Rupture
of the spleen
Splenic rupture should be suspected after any
trauma, but particularly if there has been direct injury to the left upper
quadrant of the abdomen from any angle. Occasionally a fall without direct
trauma to the trunk can rupture the spleen, especially if it is diseased or
enlarged, for example in infectious mononucleosis or malaria. Advantage was
once taken of the fragility of the enlarged spleen in Far Eastern countries
where malaria is endemic. Murderers would achieve their purpose by digging a
victim beneath the left ribs with a weapon known as the ‘larang’; the
enlarged malarial spleen would rupture. A splenic injury should be suspected if
there are fractures of the overlying ribs. Iatrogenic rupture remains common and
is a reminder of the need for care when dissecting in the left upper quadrant
of the abdomen, especially if adhesions are present.
Cases
of ruptured spleen may be divided into three groups.
•
The patient succumbs rapidly from massive haemorrhage —this
type rarely occurs in the normal spleen but is a reminder that a slipped pedicle
suture can lead to rapid exsanguination.
•
Initial shock, recovery and signs
of bleeding —
the initial shock
is due to the blood loss, tamponade occurs and then further bleeding takes
place. General signs of internal haemorrhage are variable but local signs show
upper abdominal guarding and, later, local bruising and abdominal distension.
Pain referred to the left shoulder is known as Kehr’s sign. There may be
hyperaesthesia in this area. The sign can often be demonstrated 15 minutes after
elevation of the foot of the bed. It is due to blood in contact with the
undersurface of the diaphragm, the pain being mediated through afferent fibres
in the phrenic nerve. Shifting dullness may be present in the flanks and on
rectal examination fullness in the pelvis is present. The
elicitation
of these difficult signs should give way to appropriate ultrasonography or CT
scanning to determine the site from which the bleeding is occurring.
•
The delayed case —
after initial
signs have passed off and the
be
rare as scanning should delineate such patients and a
If
ultrasonography cannot be performed and reliance has
the
— obliteration
of the splenic outline;
— obliteration
of the psoas shadow;
— indentation
of the left side of the gastric air bubble;
—
fracture of one or more lower ribs of the left side;
—
elevation of the left hemidiaphragm;
— free fluid between gas-filled intestinal coils.
Treatment
of rupture of the spleen
Previously, immediate laparotomy has been the
only reliable course. With better understanding of the problems associated with
splenectomy, particularly in countries where malaria is common, splenic
preservation should be undertaken where possible. Blood is evacuated and the
spleen inspected. If by careful compression of the spleen the bleeding can be
controlled a vicryl mesh bag can be constructed and the spleen placed in the
bag which is then tightened to compress the spleen and to stop the bleeding.
This manoeuvre is invaluable in children who are most at risk from splenectomy.
Rupture
of a malarial spleen
As has been mentioned, in tropical countries
this is not an infrequent catastrophe. The delayed type of rupture (following
‘trivial’ injury) is also very common and the patient is admitted with a
perisplenic haematoma. If splenectomy can be performed before the haematoma
bursts into the general peritoneal cavity, the prognosis is less grave. Enlarged
spleens from any cause can rupture spontaneously or with mild trauma.
The
operation is considerably more difficult than in the case of a ruptured normal
spleen. Surgeons with tropical experience have surmounted these difficulties by
ligating the splenic vessels as they run along the superior border of the body
of the pancreas before disturbing the haematoma.