first 24 hours.
 When the hemoglobin level is stable and operative
intervention unlikely, the patient may eat.

40.  Do not routinely perform repeat CT imaging during the
course of hospitalization
 Follow-up study is performed for patients whose clinical
situation (ie, falling hemoglobin, increasing abdominal
pain, left shoulder pain, fever) indicates a need.
 With higher grade injuries (III to V), a repeat scan
within 24 to 48 hours may be needed if the clinical
situation is unclear

41. Duration of observation should be individualized based upon
 the grade of splenic injury,
 nature
 severity of other injuries
 patient's clinical status
 higher-grade injury generally required longer observation periods
 duration of observation following splenic injury is that the
number of days of observation is equal to the injury grade plus one

42. One multicenter trial found that
 86
percent of patients who failed nonoperative
management did so within 96 hours of hospital
admission,
 with 61 percent of failures occurring during the first 24
hours

43. FAILURE OF OBSERVATION
 require either splenic embolization, or more commonly, operative management
 "delayed splenic rupture". more accurately describes those patients with
splenic parenchymal pseudoaneurysms
 hemodynamic instability
 the development of diffuse peritoneal signs
 decreasing hemoglobin attributed to splenic hemorrhage.
 Hypotension may be absolute or relative, or evidenced as persistent tachycardia
in spite of adequate fluid resuscitation.

44. SPLENIC EMBOLIZATION
 Requires specialized imaging facilities and a vascular interventionalist
 Potentially most useful when employed selectively in hemodynamically
stable patients who have CT findings that include active contrast
extravasation, splenic pseudoaneurysm, or large volume hemoperitoneum
 Retrospective reviews have found variable success rates (57 to 93 percent)
for splenic salvage that includes embolization in patients with higher-grade
(III, IV, V) splenic injuries
 Retrospective studies have demonstrated that nonoperative management is
more successful with the adjunctive use of angio-embolization

46. FOLLOW-UP CARE
 Resumption of normal activities
 restricted from participation in high-risk activities up to
three months
 retrospective
review, healing was demonstrated
radiographically within two months of injury in 80
percent of patients; however, grade V injuries were excluded
in this
 Imaging studies
 not routinely perform repeat CT imaging

47. OPERATIVE MANAGEMENT
 Splenic salvage or splenectomy
 sustaining abdominal trauma who are hemodynamically
unstable
 not candidates for nonoperative management
 those who fail nonoperative management strategies
require

49. SUMMARY AND RECOMMENDATIONS
Splenic injury can result from either blunt or penetrating chest or
abdominal trauma; blunt mechanisms are more common
Splenic injury can also be due to iatrogenic injury
Perform initial resuscitation, diagnostic evaluation, and management of
the trauma patient based upon protocols from the Advanced Trauma Life
Support
A suspicion for splenic injury is increased with left upper quadrant and/or
left chest trauma

50. clinical history and physical examination are not sufficiently sensitive or
specific for the presence of splenic injury
Findings indicative of splenic injury on focused assessment with
sonography for trauma (FAST)
CT
scan)
findings
consistent
with
splenic
injury
…hypodensity, intraparenchymal or subcapsular hematoma, intravenous
contrast blush,
active intravenous
contrast extravasation
or
hemoperitoneum

51.  Hemodynamically stable patients with low grade (I to III) injuries, we suggest
nonoperative management over definitive surgical intervention
Failure of nonoperative management indicates a need for angiographic
embolization, if not initially used, or surgical exploration

52. For patients who develop hemodynamic instability during the course of
nonoperative management, we suggest surgical exploration over splenic
embolization
Asplenic patients are regarded as having impaired immunity to encapsulated
organisms and should be immunized against encapsulated organisms

53. THANK YOU