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Rupture of the Spleen.

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Abstract

VOL: 100, ISSUE: 17, PAGE NO: 31

 What is it?

The spleen is a spongy, soft organ. It is located in the upper left part of the abdomen and has a number of functions including: - Production of white blood cells (lymphocytes); - Filtration of waste products from the blood; - Destruction of old or damaged red blood cells (erythrocytes); - Rupture of the spleen is most commonly caused by a severe blow to the abdomen due to serious road or industrial accidents, falls from a height, contact sports, and beatings. - The spleen is supplied by a large artery, so there is a risk of severe internal bleeding in cases where the spleen is ruptured.

Signs and symptoms

- Upper left quadrant abdominal tenderness.

- Possible left shoulder tenderness due to irritation of the subdiaphragmatic nerve root.

- Guarding and abdominal rigidity. 

- Mild pallor.

- If bleeding exceeds 5-10 per cent of blood volume, clinical signs of early shock may manifest, including tachycardia, tachypnoea, restlessness, and anxiety.

- With increasing abdominal bleeding there may be abdominal distension, peritoneal signs, and overt shock.

- Symptoms of low blood pressure and lack of oxygen include light-headedness, blurred vision, confusion, and fainting - this is a surgical emergency.

Diagnosis

- An abdominal X-ray can exclude other causes.

- Unstable patients suspected of splenic injury and intra-abdominal haemorrhage should undergo exploratory laparotomy and splenic repair or removal.

- Diagnostic peritoneal lavage may be a valuable adjunct if time permits and there are multiple injuries.

- In stable patients (systolic BP>100mmHg; heart rate <120BPM) a computerised tomography scan is the ideal non-invasive means of evaluating the spleen.

- Ultrasound is useful for examining solid organs and detecting free fluid in the abdomen.

Treatment

- Fluid resuscitation.

- Non-surgical treatment is possible in haemodynamically stable patients provided intensive monitoring is available. This involves strict bedrest and blood transfusions as required.

- In many cases the entire spleen is removed (splenectomy) but some ruptures can be surgically repaired.

- Patients should be vaccinated against pneumococcus before a splenectomy whenever possible.

Long-term management

- Asplenic patients are at increased risk of infections.

- An annual flu vaccination is recommended after a splenectomy.

- In some circumstances prophylactic antibiotics are recommended, particularly if the patient has another condition (sickle-cell disease or cancer, for example) that increases the risk of life-threatening infections.

- Although an asplenic patient’s ability to fight infection is impaired, other organs (primarily the liver) compensate for the loss by increasing their infection-fighting ability.

Precautionary measures

The following general measures may help to prevent serious infection in asplenic patients;

- Carry a ‘no spleen’ card that provides details of vaccinations, antibiotic therapy, and action to be taken in case of a flu-like illness;

- Seek urgent medical attention at early signs of infection, irrespective of prophylaxis;

- Take aspirin prophylaxis against thrombosis (this should be controlled by a haematologist);

- Avoid risk of malaria when in tropical countries by using insect-repellent creams, mosquito nets or screens, wearing long sleeves and trousers in the evening, and taking anti-malarial medication.

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