Ruptured Spleen

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[edit] Ruptured spleen

Introduction:

Another source of left upper abdominal pain can be a splenic rupture. The most common cause of a ruptured spleen is trauma to the left lower chest wall through an automobile accident, a sports injury or a personal injury. The trauma can lead to a central hematoma, in which case the symptoms are not as obvious and more protracted.

With a direct rupture of the splenic capsule there is massive blood loss into the abdominal cavity with acute symptoms and development of shock. Here is are images of a CT scan in a young man with a splenic rupture.

Symptoms:

In the rapid course the cause of the ruptured spleen is perhaps more obvious because of the trauma that is apparent, however, with multiple injuries such as bone fractures elsewhere the splenic rupture may initially be overlooked.

There is acute left upper abdominal pain and problems taking a deep breath in as with full inspiration the diaphragm moves the spleen down somewhat, which is very painful. The blood loss can cause generalized peritonitis with a rock hard abdomen and it can cause circulatory collapse and severe anemia. This acute clinical picture can also happen in a patient with a severe course of mononucleosis (Epstein-Barr viral infection). There the spleen can swell very rapidly as a reaction to the virus and the capsule can tear much easier with relatively minor trauma.

In the situation where an inside tear lead to a hematoma within the spleen, the clinical picture is much more subtle and the patient experiences chronic low grade left upper abdominal pain. On examination the physician may feel some fullness in the splenic area and some diffuse tenderness. A CT scan shows the details of the intrasplenic hematoma.

Treatment:

As these hematomas usually do not stop there, but over time grow to a larger size and eventually rupture into the abdomen, a surgeon needs to be consulted to remove the spleen or attempt a spleen preserving surgery.

Most of the time though the splenic tissue is so fragile that the only surgical option is to remove the spleen. Following a splenectomy (=the removal of the spleen) the patient is more susceptible to certain bacterial infections such as meningococcal, Haemophilus influenza, pneumococcal, streptococcal and E. coli infections. In a child usually the pediatrician recommends prophylactic antibiotic coverage for about 3 years to prevent these infections to lead to life threatening septicemias. The other great progress in recent years is the addition of several vaccines (pneumococcal, meningococcal and Haemophilus vaccines). With all of these tools it no longer is a stigma to have the spleen removed and the long-term prognosis is good.

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Abdominal pain

References:

1. DM Thompson: The 46^th Annual St. Paul's Hospital CME Conference for Primary Physicians, Nov. 14-17, 2000, Vancouver/B.C./Canada

2. C Ritenbaugh Curr Oncol Rep 2000 May 2(3): 225-233.

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4. M Ohkawa et al. Br J Urol 1993 Dec 72(6):918-921.

5. Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc., pages 976-983: "Chapter 107 - Acute Abdomen and Common Surgical Abdominal Problems".

6. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc. , p. 185:"Abdominal pain".

7. Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier, p. 71: "Chapter 4 - Abdominal Pain, Including the Acute Abdomen".

8. Ferri: Ferri's Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.