1. Dr. Raheel Anis

2. INTRODUCTION Spleen is one of the most commonly injured intra-abdominalorgans In up to 60 percent of patients, the spleen is the only organinjured Diagnosis and prompt management of potentially life-threatening hemorrhage is the primary goal Any attempt to salvage the spleen is abandoned in the face ofongoing hemorrhage or other life-threatening injuries Emergent and urgent splenectomy remains a life-savingmeasure for many patients 3. Anatomy 4. Anatomy Spleen lies in posterior portion of left upper quadrant, deep to9, 10 and 11 ribs Convex surface lies under lt hemidiaphargm Concavities on medial side due to impression by neighbouringstructures Average length 7-11cm Weight 150 grams (70-250) Tail of pancreas lies incontact with spleen in 30% and within 1cmin 70% 5. SituatedPosteriorlyleftupperabdomen Covered by peritoneum except at thehilum Posterior and lateral surface relatedto left hemidiaphragm posterolateral lower ribsand Lateral surface attached throughsplenophrenic ligament 6. Posteriorlyrelated to left iliopsoas muscle & left adrenal glands Posterior medial surface relatedto body & tail of pancreas Anteriomedially related to greatcurvature of stomach 7. Inferiorlyrelated to distal transverse colon & splenic flexure Lower pole attached to colonthrough splenicocolic ligament Theseattachments require devision during mobilisation 8. ARTERIAL SUPPLY Receives blood supply from celiac axis 1.Spleenic artery2.Short gastric vessels that connect left gastroepiploic artery. & splenic circulation along greater curvature of stomach 9. VENOUS DRAINAGE Through splenic vein Joins superior mesenteric vein to form portal vein 10. PHYSIOLOGIC FUNCTIONS A. Filtering splenic blood flow 350 ml/day 1. Removal of abnormal red blood cells approximately 20 ml of aged RBC are removed daily 2.Removal of abnormal WBC , Plateletes B. Immunologic Function1. Opsonin production 2. Antibody synthesis (IgM) 3. Protection from infection C. Storage Function1. Plateletes 1/3 are stored in the spleen 2. In splenomegaly, up to 80% of the plateletes may be stored in the spleen thrombocytopenia 11. MECHANISM OF INJURY Splenic injury most commonly occurs following blunt traumadue to motor vehicle collisions Penetrating splenic trauma is less common than blunt injury Iatrogenic traumatic injuries to the spleen can result fromsurgical or endoscopic manipulation colon, stomach, pancreas, Kidney primary mechanism is capsular tear, laceration from retraction devices, or tension on the spleen during manipulation of the colon 12. HISTORY AND PHYSICAL EXAMINATION History of trauma, Left-upper quadrant, left rib cage, or left flank Negative history does not reliably exclude splenic injury Penetrating object can injure the spleen even if the entrancewound is not in proximity to the spleen 13. SIGN & SYMPTOMS Complain of left upper abdominal, left chest wall, or leftshoulder pain (ie, Kehr's sign). (Kehr's sign) is pain referred to the left shoulder that worsenswith inspiration and is due to irritation of the phrenic nerve from blood adjacent to the left hemidiaphragm Abdominal tenderness and peritoneal signs Abdominal wall contusion or hematoma (eg, seat belt sign), Associated injuries With blunt abdominal trauma, lower rib fractures, pelvic fracture, andspinal cord injury may also be present 14. ON EXAMINATION Vitals are most important r/o left lower rib tenderness 14% patients with left lower rib tenderness have splenic injury In children plasticity of chest will have splenic injury without rib # Ecchymoses or abration over LUQ 15. Diagnostic evaluation Focused assessment with sonography in trauma (FASTexam), FAST exam is more useful in hemodynamically unstable patients Computerized tomography (CT scan). Diagnostic peritoneal aspiration/lavage (DPA/DPL) is less common 16. SPECIFIC DIAGNOSTIC FINDINGS FAST findings oSigns of splenic injury observed with FAST examination include a finding of hypoechoic (ie, black) rim of subcapsular fluid or intraperitoneal fluid usually found around the spleen or in Morrisons pouch (hepatorenal space). 17. CT findings In non-injured patients CT scan is typically performed with both oral (PO) and intravenous (IV) contrastFor obvious reasons, non-intravenous contrast CT scan cannot establish the presence of active bleeding (ie, contrast blush, active extravasation). 18. CT scan findings that indicate splenic injury include Hemoperitoneum Localized fluid collections around the spleen(especially those with an elevated Hounsfield unit measurement) are highly suggestive of hemoperitoneum. Briskly bleeding splenic lacerations may establish blood density fluid throughout the abdomen. Hypodensity Hypodense regions represent areas of parenchymal disruption, intraparenchymal hematoma or subcapsular hematoma. Contrast blush or extravasation Contrast blush describes hyperdense areas within the splenic parenchyma that represent traumatic disruption or pseudoaneurysm of the splenic vasculature. Active extravasation of contrast implies ongoing bleeding and the need for urgent intervention 19. SPLENIC INJURY WITH EXTRAVASATION OF CONTRAST 20. MINOR BLUNT SPLENIC INJURY 21. MODERATELY SEVERE BLUNT SPLENIC INJURY 22. OTHER IMAGINGS Plain films, organ-based ultrasound imaging, and magnetic resonanceimaging (MRI) are of limited value in the acute diagnosis of splenic injury Plain films are generally nonspecific but may demonstrate rib fracture, or medial displacement of the gastric air bubble (ie, Balance sign) raising suspicion for a splenic injury. MRI and organ-based ultrasound examination may be time-consuming to perform, and may put the patient in a location of the hospital remote from ready access and intervention. However, MRI may be applicable in a subset of hemodynamically stable patients who cannot undergo CT scan (eg, allergic to IV contrast) 23. SPLENIC INJURY GRADING The AAST criteria for hematoma and laceration for each splenic injury grade are as followsGrade I Hematoma: subcapsular, 5 cm or expanding. Laceration: >3 cm in depth or involving a trabecular vessel. Grade IV Laceration involving segmental or hilar vessels with major devascularization (ie, >25 percent of spleen) Grade V Hematoma: shattered spleen. Laceration: hilar vascular injury which devascularizes spleen. 24. MANAGEMENT APPROACH Splenic injury can be initially managed with.. Observation Angiographic embolization Surgery depending upon the hemodynamic status Grade of splenic injury Presence of other injuries and medical comorbidities. 25. HEMODYNAMICALLY UNSTABLE Based upon ATLS principles, the hemodynamically unstable trauma patient with a positiveFAST scan or DPA/DPL requires emergent abdominal exploration to determine the source of intraperitoneal hemorrhage 26. HEMODYNAMICALLY STABLE Hemodynamically stable patients with low-grade (I to III) blunt or penetrating splenic injurieswithout any evidence for other intra-abdominal injuries, active contrast extravasation, or a blush on CT, may beinitially observed safely. 27. CT scan findings of contrast extravasation or vascular blushhave higher failure rates for observational management Patients may benefit from initial splenic embolizationfollowed by continued observation Another indication for embolization is intraparenchymalpseudoaneurysm formation Splenic embolization is controversial for higher grade (IV, V)injuries and in patients older than 55 28. NONOPERATIVE MANAGEMENT Nonoperative management, encompassing bothobservation and embolization techniques, is used to manage 50 to 70 percent of cases Typically for patients with lower grade injuries 29. Rationale for nonoperative management is basedupon the assumption that salvaging functional splenic tissue avoids the surgical and anesthetic risks and complications associated with laparotomy and abrogates the risk of postsplenectomy sepsis. 30. CONTRAINDICATIONS TO NONOPERATIVE MANAGEMENT Nonoperative management is not appropriate in patients with Hemodynamic instability, Generalized peritonitis, Other intra-abdominal injuries requiring surgical exploration Portal hypertension is a relative contraindication Higher-grade splenic injury (>Grade III), J 31. RELATIVE CONTRAINDICATIONS Portal hypertension Higher-grade splenic injury (>Grade III), Active contrast extravasation Large volume hemoperitoneum (though difficult to accuratelyquantify), Refusal of blood transfusion Altered neurologic status precluding adequate serial abdominalexamination 32. The optimal management of hemodynamically stablepatients with higher-grade (IV, V) injuries remains controversial Though grade V injuries are generally unsuitable forembolization due to vascular disruption Grade IV injuries to be a relative contraindicationto splenic embolization 33. ONE SMALL RETROSPECTIVE REVIEW 60 percent of patients with higher grade injuries weretaken directly to the operating room remaining patients were managed nonoperatively with 55percent of these patients ultimately requiring surgery prefer to initially manage hemodynamically stable patientswith Grade III or IV splenic injury with angiographic embolization as part of their nonoperative management, provided that they do not have large volume hemoperitoneum or other injuries that require abdominal exploration or medical comorbidities providing a contraindication. 34. Embolization is also relatively contraindicated inpatients older than 55 due to higher failure rates in these patients Retrospectivereviews suggest, however, that carefully selected individuals over 55 who are hemodynamically stable, and have no significant medical comorbidities, can also be safely managed with observation, with or without embolization 35. OBSERVATION Successfulobservation during non-operative management for splenic trauma depends upon Proper patient selection Availability of adequate resources Closely monitored by nursing and medical staff 36. Initially place the patient on bed rest, Serial hemoglobin levels every six hours in the first24 hours. NPO for at least the first 24 hours. When the hemoglobin level is stable and operativeintervention unlikely, the patient may eat. 37. Do not routinely perform repeat CT imaging during thecourse of hospitalization Follow-up study is performed for patients whose clinicalsituation (ie, falling hemoglobin, increasing abdominal pain, left shoulder pain, fever) indicates a need. With higher grade injuries (III to V), a repeat scanwithin 24 to 48 hours may be needed if the clinical situation is unclear 38. Duration of observation should be individualized based upon the grade of splenic injury, nature severity of other injuries patient's clinical status higher-grade injury generally required longer observation periods duration of observation following splenic injury is that thenumber of days of observation is equal to the injury grade plus one 39. One multicenter trial found that 86percent of patients who failed nonoperative management did so within 96 hours of hospital admission, with 61 percent of failures occurring during the first 24hours 40. FAILURE OF OBSERVATION require either splenic embolization, or more commonly, operative management "delayed splenic rupture". more accurately describes those patients with splenic parenchymal pseudoaneurysms hemodynamic instability the development of diffuse peritoneal signs decreasing hemoglobin attributed to splenic hemorrhage. Hypotension may be absolute or relative, or evidenced as persistent tachycardia in spite of adequate fluid resuscitation. 41. SPLENIC EMBOLIZATION Requires specialized imaging facilities and a vascular interventionalist Potentially most useful when employed selectively in hemodynamically stable patients who have CT findings that include active contrast extravasation, splenic pseudoaneurysm, or large volume hemoperitoneum Retrospective reviews have found variable success rates (57 to 93 percent) for splenic salvage that includes embolization in patients with higher-grade (III, IV, V) splenic injuries Retrospective studies have demonstrated that nonoperative management is more successful with the adjunctive use of angio-embolization 42. FOLLOW-UP CARE Resumption of normal activities restricted from participation in high-risk activities up tothree months retrospectivereview, healing was demonstrated radiographically within two months of injury in 80 percent of patients; however, grade V injuries were excluded in this Imaging studies not routinely perform repeat CT imaging 43. OPERATIVE MANAGEMENT Splenic salvage or splenectomy sustaining abdominal trauma who are hemodynamicallyunstable not candidates for nonoperative management those who fail nonoperative management strategiesrequire 44. SUMMARY AND RECOMMENDATIONS Splenic injury can result from either blunt or penetrating chest or abdominal trauma; blunt mechanisms are more common Splenic injury can also be due to iatrogenic injury Perform initial resuscitation, diagnostic evaluation, and management of the trauma patient based upon protocols from the Advanced Trauma Life Support A suspicion for splenic injury is increased with left upper quadrant and/or left chest trauma 45. clinical history and physical examination are not sufficiently sensitive or specific for the presence of splenic injury Findings indicative of splenic injury on focused assessment with sonography for trauma (FAST) CT scan) findings consistent with splenic injury hypodensity, intraparenchymal or subcapsular hematoma, intravenous contrast blush, active intravenous contrast extravasation or hemoperitoneum 46. Hemodynamically stable patients with low grade (I to III) injuries, we suggest nonoperative management over definitive surgical intervention Failure of nonoperative management indicates a need for angiographic embolization, if not initially used, or surgical exploration 47. For patients who develop hemodynamic instability during the course of nonoperative management, we suggest surgical exploration over splenic embolizationAsplenic patients are regarded as having impaired immunity to encapsulated organisms and should be immunized against encapsulated organisms 48. THANK YOU