In people who are hemodynamically stable, a CT scan is typically used to help determine the grade of injury. In the emergency trauma setting, an ultrasound scan is performed while other monitoring and management continue uninterrupted.
This scan is done according to the focused assessment with sonography for trauma FAST protocol, which forms part of the advanced trauma life support ATLS protocol developed by the American College of Surgeons. A FAST ultrasound enables clinicians to scan for fluid in four areas of the abdomen, including the space around the spleen. The doctor draws fluid from the abdominal cavity. Nowadays, this is rarely performed.
A ruptured spleen is often identified by a CT scan. In some cases, such as where a patient has kidney stones or is allergic to the contrast substance used in a CT scan, a stable individual with a suspected ruptured spleen may undergo an MRI scan. This can also show problems with the soft tissues of the body. Splenic injury is classified by severity, taking into account the level of laceration, injury to the veins and arteries, and clotting.
The American Association for the Surgery of Trauma grading system for spleen injury is as follows:. The grading of a ruptured spleen helps doctors determine whether surgical or non-operative management is indicated for treatment.
Gaucher's disease is a inherited disease that results in a build up of lipids. Symptoms and outlook vary widely. It normally affects the spleen first. An aneurysm is a weakening and bulging of an artery wall. Many have no symptoms and are not dangerous. However, at their most severe, aneurysms can…. Whiplash is a series of neck injuries that occur as a result of the sudden distortion of the neck, often due to being struck from behind in an…. In this article, we discuss the spleen. We will explain what the spleen does, the types of cells involved, and what happens when it goes wrong.
What are the different types of bleeding, and how can a person treat them? Read on to learn more. Everything you need to know about ruptured spleen. Medically reviewed by Andrew Gonzalez, M. Symptoms Treatment Recovery Complications Causes Diagnosis Stages The spleen is an organ located in the left-upper quarter of the abdomen, beneath the ribs. Injuries can be relatively mild or very severe. Doctors often classify The tears range from small ones that stop bleeding spontaneously to very large ones that cause potentially fatal bleeding.
Sometimes a collection of blood hematoma forms under the covering of the spleen or deep within it. The spleen is the most commonly injured organ in the abdomen as a result of motor vehicle crashes, falls from a height, athletic mishaps, and beatings.
Sometimes other abdominal organs also are damaged. Enlargement of the spleen for example, due to Epstein-Barr virus causing infectious mononucleosis Infectious Mononucleosis Epstein-Barr virus causes a number of diseases, including infectious mononucleosis. The virus is spread through kissing.
Symptoms vary, but the most common are extreme fatigue, fever, sore throat When the spleen is injured, blood may be released into the abdomen. The amount of bleeding depends on the size of the injury.
A hematoma of the spleen does not bleed into the abdomen at first but may rupture and bleed in the first few days after injury, although rupture sometimes does not occur for weeks or months. An injured or ruptured spleen can make the abdomen painful and tender.
Blood in the abdomen acts as an irritant and causes pain. The pain is in the left side of the abdomen just below the rib cage. Differential WCC showed a predominant neutrophil count of Peripheral blood film revealed leucocytosis with neutrophilia with no evidence of blast cells or atypical lymphocytes. Patient was reluctant to undergo a bone marrow aspiration and trephine biopsy. Abdominal ultrasonography demonstrated a large splenic collection. There were no intra abdominal or pelvic lymph nodes enlargement.
Based on computed tomography findings, a preliminary diagnosis of spontaneous splenic rupture was made. A surgical consult was obtained and an explorative laparotomy was performed on the patient. Intra operative findings showed a ruptured spleen with extensive adhesions to the omentum.
No intra peritoneal lymph nodes enlargement were found. Splenectomy was then performed and subsequently, the patient was transferred to intensive care unit for close observation. From a histological perspective, the gross appearance of the obtained specimen revealed an enlarged spleen with irregular outer surfaces. A cut section of the spleen showed a firm, cream coloured layer occupying almost entire spleen with large area of necrosis with splenic infarcts.
There as minimal amount of normal looking parenchyma tissues at the peripheral aspect of the specimen. Further histological examination revealed a diffuse infiltration of malignant lymphoid cells, which exhibited irregular nuclear membrane with vesicular nuclear chromatin and prominent nucleoli.
The adjacent splenic parenchyma showed a congested and expanded red pulp with infiltration by atypical lymphoid cells [Fig. Thirteen days later, the patient was discharged with prophylactic meningococcal, pneumococcal and influenza vaccinations. He was referred to the haemato-oncologist outpatient clinic at a tertiary care centre for post - operative chemotherapy. Unfortunately, the patient did not turn up for subsequent follow ups, rendering it difficult to further document any information with regards to treatment response in this report.
There is a variation in symptom manifestation in patients with splenic rupture. The presence of abdominal pain in splenic rupture has been frequently reported [ 8 ]. Abdominal pain, tenderness in the epigastrium and discomfort in the left upper quadrant may be seen in patients who has experienced minor injury [ 9 ].
In larger splenic injuries, signs of hypovolemic shock was a common presentation [ 10 ]. The clinical signs of shock include tachycardia, rapid breathing, paleness, reduced capillary filling time and hypotension [ 10 ].
In the absence of trauma, clinicians should exercise a high index of suspicion to rule out other rare causes of splenic rupture.
Bassler et al. The aetiology of atraumatic splenic ruptures were listed in the decreasing order of prevalence as follows: infectious mainly malaria and infectious mononucleosis , medical procedures related mostly related to colonoscopy , haematological commonly non-Hodgkin Lymphoma and Acute Lymphoblastic Leukemia , neoplastic disease, medication related anti coagulation and thrombolytics , pregnancy-related and others.
Majority of these cases had a haematological origin NHL was reported as the cause for splenic rupture in 6. Based on this systematic review, compounded with other evidence [ 4 , 8 , 12 ], we identified only a handful of splenic rupture that can be attributed to diffuse large B-cell lymphoma [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. Other subtypes of non-Hodgkin lymphoma splenic T cell lymphoma, blastic variant Mantle cell lymphoma, Mantle cell lymphoma, anaplastic large cell lymphoma, unspecified malignant lymphoma and hepatosplenic gamma delta T cell lymphoma were reported with similar prevalence rates [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].
Cases of diffuse histiocytic lymphoma, follicular low grade lymphoma, malignant lymphomonocytic B-cell lymphoma and diffuse histiocytic lymphoma were reported infrequently [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].
In another review by P. Renzulli et al. The six major aetiological groups were classified as follows: neoplastic The review also noted that the neoplastic subgroup was significantly associated with increased mortality rates [ 12 , 34 ].
Non-traumatic splenic rupture secondary to haematological malignancies is still widely considered as an uncommon occurence [ 35 ]. Nonetheless, limited case reports advocate early recognition and intervention of this rare cause of splenic rupture [ 8 , 36 , 37 ]. In addition, several authors have attributed the low index of suspicion as a major reason for the delayed diagnosis of similar cases of spontaneous splenic rupture secondary to NHL [ 36 , 38 , 39 ].
To that effect, our case report presents rare descriptions where splenic rupture was detected as the first manifestation of a DLBCL [ 11 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 40 , 41 , 42 ]. The cancer of B lymphocytes can be fatal if left untreated [ 43 ].
Although it is thought to occur equally in all age groups, DLBCL appears to affect a predominantly middle age population [ 43 ]. Risk factors for developing DLBCL include evidence of family history of lymphoma, autoimmune disease, human immunodeficiency virus infection, hepatitis C virus seropositivity, high body mass and certain occupational exposures.
The suggested mechanism of a non-traumatic splenic rupture in lymphoma include splenic enlargement, cellular infiltration, and eventual splenic infarction with associated capsular haemorrhage [ 44 ]. Although splenic enlargement itself poses the greatest risk for non-traumatic splenic rupture, there are also other factors that could possibly explain the reasons for a splenic rupture [ 44 ]. Initial presentation with B symptoms fever, night sweats and significant weight loss accounts for one third of the cases [ 45 ].
In most patients, the prevalent clinical findings are peripheral lymphadenopathy with an enlarged spleen [ 45 ]. Patients also can present with advanced extranodal disease on admission [ 45 ].
However, the combination of rare manifestation [splenic rupture, primary liver lymphoma and the presence of the Asian variant of intravascular lymphoma AIVL ] often delays the diagnosis of the underlying malignancy [ 45 ]. The gold standard for the diagnosis diffuse large B-cell lymphoma DLBCL is dependent upon surgical excision biopsy of the lesion [ 45 , 46 ].
Additional test that help the diagnosis include immunophenotyping using immunohistochemistry or flow cytometry or a combination of both techniques [ 46 ]. At present, full contrast enhanced staging computerized tomography CT of the neck, chest, abdomen and pelvis is the modality of choice for staging such patients [ 46 ]. In addition, cases where central nervous system involvement CNS is suspected, lumbar puncture for cerebral fluid analysis is also required [ 46 ].
Recently, fluorodeoxyglucose positron emission tomography FDG-PET is strongly recommended as PET scan is more sensitive, especially for extra nodal disease and improve staging accuracy and subsequent response assessment[ 46 , 47 , 48 ].
These findings were consistent with a diffuse large B-cell lymphoma, non-Germinal centre B-cell non-GCB type [ 45 , 46 ]. Chemotherapy forms the cornerstone in the therapy of B-cell lymphoma, both as curative and palliative options. Patients often present with disseminated disease upon diagnosis, making radiation therapy of limited efficacy at this stage of the disease [ 44 , 45 , 46 ]. Chemotherapy regime such as R-CHOP rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone and R-ACVBP rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycin, prednisolone are stratified according to age, international prognostic index and feasibility of dose -intensified approaches [ 44 , 45 , 46 ].
Third, the selected subjects were mostly middle-aged and older. The study did not involve individuals of the pediatric age.
According to the results of the study, the mean age of men, who died due to acute spleen rupture, was In the study of the standard dimensions of the normal spleen in Iranian population from the Razavi Khorasan Province, the weight of the spleen varied from 1 to with mean value of The spleen dimensions were significantly higher in men than in women. The mean length of spleen in Bangladeshi people was 9. In another research, in Kumaon Region of Uttarakhand, contrary to findings in the present study, the spleen weight in females was bigger than in males In the study performed by Caglar et al.
Furthermore, in the mentioned study spleen weight significantly correlated with the height of individuals. Despite the fact that the spleen is not a vital organ, it performs several important functions. Another significant function is the removal of the aged red blood cells and platelets splenectomy is one of the possible ways of managing platelet deficiency. These cells can also be stored in the spleen. Therefore, in cases of hemorrhagic shock the spleen can shrink and emit a certain amount of blood, which compensates anemia, though partially.
Spleen can be injured under the compressive or tractive forces. Compressive injury manifests as the disruption of the organ. However, due to the spleen intraperitoneal position it can also be separated from its vascular pedicle by traction. Nevertheless, spleen more often ruptures because of an increased intra-abdominal pressure in the process of a blunt trauma, when a hit is to the region of the spleen.
Road traffic accidents, fall from height, violence hit to the region of the spleen , and sports-related injuries commonly cause spleen trauma, gunshot injuries—less frequently.
Tissue plasticity plays a significant role in the process of a blunt abdominal trauma: a kick to the thorax can leave minimal subcutaneous bruises, whereas the abdominal organs liver and spleen may be seriously damaged due to the dense structure. The common reasons of spleen enlargement: malaria, EBV infection, liver diseases, blood cancer lymphoma, leukemia , angiosarcoma, and amyloidosis.
Fractured ribs and increased intraabdominal pressure during resuscitation can cause spleen rupture. It happens in about 0. In case of a less-energy trauma e. Finally, when the capsule fails to resist the pressure under it and ruptures it induces a subacute bleeding. Consequently, the diagnostic process becomes more complicated. Children are likely to traumatize in a more specific way—falling on the bicycle handlebar while riding.
At the moment of falling, an increased intraabdominal pressure can cause spleen rupture. Acute spleen rupture prevalently happens during blunt abdominal trauma because of suddenly increased intraabdominal pressure. It suggests that external body injuries may not always be seen. However, traumatized patients usually complain about pain in the left upper part of abdomen, as well as in the region of left shoulder Kehr's symptom.
Therefore, these clinical symptoms are first to be evaluated suspecting spleen injury. Moreover, confusion, dizziness, disorientation, blurry vision, pallor, tachycardia, hypotension, and loss of consciousness are pathognomic signs denoting intensive internal bleeding and developing hemorrhagic shock.
CT is usually performed with hemodynamically stable patients and helps to detect active extravasation, visualize retroperitoneum and diaphragm injuries. Fractured ribs, bones of pelvis girdle, and vertebral column are commonly diagnosed along with spleen rupture. Two-stage spleen rupture cases are rarer than the acute, although their lethal outcome is more frequent due to the complicated diagnostics.
Indications for conservative treatment of parenchymal organs are nonsevere injury, hemodynamic stability, abdominal trauma without multiple ruptures of several organs, no anticoagulant therapy, and successfully performed angioembolization.
The mean weight of spleen in control group with no spleen rupture was Acute and subacute spleen rupture dating, and morphological evaluation of their properties are found to be important and applicable in clinical practice and forensic pathology. Traumatic spleen rupture diagnosed during postmortem dissection. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors have no conflicts of interest to disclose. National Center for Biotechnology Information , U. Journal List Medicine Baltimore v. Medicine Baltimore. Published online Oct 4. Author information Article notes Copyright and License information Disclaimer.
Ciurlionio str. Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4. The work cannot be used commercially without permission from the journal. Abstract Spleen is typically injured in blunt abdominal trauma.
Keywords: blunt trauma, forensic science, injury, intoxication, pathology, spleen rupture.
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