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 concern about a serious intra-abdominal bleed has been postponed, late rupture can occur. Such cases should now

be rare as scanning should delineate such patients and a haematoma around a spleen should be an indication for either laparotomy or, at the minimum, close observation.

If ultrasonography cannot be performed and reliance has to be made on a plain X-ray of the abdomen it is important to ensure a high-quality soft-tissue X-ray so that 

the following signs can be elicited:

     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.