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Splenic tear - symptoms, causes and treatment options

Splenic tear - symptoms, causes and treatment options



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Detect and treat spleen injury

A splenic rupture is understood to be the rupture of the spleen (splenic tear). This injury usually results from an accident with a strong impact in the abdominal region (blunt abdominal trauma). Heavy bleeding with abdominal pain can result. Sometimes this occurs with a time delay. Depending on the extent of the trauma and other factors, there are various treatment methods, in which the first step is always conservative treatment and organ preservation. However, a severe splenic tear with severe blood loss is an acute emergency that requires immediate medical care and often surgery.

Definition

A crack injury of the spleen is referred to in medical jargon as splenic rupture, whereby a distinction is made between a one-time and two-time rupture. In the case of a one-time injury, the outer capsule of the spleen and the functional tissue of the spleen (splenic parenchyma) are affected at the same time and there is an immediate bleeding into the abdominal cavity. If the incident is particularly severe with massive bleeding, the injury can quickly pose an acute risk to life for those affected.

It is different with the rarely occurring two-stage rupture, in which the capsule initially remains intact and thus retains the bleeding into the abdominal cavity for a certain time. This leads to the formation of a hematoma in the spleen, which, depending on the severity of the injury and bleeding, can result in internal pressure up to a capsule tear.

According to the American Association of the Surgery of Trauma (AAST), there are five straight lines (grade I-V) for a splenic rupture with hematoma or capsular tear. The most serious forms of injury are the destruction of the entire organ or tearing at the stalk, which normally ensures the blood supply to the spleen. Other classifications of spleen injuries are also used in practice.

Symptoms

The most common symptoms of bleeding into the abdominal cavity are acute abdominal pain and pain in the left or entire upper abdomen (spleen pain). Sometimes the pain radiates to the left flank and shoulder (sweeping sign). Depending on the severity of the injury, there may also be a strong and sometimes very painful abdominal wall tension.

If blood infiltration is slow and the spleen is torn, the injury may remain symptom-free for a period of time after an initial pain interval. If the symptoms remain low, it is not infrequently difficult to identify the injury, especially in polytrauma.

From a certain amount of blood loss and a consequent insufficient supply of blood to the body (and brain), general symptoms such as dizziness, headache, visual disturbances or confusion can also occur. If there is a large amount of blood loss, dangerous reactions such as shortness of breath and shock conditions (circulatory shock, hemorrhagic shock) can quickly occur.

Causes

The spleen is in a fairly well protected position under the left costal arch. In order for the organ to tear, massive force is required, for example due to a car accident or a fall from the bicycle, in which the handlebar or another object is rammed into the left side. In most cases, such blunt abdominal injuries are the cause of a splenic rupture.

Children, in particular, whose physical development has not yet been completed are susceptible to this type of injury. In certain circumstances, medical examinations also need to clarify indications of injuries due to abuse.

In rare cases, spontaneous splenic tears occur without external influences. The reason for this type of injury are various diseases that lead to an enlargement of the spleen and an excessive tension pressure of the organ. Pfeiffer's glandular fever (infectious mononucleosis or Epstein-Barr virus) is only one example of a disease that can lead to spontaneous splenic rupture if complications arise.

Diagnosis

If there is a trauma, this fact is examined in detail according to the physical condition in the anamnesis and physical examination. The bruises, bruises or (rib) fractures typical of blunt injuries in the left upper abdomen may be visible on the outside.

When the abdomen is tapped, there is a so-called flank damping on the left, which is caused by the blood that has leaked into the abdominal cavity and has clotted there (Ballance sign). Typical pressure pains can also be triggered in those affected.

If a splenic rupture is suspected or internal injuries must be excluded, imaging methods such as ultrasound or computed tomography (CT) with contrast medium are advised. In acute emergencies, a quick abdominal ultrasound method (FAST sonography) is sufficient to detect free fluid in the abdominal cavity and thus immediately initiate further therapy. Under certain circumstances, close-meshed ultrasound check-ups are advised. CT images can provide more precise information, but they can only be created if those affected are in a stable state.

If there is only a very slight splenic tear, a blood test may also be carried out in addition to the imaging diagnostics to reveal possible internal bleeding and its extent via certain blood values. Declining values ​​for hematocrit and hemoglobin are characteristic, while at the same time leukocytosis is evident.

Treatment

Until the 1980s, surgical removal of the spleen was the standard procedure for rupture of the spleen. Over the years, however, advanced treatment methods have been developed that often prevent surgical intervention or enable organ preservation. The severity primarily determines the type of therapy, but especially in children and adolescents non-operative measures and preservation of the spleen are aimed for. Affected people who are unstable and cannot be stabilized even after blood substitution, must be operated on in any case.

Conservative therapy

In conservative therapy, intensive care with bed rest and possibly blood transfusions are the most important medical measures up to severity III (AAST). If this is unsuccessful, selective angioembolization can sometimes be preferred to surgery. However, this usually only affects adults. Splenic blood vessels are artificially closed to stop the internal bleeding, but to maintain the spleen and its function.

Surgery

If surgery cannot be avoided, complete removal of the spleen (splenectomy) is the last option. This is done primarily in the most serious cases. Before this, attempts are usually made to preserve the organ or at least parts of it. Surgical procedures that are used here are direct reconstructions of the spleen, for example by sewing, gluing or packing the spleen into an absorbable network (splenorrhaphy). If this is not possible, a partial resection can promise success if enough intact spleen tissue can still be obtained. In some cases, procedures are used that leave very little residual tissue in the body and exploit the possibility of renewable tissue and the preservation of sufficient organ function.

As with any surgery, complications are possible. And even if the spleen is not a vital organ, it takes on important functions in the immune system. After complete removal or in the event of inability to function (asplenia), there is an increased risk of infection among those affected.

There is a great risk here from so-called postsplenectomy sepsis (overwhelming postsplenectomy syndrome, in short: OPSI), which occurs particularly in children. Infection becomes increasingly evident within the first three years after the procedure. The main pathogens of dangerous sepsis include pneumococci and Haemophilus influenzae. Vaccination against Haemophilus influenzae-B (HIB), meningococcal and pneumococcal is therefore absolutely necessary within the first two to four weeks after the operation. Maintaining vaccination protection is particularly important for people without a functioning spleen. Long-term antibiotic prophylaxis is often recommended for children.

Since the spleen is also involved in the breakdown of platelets (platelets) in a healthy state, the number of platelets after splenectomy can initially increase and the risk of thrombosis increase. The administration of blood-thinning substances such as acetylsalicylic acid or heparin can counteract this risk.

With regard to the diverse functions and possible diseases of the spleen, naturopathy offers various useful and effective supplements to conventional therapies. In any case, a splenic tear requires quick conventional medical and special surgical treatment. (tf, cs)

Author and source information

This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.

Dr. rer. nat. Corinna Schultheis

Swell:

  • Pschyrembel: Clinical dictionary. 267th, revised edition, De Gruyter, 2017
  • Herold, Gerd and co-workers: internal medicine. Self-published by Gerd Herold, 2019
  • German Society for Pediatric Surgery (ed.): S1 guideline for traumatic splenic rupture in childhood, as of February 2015, AWMF registry number. 006/112, awmf.org
  • German Society for Trauma Surgery (ed.): The S3 guideline for polytrauma / treatment of seriously injured persons, as of July 2016, AWMF register no. 012/019, traumanetzwerk-dgu.de
  • Weitzel, Carolin et al .: Therapeutic procedure for blunt spleen injury, in: surgical practice, edition 84/2 (2018), mgo-fachverlage.de - Medizinportal
  • Müller, Thomas S. and Sommer, Christoph: The traumatic splenic rupture, in: Therapeutische Umschau, Issue 70/3 (2013), Hogrefe - Therapeutische Umschau

ICD codes for this disease: D73.5, S36.0ICD codes are internationally valid encodings for medical diagnoses. You can find yourself e.g. in doctor's letters or on disability certificates.


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