INTRODUCTION Primary goals: control hemorrohage Secondary goal: preservation of functional splenic tissue (usually done conservatively or operative

e salvage techniques). Treatment: life saving treatment may include a splenectomy SPLENIC ANATOMY AND PHYSIOLOGY (See "Surgical management of splenic injury in the adult trauma patient" section on !"natomy of the spleen!.) .) MECHANISM OF INJURY #ore li$ely to %e due to %lunt injury penetrating injury more li$ely to %e in the liver& 'atrogenic: colon stomach pancreas spleen reconstruciton of pro(imal a%do aorta )apsular tear *aceration from retrat devices Tension on spleen during manipulation of colon (ris$ greates +hen pt under going oclon resection) ,- of splenic injury during colorectal surgery . transverse colectomy most common for pslenic injury. The spleen and liver are the most commonly injured intra.a%dominal organs follo+ing %lunt trauma. 'n up to /0 percent of patients the spleen is the only organ injured 123. Specific elements of the history physical e(amination and diagnostic evaluation pertaining to splenic injury are presented %elo+. History and physi a! "#a$ination 4(: trauma to the left.upper quadrant left ri% cage or left flan$ should increase the suspicion for splenic injury. 4o+ever a negative history does not relia%ly e(clude splenic injury. " penetrating o%ject can injure the spleen even if the entrance +ound is not in pro(imity to the spleen. The patient may complain of follo+ing pains: left upper a%dominal left chest +all or left shoulder pain (ie 5ehr!s sign). 5ehr!s sign is pain referred to the left shoulder that +orsens +ith inspiration and is due to irritation of the phrenic nerve from %lood adjacent to the left hemidiaphragm. #ost common o6e: a%dominal tendenress peritoneal signs (%ut not sensitive) #ore sensitve signs: *78 or general a%do tenderness a%dominal +all contusion hematoma (seat %elt sign) left lo+er chest +all tenderness contusion 'nvestigations: 9"ST e(am (%eter in hemodynamically unsta%le patients %ut not sensitive high false negative rate for intraparenchymal inury): )T scan (usually oral contrast not needed %ut iv contrast still useufl non contrast ct useful if pt has contrast issues ) : #;' useless FAST %indin&s Signs of splenic injury o%served +ith 9"ST e(amination include a finding of hypoechoic (ie %lac$) rim of su%capsular fluid or intraperitoneal fluid usually found around the spleen or in #orrison<s pouch (hepatorenal space). CT %indin&s 'n non.injured patients )T scan is typically performed +ith %oth oral (P=) and intravenous ('>) contrast. ?eed to diffrentiate %et+een ascities and %lood @ 4=7?S9'A*B 7?'T S)"*A @ linear attenuation coeifficent of materal realtive to +ater. )T scan findings that indicate splenic injury include: 4emoperitoneum C *ocaliDed fluid collections around the spleen (especially those +ith an elevated 4ounsfield unit measurement) are highly suggestive of hemoperitoneum. Eris$ly %leeding splenic lacerations may esta%lish %lood density fluid throughout the a%domen. 4ypodensity C 4ypodense regions represent areas of parenchymal disruption intraparenchymal hematoma or su%capsular hematoma. )ontrast %lush or e(travasation C )ontrast %lush descri%es hyperdense areas +ithin the splenic parenchyma that represent traumatic disruption or pseudoaneurysm of the splenic vasculature.

"ctive e(travasation of contrast implies ongoing %leeding and the need for urgent intervention 1,0 ,,3. (See !#anagement approach! %elo+.) Oth"r i$a&in& Plain films organ.%ased ultrasound imaging and magnetic resonance imaging (#;') are of limited value in the acute diagnosis of splenic injury. Plain films are generally nonspecific %ut may demonstrate ri% fracture or medial displacement of the gastric air %u%%le (ie Ealance sign) raising suspicion for a splenic injury. #;' and organ.%ased ultrasound e(amination may %e time.consuming to perform and may put the patient in a location of the hospital remote from ready access and intervention. 4o+ever #;' may %e applica%le in a su%set of hemodynamically sta%le patients +ho cannot undergo )T scan (eg allergic to '> contrast) 1,F3. ?oncontrast )T remains prefera%le for the acute diagnosis of splenic injury due to speed and accessi%ility. SPLENIC INJURY GRADING Grading relates to success of nonoperative management %ut not consitent predict need for initial operaitve interevniton The ""ST criteria for hematoma and laceration for each splenic injury grade are as follo+s 1,H3: Grade ' 4ematoma: su%capsular I,0 percent of surface area. *aceration: capsular tear I, cm in depth into the parenchyma (picture ,). Grade '' 4ematoma: su%capsular ,0 to J0 percent of surface area. *aceration: capsular tear , to H cm in depth %ut not involving a tra%ecular vessel. Grade ''' 4ematoma: su%capsular KJ0 percent of surface area =; e(panding ruptured su%capsular or parenchymal hematoma =; intraparenchymal hematoma KJ cm or e(panding. *aceration: KH cm in depth or in'o!'in& a tra(" )!ar '"ss"!* Grade '> *aceration involving s"&$"nta! or hi!ar '"ss"!s +ith $a,or d"'as )!ari-ation (ie KFJ percent of spleen) (picture F). Grade > 4ematoma: shattered spleen. *aceration: hilar vascular injury +hich devasculariDes spleen. The ""ST )T grade is not al+ays concordant +ith the grade of injury identified in the operating room due to technical issues and varia%ility of )T scan interpretation 1,L ,J3. " modified )T grading system has %een proposed that may %etter identify those patients +ho +ould %enefit from initial angiographic em%oliDation 1,M3. MANAGEMENT APPROACH (options: o%serviation angiographic em%oliDation surgery) . 4emodynamically unsta%le positive fast @ =T 1F0 F,3. (See !Trauma evaluation! a%ove.) 4emodynamically sta%le 4emodynamically sta%le patients +ith lo+.grade (' to ''') %lunt or penetrating splenic injuries +ithout any evidence for other intra.a%dominal injuries active contrast e(travasation or a %lush on )T may %e initially o%served safely. 'n general patients +ho meet the criteria for o%servation %ut +ho require intervention to manage e(tra.a%dominal injuries (eg leg fracture sta%iliDation) can also %e safely o%served. (See!=%servation! %elo+.) )T scan findings of contrast e(travasation or vascular %lush have higher failure rates for o%servational management 1,,3. These patients may %enefit from initial splenic em%oliDation follo+ed %y continued o%servation to verify the success of the intervention. "nother indication for em%oliDation is intraparenchymal pseudoaneurysm formation. Splenic em%oliDation is controversial for higher grade ('> >) injuries and in patients older than JJ. (See !Splenic em%oliDation! %elo+.) Surgery is indicated in patients +ho cannot %e adequately o%served (due to limited resources or other injuries) are unli$ely to tolerate a significant episode of hypotension and those +ho fail nonsurgical management (ie o%servation em%oliDation). (See !9ailure of nonoperative management! %elo+ and !=perative management! %elo+.) NONOPERATI.E MANAGEMENT
1. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined.

The rationale for nonoperative management is %ased upon the assumption that salvaging functional splenic tissue avoids the surgical and anesthetic ris$s and complications associated +ith laparotomy and a%rogates the ris$ of postsplenectomy sepsis. 4o+ever immune competence after injury that does not require removal of the spleen (eg em%oliDation partial splenectomy/ d"p"nds on th" i$$)no!o&i %)n tiona!ity o% th" r"sid)a! sp!"ni tiss)" and do"s not app"ar to (" &rad" sp" i%i *

Contraindi ations to nonop"rati'" $ana&"$"nt a) hd insta%ility %)generalised perotinitis c)other intra%dominal injuries R"!ati'" ontraindiations: a) portal hypertension due to increased venous pressures that may clot formation and control of hemorrhage even after successful spleni emo%ilisation %) Kgrade ''' c) active contrast e(travasation d) large volume hemopertioneum (difficult to quantify accurate) Grades of trauma @ high grade .K high failure rate. Eut grades can %e unpredicta%le. 7sually grade J unsuita%le for em%olisation due to vascualr disruption. Amo%ilisation relative contraindicaiton: a) agKJJ due to failure rate (due to thinning of spenic capsule) %ut ne+est studies sho+ that those +ho are over JJ +ho are hd sta%le and are other+ise healthy can %e safetly managed +ith o%servation +ith or +ihtout emo%ilsation O(s"r'ation Ne initially place the patient on %ed rest though no clear %enefit e(ists for this practice. Ne o%tain serial hemoglo%in levels every si( hours in the first FL hours. Patients are not given a diet (ie nil per os 1?P=3) for at least the first FL hours. Nhen the hemoglo%in level is sta%le and operative intervention unli$ely the patient may eat. 9or patients %eing o%served +e do not routinely perform repeat )T imaging during the course of hospitaliDation. 9ollo+.up study is performed for patients +hose clinical situation (ie falling hemoglo%in increasing a%dominal pain left shoulder pain fever) indicates a need. 'n some patients +ith higher grade injuries (''' to >) a repeat scan +ithin FL to LO hours may %e needed if the clinical situation is unclear such as in the setting of evolving neurologic injury +hen the physical e(amination may %e sequentially less relia%le than upon admission. " common %ut not evidence.%ased practice regarding the duration of o%servation follo+ing splenic injury is that the n)$("r o% days o% o(s"r'ation is "0)a! to th" in,)ry &rad" p!)s on" 1 H/3. "n o%servation period of %i'" days identifies at least MJ percent of patients +ho +ould require some form of intervention 1H2 HO3. =ne multicenter trial found that O/ percent of patients +ho failed nonoperative management did so +ithin M/ hours of hospital admission +ith /, percent of failures occurring during the first FL hours 1F23. Patients +ith higher.grade injuries may require more prolonged periods of o%servation. (See !9ailure of o%servation! %elo+.) Fai!)r" o% o(s"r'ation Patients +ho fail o%servation require either splenic em%oliDation or more commonly operative management. Patients may fail o%servational management either as an inpatient or more rarely as an o)tpati"nt pr"s"ntin& +ith 2d"!ay"d sp!"ni r)pt)r"". It is !i3"!y that 2d"!ay"d r)pt)r"2 $or" a )rat"!y d"s ri("s thos" pati"nts +ith sp!"ni par"n hy$a! ps")doan")rys$s the +alls of +hich degrade during the normal process of clot dissolution +ith %leeding in a delayed fashion. 'ndications to pursue intervention include hemodynamic insta%ility the development of diffuse peritoneal signs or decreasing hemoglo%in attri%uted to splenic hemorrhage. 4ypotension may %e a%solute or relative or evidenced as persistent tachycardia in spite of adequate fluid resuscitation. The clinical manifestations of hypovolemia due to %lood loss are discussed in detail separately. (See "Shoc$ in adults: Types presentation and diagnostic approach" section on !)linical presentation!.) Nhen o%serving the patient +ith splenic injury there is no consensus +ith respect to level of hemoglo%in change in hemoglo%in or transfusion volume that prompts a need for intervention. Some surgeons intervene prior to the need for any transfusion as a means of avoiding allogeneic e(posure +hile others ma$e provisions for one to t+o units of P;E) prior to further intervention. Sp!"ni "$(o!i-ation ;etrospective revie+s have found varia%le success rates (J2 to MH percent) for splenic salvage that includes em%oliDation in patients +ith higher.grade (''' '> >) splenic injuries 1,0 F/ HM L,.LL3. " num%er of small retrospective studies have demonstrated that nonoperative management is more successful +ith the adjunctive use of angio.em%oliDation 1,0 LJ.LO3. 'n one study of HM patients splenic artery em%oliDation increased the success rate for nonsurgical management from 2L to OM percent 1L/3. 'n a cohort analysis FFF patients +ith %lunt splenic injury treated %et+een ,MM, and ,MMO +ere compared +ith L0O patients treated %et+een ,MMO and F00J 1L23. The frequency of nonoperative management (/,

versus OJ percent respectively) injury severity scale (F, versus F2 respectively) frequency of splenic artery em%oliDation (H versus FH percent respectively) and success of nonoperative management (22 versus M/ percent respectively) all increased significantly %et+een the earlier and later cohort. 4ospital mortality rates (,F versus / percent) and mean hospital length (,J versus M days) decreased significantly. The technique of splenic em%oliDation involves first gaining percutaneous access to the a%dominal aorta via the %rachial or femoral artery. The celiac a(is is cannulated and a celiac arteriogram is performed to confirm the )T findings and evaluate the splenic vasculature. Th" pr"s"n " o% ontrast "#tra'asation %ro$ th" sp!"ni par"n hy$a s)pp!i"d (y th" short &astri '"ss"!s on "!ia art"rio&ra$ sho)!d pro$pt op"rati'" int"r'"ntion4 as th"s" in,)ri"s ar" !"ss a$"na(!" to "$(o!i-ation d)" to th" t" hni a! di%%i )!ti"s in a "ssin& th" short &astri '"ss"!s* Splenic artery em%oliDation may not completely interrupt %lood flo+ from short gastric vessels due to their collateral flo+ from the left gastric and gastroepiploic arteries. =ngoing %leeding from these vessels may not %e o%vious +ith selective splenic artery angiogram and thus selective celiac arteriography should %e performed. 5"n"%its and ris3s o% nonop"rati'" $ana&"$"nt . "n additional %enefit of successful nonoperative management is the preservation of functional splenic tissue. Bisadvantages of nonoperative management include an increased ris$ of missed in,)ry4 parti )!ar!y ho!!o+ 'is )s in,)ry4 a ris3 o% d"!ay"d (!""din&4 trans%)sion6r"!at"d i!!n"ss4 and4 +h"n )s"d4 th" additiona! ris3s asso iat"d +ith "$(o!i-ation t" hni0)"s* Patients +ith missed hollo+ viscus injury present +ith +orsened a%dominal pain and the development of peritoneal signs generally %y postinjury day four. These patients require operative intervention and should undergo concomitant definitive management of their splenic injury if indicated. (See "Traumatic gastrointestinal injury in the adult patient".) Elood transfusion is associated +ith complications that can include intravascular volume overload (Transfusion "ssociated )irculatory =verload 1T")=3) transfusion.related acute lung injury (T;"*') hypothermia coagulopathy immunologic and allergic reactions as +ell as immunomodulation (Transfusion ;elated 'mmune #odulation T;'#). Some clinicians feel these ris$s do not justify nonoperative management strategies given an uncertain %enefit. The ris$s associated +ith %lood transfusion are discussed in detail else+here. (See "7se of %lood products in the critically ill" section on !)omplications! and "Transfusion reactions caused %y chemical and physical agents" section on !Transfusional volume overload (T")=)! and "Transfusion.related acute lung injury (T;"*')" and "*eu$oreduction to prevent complications of %lood transfusion" section on !'mmunosuppression!.) Splenic em%oliDation is associated +ith additional ris$s that include %leeding pseudoaneurysm formation at the arterial puncture site splenic infarction splenic6su%diaphragmatic a%scess inadvertent em%oliDation of other organs (eg $idneys) or lo+er e(tremities allergic reaction to contrast and contrast.induced nephropathy. The ris$ of contrast.induced nephropathy may %e greater +hen em%oliDation is performed follo+ing contrast )T scan especially in patients +ho may already %e 'o!)$" d"p!"t"d Fai!)r" o% nonop"rati'" $ana&"$"nt 9ailure of nonoperative management (o%servation and6or em%oliDation) is defined as the need for operative intervention and is generally associated +ith ongoing %leeding as indicated %y the need for ongoing volume e(pansion or transfusion or hemodynamic insta%ility. 4ypotension may %e a%solute or relative or evidenced as persistent tachycardia despite adequate fluid resuscitation. The clinical manifestations of hypovolemia due to %lood loss are discussed in detail separately. (See "Shoc$ in adults: Types presentation and diagnostic approach" section on !)linical presentation!.) 9ailure rates for o%servational management range from / to F0 percent and depend upon age injury severity score grade of splenic injury frequency +ith +hich em%oliDation techniques are employed and most importantly the appropriateness of patient selection for nonoperative management 1FJ F2 FO J,3. 'n retrospective studies up to L0 percent of patients failing nonoperative management +ere found to have inappropriate indications for a nonoperative approach 1FJ JF JH3. ;e%leeding and6or secondary splenic "rupture" follo+ing "successful" nonoperative management is a rare %ut potentially disastrous complication that cannot %e relia%ly predicted. #ore than M0 percent of

secondary splenic "ruptures" occur +ithin ,0 days follo+ing the initial traumaP most of the remainder occur +ithin t+o +ee$s 1F2 JL3. Fo!!o+6)p ar" R"s)$ption o% nor$a! a ti'iti"s 7pon discharge patients are typically restricted from participation in high.ris$ activities such as s$iing mountain %i$ing s$ydiving +restling contact sports military com%at and vigorous se(ual intercourse for a period of up to thr"" $onths* Nhile there are no clinical studies to support this duration one assumes that repeat trauma to the fragile healing spleen could lead to re.injury 1HL3. 'n one retrospective revie+ healing +as demonstrated radiographically +ithin t+o months of injury in O0 percent of patientsP ho+ever grade > injuries +ere e(cluded in this study 1JJ3. I$a&in& st)di"s Nith successful nonoperative management of splenic injury +e do not routinely perform repeat )T imaging. The Aastern "ssociation for the Surgery of Trauma (A"ST) guidelines do not support routine follo+.up imaging. 'n one survey of A"ST mem%ers OJ percent of respondents did not routinely re.image 1HL3. The delayed presentation of splenic pseudoaneurysms have %een reported and may support a decision to re.image 1HM J/3. ;epeat )T scan or ultrasound (provided that the injury can %e adequately visualiDed) can %e considered in select patients 1J23. ;e.imaging may %e indicated to lift an activity restriction or for patients +hose +or$ requirements or lifestyles place them at higher ris$ for re.injury if healing is not complete. A(amples include professional athletes military service personnel and e(treme sports enthusiasts. ;e.imaging may also %e appropriate for those +ho are planning to travel to regions of the +orld +ith limited healthcare access to document complete healing prior to travel. 9or these patients re.imaging is typically performed at three months follo+ing the injury. OPERATI.E MANAGEMENT Patients sustaining a%dominal trauma +ho are hemodynamically unsta%le those +ho are not candidates for nonoperative management and those +ho fail nonoperative management strategies require surgical e(ploration and either splenic salvage or splenectomy. The choice of procedure depends upon the nature and severity of splenic injury clinical status of the patient and associated injuries. Surgical management of traumatic splenic injury is discussed separately. (See "Surgical management of splenic injury in the adult trauma patient".) IMMUNOCOMPETENCE AFTER SPLENIC INJURY 'mmuniDation is recommended for asplenic patients since splenectomy impairs opsoniDation of encapsulated organisms 1JO JM3. 'nformation on specific vaccines and vaccine schedules are discussed else+here. (See "Prevention of sepsis in the asplenic patient" section on !'mmuniDations!.) 9ollo+ing splenic salvage surgery splenic em%oliDation or nonoperative management +e feel that immuniDation is not necessary though some clinicians may disagree 1/H.//3. "vaila%le in vitro studies indicate immunocompetence in these patients 1/J /2.203. "s an e(ample one controlled trial evaluating red %lood cell pit counts found no differences for patients follo+ing successful nonoperatively managed high.grade injury (0./ percent) and controls (0.2 percent)P counts follo+ing splenectomy +ere F0.2 percent 12,3. 9urthermore in clinical studies of patients undergoing partial splenectomy for reasons other than trauma humoral immunity +as depressed only transiently follo+ing partial splenectomy and compared +ith total splenectomy partial splenectomy +as associated +ith less ris$ for postsplenectomy infection 12F 2H3.