A ruptured spleen or splenic rupture is an injury to the spleen. Splenic rupture is usually caused by blunt abdominal trauma. It results in severe bleeding in the abdomen, which may require emergency surgery.
In the case of a ruptured spleen
- only the spleen capsule is affected by the injury, or
- the inner tissue of the spleen, the so-called spleen parenchyma.
In addition, a ruptured spleen can also result in the blood vessels of the spleen being torn off. Depending on the extent of the injury, the spleen rupture is assigned one of five degrees of severity.
The spleen is an organ located in the left upper abdomen below the left costal arch. It is responsible for removing old red blood cells and platelets. It also plays a decisive role in the body's defense against foreign substances.
With a length of ten to twelve centimetres, the spleen is the largest lymphatic organ in the human body. It is six to eight centimetres wide, three to four centimetres thick and weighs 150 to 200 grams.
Trabeculae carrying blood vessels (splenic beams) extend from the connective tissue capsule into the parenchyma.
The spleen is well protected due to its position in the abdominal cavity. Therefore, massive external influences are usually necessary to injure it. This can include a violent blow or jolt to the pit of the stomach.
The location of the spleen in the human body © pixdesign123 | AdobeStock
There are five different degrees of severity for a ruptured spleen, depending on the extent of the injury. This is referred to as the AAST classification.
A grade 1 splenic rupture is characterized by
- a ruptured capsule,
- a parenchymal injury that extends less than one centimeter in depth, and
- a subcapsular, non-spreading hematoma (less than ten percent of the surface) located below the spleen capsule.
characterized. There is no bleeding.
A grade 2 splenic rupture is characterized by
- a rupture of the capsule,
- a parenchymal injury that extends one to three centimeters in depth, and
- a subcapsular hematoma (ten to 50 percent of the surface) that extends less than two centimeters into the parenchyma,
is present. Bleeding occurs.
A grade 3 splenic rupture is characterized by
- a ruptured capsule,
- a parenchymal injury that extends more than three centimeters into the depth, and
- a subcapsular hematoma (more than 50 percent of the surface) that extends more than two centimeters into the parenchyma,
is present. The tabular vessels (blood vessels within the spleen) are injured.
Grade 4 splenic rupture involves a ruptured capsule and a parenchymal injury. In the case of a parenchymal injury, more than 25 percent of the spleen is no longer supplied with blood due to an injury to the tabular vessels and the hilar vessels.
In grade 5 splenic rupture, the spleen is completely ruptured. The spleen is torn off in the splenic hilum, which results in a complete interruption of the vascular supply to the spleen.
A spleen rupture can also be differentiated according to the acute clinical symptoms:
In a single-stage splenic rupture, the spleen capsule and the splenic parenchyma rupture simultaneously immediately after the traumatic event.
In a two-stage splenic rupture, there is initially only a rupture of the splenic parenchyma. The spleen capsule is still intact and only ruptures several hours to days after the traumatic event.
A ruptured spleen can have both traumatic and non-traumatic causes. In most cases, however, a ruptured spleen is caused by blunt abdominal trauma.
The most common triggers of abdominal trauma are
- serious car accidents,
- accidents at work,
- sports accidents or
- fights
are common. The injury is characterized by blunt force trauma to the abdomen.
In rare cases, it can also be caused by
- gunshots,
- stab wounds,
- intraoperative injuries or
- left-sided rib fractures
can also result in a traumatic splenic rupture.
The less common, non-traumatic causes of a ruptured spleen include
- viral infections,
- haematological diseases and
- spleen tumors.
These diseases can result in a so-called spontaneous rupture of the spleen.
If the spleen ruptures, blood leaks from the spleen into the free abdominal cavity. This results in a lack of blood in the circulation. The severity of the symptoms depends on the severity of the spleen rupture and the extent of the blood loss.
In the case of a single-stage spleen rupture, blood leaks into the abdominal cavity immediately after the traumatic event. This leads to
- Pain in the left upper abdomen, which can radiate to the left side of the body,
- a reflex-like tensing of the abdominal wall muscles with a hard abdomen,
- tenderness of the abdomen and
- possibly an increase in abdominal girth.
In the case of a ruptured spleen, there is also an acute risk of life-threatening shock. The blood pressure in the blood vessels drops as a result of the large amount of blood leaking into the abdominal cavity. As a result, the brain and heart may no longer receive sufficient oxygen.
The reduced blood flow and lack of oxygen lead to
- Dizziness,
- light-headedness,
- confusion,
- visual disturbances,
- fainting,
- mild headaches,
- accelerated pulse and
- shallow breathing.
In the case of a two-stage splenic rupture, there is initially only a parenchymal injury, the capsule is still intact for the time being. The spleen capsule only ruptures several hours or days after the actual traumatic event. The blood therefore initially accumulates inside the spleen capsule.
The symptoms of a single-stage spleen rupture therefore only occur when the spleen capsule finally does rupture. This can take several hours or days.
The diagnostic procedure depends largely on the patient's condition and circulatory situation. As part of a physical examination, for example after a traffic or sports accident, we look for
- Bruise marks,
- belt marks,
- defensive tension,
- spontaneous pain and
- pressure pain
respected.
- Left upper abdominal pain radiating to the left side of the body,
- tenderness of the abdomen and
- bruising marks on the left side of the chest
already indicate a ruptured spleen. In addition, the vital parameters (blood pressure and heart rate) and certain laboratory values are determined.
If a ruptured spleen is suspected, an ultrasound examination of the abdomen is usually performed. In medical terms, this is known as an abdominal sonography. This allows fluid in the abdomen to be detected and the extent of a ruptured spleen to be assessed.
However, the gold standard for diagnosing a spleen injury is a CT scan of the abdomen(abdominal CT). The spleen parenchyma can be better visualized with a CT scan.
As an alternative to CT, magnetic resonance imaging(MRI) can also be performed if the patient's circulation is stable.
The treatment of a ruptured spleen is aimed at repairing and preserving the spleen. Removal of the spleen would result in serious complications.
The therapy depends on
- the severity of the spleen rupture and
- the extent of the bleeding into the abdominal cavity and thus the circulatory stability,
- the presence of concomitant injuries and
- patient-dependent factors such as age, secondary illnesses and medication.
In the past, almost every spleen injury was operated on. Today, a non-surgical (conservative) approach is preferred for blunt spleen injuries. The prerequisite for this is that the patient's circulation is stable or can be stabilized.
The conservative approach includes
- the wait-and-see strategy, in which the patient is monitored, and
- interventional therapy with angioembolization.
The spleen and thus the important function of the spleen as an immune organ are preserved.
In angioembolization, a catheter is advanced into the spleen via a vascular access. The doctor then attempts to stop the bleeding by inserting, for example
- platinum coils,
- plastic particles or
- adhesives
to bring the bleeding to a standstill.
However, if a patient cannot be stabilized by blood transfusions, surgery is required.
Splenorrhaphy is a spleen-preserving operation. The surgeon places constricting sutures and embeds the spleen in an absorbable mesh.
However, if the bleeding cannot be controlled by this or local hemostasis procedures, the spleen must be
- partially(partial splenectomy) or
- completely(splenectomy)
be removed.
Current medical recommendations suggest the following basic procedure:
- In the circulatory stable patient with spleen injury without concomitant injuries: Non-surgical treatment.
- In patients with stable circulation and spleen injury in whom the bleeding does not stop on its own: angioembolization instead of surgery.
- In the case of a grade 1, 2 or 3 splenic rupture, if surgery is required: Spleen-preserving surgery.
- In the case of a type 4 or 5 splenic rupture: splenectomy instead of spleen preservation.
After a splenectomy, the risk of contracting infectious diseases is significantly increased. The patient should therefore be vaccinated against
- influenza viruses
- pneumococci (pathogen that causes pneumonia)
- Meningococcus (pathogen that causes meningitis)
- Haemophilus influenzae Tyb b (HiB) (various inflammations and blood poisoning)
can be vaccinated.
This can prevent the OPSI syndrome ("overwhelming post-splenectomy infection"). This is the most serious complication following splenectomy. It includes severe bacterial infections and leads to a high mortality rate.
The prognosis for a ruptured spleen depends on
- blood loss,
- the accompanying injuries and
- the age of the patient
age of the patient. To prevent OPSI syndrome, the above vaccinations should be carried out and, if necessary, lifelong antibiotic prophylaxis should be given.
