Splenic Injury

Splenic Injury (Splenic Trauma) 

Introduction

Splenic injury is the most common solid organ injury following blunt abdominal trauma. The spleen is highly vascular and receives approximately 5% of the cardiac output, making hemorrhage the major cause of morbidity and mortality.

• Blunt trauma: 80–90% (motor vehicle collisions, falls, sports injuries)
• Penetrating trauma: Stab wounds, gunshot injuries
• Mortality is usually due to associated injuries or uncontrolled hemorrhage, rather than splenic injury alone.

Anatomy

Location

• Left upper quadrant
• Protected by ribs 9–11
• Between stomach and diaphragm
• Posterolateral to stomach
• Intraperitoneal

Size

• Length: 11–13 cm
• Weight: 150–200 g

Blood Supply

Artery

Splenic artery

• Largest branch of celiac trunk
• Tortuous
• Divides into segmental arteries
• End arteries (minimal collateral circulation)

Vein

Splenic vein Joins superior mesenteric vein to drain into Portal vein

Supporting Ligaments

• Gastrosplenic ligament
• Splenorenal ligament
• Splenocolic ligament
• Phrenicosplenic ligament

Importance

Loss of spleen predisposes to infection with

• Streptococcus pneumoniae
• Haemophilus influenzae type b
• Neisseria meningitidis
• Capnocytophaga canimorsus

Clinical Features

Symptoms

• Left upper abdominal pain
• Left chest pain
• Abdominal fullness
• Dizziness
• Syncope
• Lower left rib tenderness, crepitus

Signs

• Tenderness LUQ
• Guarding
• Abdominal distension
• Hypotension
• Tachycardia
• Shock

• Kehr Sign—Left shoulder pain—Caused by Blood irritating diaphragm.worsened by inspiration
• Balance Sign—Dullness to percussion in left flank ,Due to clotted blood.

Investigations

Laboratory

• CBC
• Hemoglobin
• Serial Hb every 4–6 hours initially approximately 12–24 hours (trend is more informative than a single value)
• Coagulation profile
• Type and crossmatch
• ABG
• Lactate
• Base deficit

E-FAST

• Detects hemoperitoneum
• Splenic laceration may be indicated by an anechoic band or black rim surrounding the spleen. 
• If the splenic capsule remains intact, intraperitoneal bleeding may not be present.
• Sensitivity for free fluid increases with bleeding volume but is limited for grading splenic injury.
• Cannot reliably grade splenic injury or identify vascular lesions.

Contrast CT (Gold Standard in Stable Patients)

• Sensitivity 95%
• CT determines injury grade and guides management.

AAST Splenic Injury Scale (2018 Revision)

CT Findings Suggesting Severe Injury

• Active arterial contrast extravasation (contrast blush)
• Pseudoaneurysm
• AV fistula
• Large hemoperitoneum
• Complete devascularization

These findings predict failure of non-operative management.

Management

1. Hemodynamically Unstable Patient

Immediate priorities:

• Massive transfusion protocol when indicated
• Balanced blood product resuscitation
• Tranexamic acid if appropriate for trauma
• Damage-control resuscitation
• Urgent laparotomy

Typical operative indications:

• Persistent hemodynamic instability despite resuscitation
• Peritonitis
• Ongoing hemorrhage
• Associated abdominal injuries requiring surgery

Operative options:

• Splenectomy (most common in unstable patients)
• Splenic salvage/repair in selected cases

2. Hemodynamically Stable Patient

Non-operative management (NOM) is the standard of care for most blunt splenic injuries, including many high-grade injuries, provided close monitoring and interventional radiology are available.

Components:

• ICU or monitored setting (higher-grade injuries)
• Serial examinations
• Serial hemoglobin
• Repeat imaging when clinically indicated
• Early mobilization according to institutional protocol

Success rates:

• Low-grade injuries: >95%
• Overall blunt splenic injury: approximately 85–90% in experienced trauma centers

Splenic Artery Embolization (SAE)

Indications

• Active contrast blush on CT
• Splenic pseudoaneurysm
• Arteriovenous fistula
• Ongoing bleeding in a stable patient
• High-grade (Grade III–V) injury with vascular injury or other high-risk features
• Failure of observation without hemodynamic collapse

Non-operative Management Failure Risk factors:

• Age >55 years (relative risk factor)
• High-grade injury (Grade IV–V)
• Large hemoperitoneum
• Contrast blush
• Pseudoaneurysm
• Ongoing transfusion requirement
• Persistent tachycardia
• Falling hemoglobin despite resuscitation

ICU Monitoring

• Continuous vital signs
• Serial abdominal examination
• Hemoglobin every 4–6 hours initially

Important caveat

A fall in hemoglobin alone is not an indication for surgery or embolization. Hemoglobin may decrease because of:

• Ongoing bleeding
• Hemodilution after fluid resuscitation
• Redistribution of blood

Management decisions should be based primarily on hemodynamic status, clinical examination, transfusion requirements, and CT findings, not on hemoglobin trends alone.

• Lactate and base deficit trends
• Urine output
• Blood transfusion requirements

Repeat Imaging

Not routinely required for all low-grade injuries.

Repeat CT is generally considered for:

• Clinical deterioration
• New abdominal pain
• Falling hemoglobin
• High-grade injuries (many centers perform surveillance CT at 48–72 hours to detect delayed vascular lesions)

Complications

Early

• Hemorrhagic shock
• Rebleeding
• Delayed splenic rupture
• Splenic infarction
• Splenic abscess
• Pancreatic tail injury

Late

• Pseudocyst
• Arteriovenous fistula
• Pseudoaneurysm
• Overwhelming post-splenectomy infection (OPSI)
• Reactive thrombocytosis
• Venous thromboembolism

Delayed Splenic Rupture

Occurs days to weeks after injury due to rupture of a previously contained hematoma.

Clinical features:

• Sudden abdominal pain
• Hypotension
• Syncope
• Hemoperitoneum

Requires urgent reassessment with imaging and often intervention.

Overwhelming Post-Splenectomy Infection (OPSI)

A rapidly progressive septic syndrome with mortality approaching 40–70% despite treatment.

Common organisms:

• Streptococcus pneumoniae (most common)
• Haemophilus influenzae type b
• Neisseria meningitidis

Management:

• Immediate broad-spectrum IV antibiotics
• Aggressive sepsis resuscitation

Prevention:

• Vaccination
• Patient education
• Early medical attention for fever

Vaccination After Splenectomy

Recommended vaccines:

• Pneumococcal (PCV followed by PPSV23 according to current national schedule)
• Haemophilus influenzae type b (Hib)
• Meningococcal ACWY
• Meningococcal B
• Annual influenza vaccine

Timing:

• Elective splenectomy: ideally ≥2 weeks before surgery
• Emergency splenectomy: ≥14 days after surgery (or before discharge if follow-up is uncertain)

Antibiotic Prophylaxis After Splenectomy

Recommendations vary by guideline.

Generally advised for:

• Children
• Immunocompromised patients
• During the first 1–2 years after splenectomy
• Longer or lifelong prophylaxis in selected high-risk patients

Patients should also have access to emergency antibiotics and seek urgent evaluation for any fever.

Activity Restriction

Typical guidance:

• Grade I–II: Avoid contact sports for approximately 4–6 weeks
• Grade III–V: Restrict strenuous activity for 2–3 months (or longer based on healing and imaging)

Return to full activity should be individualized.

REFERENCES

1.World Society of Emergency Surgery

2.Oelhaf RC, Wang CF, King KC. Splenic Trauma. [Updated 2025 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430920/ 

3. Irwin Rippe 9th edition