Discussion Author: Joel McFarland
Spleen injuries typically occur in the setting of blunt trauma, with clinical findings of hemodynamic instability, left flank pain, and an expanding left upper quadrant mass. Predisposing conditions include mononucleosis and lymphoma. Currently, conservative therapy is favored to preserve immune function and avoid post-splenectomy sepsis and pneumococcal infections, as well as to reduce the number of nontherapeutic laparotomies and laparotomy complications. Persistent hemodynamic instability typically requires resection, and surgery has been advocated to avoid missing other intraabdominal injuries.
CT findings include subcapsular hematomas deforming the spleen margin, hypodense fracture planes, and regions of nonenhancing parenchyma, which indicate devascularization. Intravenous contrast is important to help determine the severity, and an intraparenchymal blush has been associated with a greater need for surgical exploration.
Associated injuries include other sequelae of blunt trauma. Approximately 40 percent of splenic injury patients have left-sided rib fracture, and renal injury is not uncommon. Delayed splenic rupture may represent a previously missed diagnosis, and occurs several weeks following the initial event. A low threshold should be kept for reimaging in the appropriate clinical setting.
The American Association for the Surgery of Trauma grades splenic injuries from I-V, with measurements of hematoma and laceration size differentiating the various grades. Increasing grade is associated with higher percentages of patients requiring surgery, but even grade IV injuries are frequently managed conservatively if the patient is hemodynamically stable.
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