Ruptured spleen

The splenic rupture is an injury ( tear) of the spleen, usually by a blunt abdominal trauma. Spontaneous rupture of the spleen without trauma are rare and occur in specific infectious diseases or hematological disease before, associated with an abnormal enlargement of the spleen (splenomegaly ). The treatment of splenic rupture is usually surgically, sometimes can be treated conservatively. This organ- conserving therapy by way of preference will be given prior to removal of the spleen.

Causes

The most common cause of splenic rupture is the blunt abdominal trauma, eg at work, traffic or sports accidents. Are typical of the fall on the bicycle or motorcycle handlebar or on the ski pole. For multiple injured patients the splenic rupture is often the most threatening component of acute injuries in the abdomen. As an accompanying injury rib fractures may be present in the lower left chest area. Direct, perforating injury, for example by stab or gunshot wounds are rare. Perforating injuries can occur but also by Einspießung strongly shifted, cracked ribs.

Iatrogenic, ie caused by medical intervention splenic injuries can occur in major abdominal surgery. These are usually superficial capsule tears by train to the stomach or at the splenic flexure of the colon or get squeezed through the use of belly hook.

In addition to the traumatic splenic rupture rarely occur even traumatic, so-called spontaneous rupture of the spleen, which may lead to capsule cracks with bleeding into the environment by a rapid swelling of the spleen. The reasons for this are infections, such as mononucleosis, splenic tumors, such as malignant lymphomas and angiomas, or the portal vein into consideration.

Forms and degrees of severity

The parenchyma of the spleen is surrounded by a delicate connective tissue capsule, which can rip with appropriate force. The parenchyma itself is very soft and very well supplied with blood already in the healthy spleen. The institution is protected primarily by its location far back in the abdominal cavity through the stable structures of the spine and the lower ribs from injury.

There are different forms of injury before: The pure capsule tear without parenchymal injury usually results in only slight oozing from the exposed Parenchymfläche. Are capsule and parenchyma torn, the severity of the bleeding from the depth of the crack and the simultaneous injury of blood vessels in the spleen depends. For very severe, acute life-threatening bleeding occurs in cracks near the splenic hilum, so the incoming from the tail of the pancreas in the spleen blood vessels, with multiple fragmentation of the spleen and in hilusnahen breaks the spleen.

In some cases, it comes only with a significant delay for bleeding from the spleen: Stay with tears of the parenchyma a capsule tear out for the time being, then, an increasing hematoma developed within the capsule ( " subcapsular hematoma "). With increasing pressure, the capsule then tears after days, in extreme cases, even after several weeks on and it comes to bleeding into the abdominal cavity. In these cases, it is spoken by a two-stage rupture of the spleen, the splenic rupture is accordingly referred to as one-stage splenic rupture with immediate bleeding.

Since these different forms of injury have a direct influence on the prognosis and the surgical procedure, five severity levels are distinguished:

• Grade 1: Capsule cracks, subcapsular hematoma is not expanding
• Grade 2: Violation of capsule and parenchyma without violation of segmental arteries
• Grade 3: Violation of capsule, parenchyma and segmental arteries
• Grade 4: Violation of capsule, parenchyma and segmental or Hilusgefäßen, demolition of the vascular pedicle
• Grade 5: avulsion of the organ in the splenic hilum with devascularization (interruption of blood supply )

Symptoms and diagnosis

The first indication of the presence of splenic rupture often arises already from the history: Any blunt injury of the left upper abdomen or the left flank may be associated with a ruptured spleen. For minor injuries, low blood flow, there are non-specific upper abdominal pain, pressure pain in the epigastrium, percussion pain in the left flank and left-sided breath -related complaints. Often a pain radiating to the left shoulder ( Kehr 's sign) is given by the patients. The irritation of the diaphragm and thus to the phrenic nerve by hemorrhage or hematoma capsule leads to pain in the left side of the neck ( Saegesser characters).

At higher injury levels with severe bleeding the signs of impending or manifest hypovolaemia shocks come to the fore: Accelerated pulse with low blood pressure (tachycardia and hypotension), rapid breathing ( tachypnea up to hyperventilation), pale, cold and clammy skin, anxiety and restlessness. An increasing consciousness as a result of cerebral anoxia forces to immediate life-saving measures.

The apparatus based diagnosis in a suspected ruptured spleen is the sonography of abdominal organs. The detection of free fluid already succeed with it in small quantities, coarser Parenchymverletzungen splenic subcapsular hematoma or large can also be present. In sonographic findings but clinically unremarkable continue the investigation of suspected must be repeated closely in order not to overlook a two-stage rupture or an increasing hematoma capsule. Radiographs of the thorax and abdomen not provide further indications of the presence of splenic rupture, but be to the exclusion of other injuries (eg, rib fractures with pneumothorax) performed. In stable circulation ratios computed tomography of the abdomen may give clearer picture of the extent of Milzverletzung. The still up in the 1990s regularly performed peritoneal lavage is now because of its high error rate no longer in use.

Chemical laboratory investigations are primarily the estimation of blood loss (hemoglobin, erythrocyte count, hematocrit) and the general assessment of organ function (kidney, liver, etc. ). Blood gas analysis provides information about the oxygen saturation of the blood and shows where necessary, increasing shock an acidification of the blood (acidosis ). In the blood rule adhering shows splenic rupture in a severe increase in the leukocyte count.

Therapy

The therapeutic approach is primarily determined by the severity of the rupture. While still up in the 1980s, a ruptured spleen almost exclusively by the removal of the spleen ( splenectomy ) was treated, the improvement in the conservative control of bleeding by now a more sophisticated treatment from the viewpoint of organ preservation possible.

Ruptures 1st degree can often be treated conservatively under close control of the sonographic findings, the circuit parameters and the blood picture, as these lesions may be closed and heal in the context of endogenous hemostasis ( hemostasis ). All other degrees of severity require surgical intervention.

The basic aim of the surgical procedure is the preservation of the spleen. For this purpose, in the grades 2 and 3 by means of infrared or electro-coagulation and fibrin glue often hemostasis can be achieved, in addition, the spleen wrapped in an absorbable synthetic mesh and compress it. When Severity 4 a functioning part of the spleen can be obtained by partial resection sometimes, during the 5th grade only splenectomy may be considered.

The selection of the appropriate surgical procedure, however, depends not only on the severity of the injury. While in children and adolescents organ preservation is attempted by all means come in old age rather splenectomy for use. The reason is partly due to the lower complication rate ( Postsplenektomie syndrome ) in adults, on the other, often present comorbidities, which make the risk of intra-or postoperative complications in lengthy preservation attempts rise with high blood loss. Also unfavorable anatomical conditions as they exist, for example, in seldom overweight ( obesity), the decision can steer you in the direction of simple feasible splenectomy.

Complications

After organ- conserving therapy usually occur on any specific complications. In the early phase are non-specific surgical complications such as bleeding, wound infection or thrombosis, may be possible with pulmonary embolism.

Early postoperative complications of splenectomy are primarily complications of respiratory system: pneumonia, atelectasis, pleural effusions. In about 1-3 % of cases, pancreatic fistulas occur through undetected injury to the pancreas tail. After splenectomy there may be an increased susceptibility to infections, in 1-5% of cases, a dangerous Postsplenektomie syndrome, a fulminant sepsis, come. In addition, patients tend after splenectomy due to the increasing platelet counts increased the occurrence of thromboembolic events.