COLLECTIVE REVIEW spleen, delayed rupture
Delayed Rupture of the Spleen [Dang C, Schlater T,, Bui H, Oshita T: Delayed rupture of the spleen. Ann Emerg Med April 1990;19:399-403.] INTRODUCTION The term "delayed splenic rupture" is analyzed and clarified, and modalities for the determination of splenic injury in the emergency department setting are evaluated. HISTORIC BACKGROUND In 1977, Olsen and Polley credited Evans with describing, in 1866, delayed splenic rupture from blunt abdominal injury for the first time.l He reported a 63-year-old dustman who died five days after blunt abdominal trauma. After he reviewed the autopsy report of an intrasplenic hematoma and a capsule laceration, Evans concluded that the capsule tear most likely occurred on the fourth day after the blunt trauma to the abdomen. In 1898, Ballance proposed that the splenic capsular tear occurs at the onset of injury rather than some time later. ~ Hemorrhage from the initial splenic rupture is stopped with a contained perisplenic hematoma and followed later by serious secondary hemorrhage. In 1907, Baudet called attention to an interval of quiescence between the injury and the delayed rupture. 3 This interval, which lasts more than 48 hours and during which the patient is nearly free of symptoms, has become known as the "latent period of Baudet."
Chat Dang, MD* Theodore Schlater, MDt Los Angeles, California Hum Bui, MD:~ Patton, California Takashi Oshita, MD Los Angeles, California From the Departments of Emergency Medicine* and Surgery, I- King/Drew Medical Center, Los Angeles, California; and Patton State Hospital, Patton, California.:~ Received for publication October 24, 1988. Revisions received May 25, and September 18, 1989. Accepted for publication December 12, 1989. Address for reprints: Chat Dang, MD, Department of Emergency Medicine, King/ Drew Medical Center, 12021 South Wilmington Avenue, Los Angeles, California 90059.
THE CONTROVERSY Surgical literature defines delayed splenic rupture as splenic rupture occurring 48 hours after the trauma.4, s This definition is based only on the temporal relationship to the initial injury rather than on the underlying pathological process. Indeed, there are three possible mechanisms for delayed splenic rupture: contained, slowly expanding subcapsular hematoma with eventual sudden rupture of the capsule; primary splenic rupture with a nonexpanding perisplenic hematoma followed by secondary hemorrhage; and continued slow bleeding into the peritoneal cavity from an undetected primary laceration with delayed recognition. Using presently available diagnostic modalities, the term "true delayed splenic rupture" should be used only when the initial splenic imaging is negative. Once an initial splenic injury is missed, the distinction between delayed splenic rupture and delayed diagnosis of an initial rupture is academic as there is no therapeutic difference. In 1932, McIndoe studied 46 cases of "delayed hemorrhage following traumatic rupture of the spleen. ''6 His choice of words was careful and accurate. He considered the splenic injury to have occurred as a result of trauma and the cessation of initial bleeding to have accounted for the latent interval. McIndoe arbitrarily chose a latent period of at least 48 hours before the renewal of profuse secondary hemorrhage as the inclusion criterion for his review. Subsequently, the term "delayed splenic rupture" was loosely used for circumstances of slow but progressive clinical deterioration until internal hemorrhage was clinically recognized. In 1943, Zabinski and Harkins reviewed cases from the literature of 175 patients and cases of four of their own patients, seeking the condition of 19:4 April 1990
Annals of Emergency Medicine
399/93
SPLENIC RUPTURE Dang et al
original injury, insidious latent period, and f u l m i n a t i n g s e c o n d a r y hemorrhage, z They provided a detailed analysis of 72 cases, 16 of which would have been excluded by McIndoe because they occurred within 48 hours (14) or because of progressive clinical d e t e r i o r a t i o n (two). Based on an average of five studies, they concluded that delayed rupture represented about 14% of all splenic ruptures (15 of lll cases). This percentage has been often cited in the surgical literature. In 1974, Olsen stated that the 14% incidence was "an expression of past diagnostic limitations. ''8 Based on his study of 154 patients with splenic injury, 152 patients (98.7%) were found to have hemoperitoneum at the initial peritoneal lavage. There was one falsenegative lavage. Thus, only one of 154 patients (0.6%) had "true delayed splenic rupture." Based on their studies with peritoneal lavage, visceral angiography, and isotope scan, Benjamin et al s in 1976 and Olsen and Polley I in 1977, independently concluded that usually, delayed splenic rupture is actually a delay in diagnosis of the condition. Benjamin et al's s retrospective investigation revealed that his hospital had a 2% incidence rate of delayed rupture (six of 302) using peritoneal lavage as the only diagnostic procedure. Olsen and Polley arrived at an incidence rate of 1% (three of 314). 1 They used peritoneal lavage in the initial assessment of all patients with more than trivial blunt abdominal trauma, resorting to angiography only when more precise information was needed. Occasionally they performed radionuclide scans, usually in children. They concluded that because subcapsular hematomas of the spleen were infrequent, peritoneal lavage could be trusted in the detection of most splenic injuries. DIAGNOSTIC CONSIDERATIONS Several diagnostic techniques have been used extensively in the detection of blunt splenic injury. They are indicated whenever the possibility of a splenic injury is present, but immediate surgery is not warranted. The i n d i c a t i o n s for e v a l u a t i o n of a splenic injury include mechanism of injury likely to injure the spleen; pain or tenderness over the left upper abdomen or lower chest; discomfort 94/400
in the left shoulder or scapula (referred pain from diaphragmatic irritation); evidence of direct trauma to the left thoracoabdominal area in the form of local bruises, abrasions, seatbelt imprints, or tire markings; direct or indirect thoracoabdominal trauma in a patient with a depressed sensorium or spinal cord injury; or unexplained post-traumatic hypovolemia. Since its introduction in 1965, peritoneal lavage has probably been the main investigational tool used, with a reported accuracy in the detection of hemoperitoneum of 95% to 99%.l,5,9 In a 1986 prospective study of 91 patients undergoing both computed tomography (CT) and peritoneal lavage after blunt abdominal trauma, Fabian et al reported four patients with normal initial CT interpretations who required splenectomy or splenorrhaphy. 1° The preliminary readings were performed by available radiology staff (attending and/or resident). When reviewed by experienced tomographers, the interpretations were found to be false-negatives. Besides errors due to the limited experience of the staff making the initial diagnosis, other sources of CT falsenegatives could be artifacts due to an internal metal hemoclip 11 or ribs or to air contrast interfaces within the stomach;12A3 failure to scan affected areas;14 intrasplenic or perisplenic hemorrhage isodense with contrastenhanced spleen; 15 and a n a t o m i c variants such as congenital clefts and lobulations. 12 Despite these shortcomings, CT has become popular in the evaluation of splenic and other intra-abdominal injuries.~A 6-2° CT offers several advantages over other diagnostic modalities. With more mobile CT units available, CT is easier to obtain as it does not require the technical skills of an angiographer. CT provides det a i l s on t h e a m o u n t of h e m o peritoneum, the extent of the splenic laceration and hematoma, and any associated intraperitoneal or retroperitoneal injuries. These data are invaluable in the selection of conservative treatment for blunt abdominal trauma. 14,2o-22 The sensitivity, specificity, and accuracy of CT diagnosis after blunt a b d o m i n a l t r a u m a have been reported by Fabian et al to be 85%, 100%, and 97%, respectively. 1° For splenic trauma, rates of CT accuracy Annals of Emergency Medicine
exceeded 95% for Jeffrey et a112 and Buntain et al. 2° Sortland et al reported a sensitivity of 96% and a specificity of 100% for CT diagnosis of splenic injury. 21 The results of CT should not lull emergency physicians or surgeons into a false sense of security. 13 A negative CT does not mean that the patient can be discharged; rather, a negative CT scan should combine with appropriate clinical circumstances to lead to discharge. Visceral angiography and radionuclide studies have had good results in the evaluation of splenic injuries in adult and pediatric patients. 11,23,24 In 1984, Filler 23 reviewed the cases of 127 pediatric patients treated for blunt splenic trauma between 1972 and 1981; all were less than 16 years old. The diagnosis was established by spleen scan and angiography in the 71% clinically stable patients who had been treated nonoperatively. The diagnoses were confirmed at surgery in the 29% of the patients who required surgery. No delayed splenic rupture occurred in the nonoperative group, and the spleen was preserved in three fourths of the surgical cases. Additional studies of the use of scintigraphy in splenic trauma reported a sensitivity of about 90% and specificity of about 80%. 11,21,25 The main advantage of scintigraphy is the ability to provide a better examination without sedation in uncooperative adults and children. 21 However, liver-spleen scintigraphy is organ specific and does not provide information on the rest of the abdomen. It may be used as a screening test acutely and for follow-up of splenic injuries treated conservatively. 26 Computed scintigraphic tomography or computed emission tomography (CET) uses a higher dose of t e c h n e t i u m - 9 9 m sulfur or stannous colloid, m o r e s c i n t i g r a p h i c views of the spleen, and a computer to reconstruct the image in a transverse plane. CET has not been proved superior to the classic vertical plane scintigraphy in the evaluation of splenic trauma. 2s Angiography could be considered the standard for m a n y diagnoses, based on the interpretation of the anatomy of the vascular tree (eg, normal, stretched, displaced, occluded, compressed, or leaking contrast material). Fisher et al 2z published a detailed classification of angiographic findings in splenic trauma based on 19:4 April 1990
their experience with 102 patients. However, a negative angiogram finding does not exclude splenic injury if bleeding spontaneously stopped and no hematoma resulted. Other problems in diagnosis occur in patients with a n a t o m i c variations such as deep lobulation and multiple spleens. 28 The required skills of an angiographer have made the procedure less readily available. Laparoscopy allows direct visualization of the spleen but is rarely used. 29 Ultrasound has also been advocated for splenic injury. 9A9,3°,3[ Real-time sonography provides multiorgan imaging without the need for contrast injection. Splenic hematomas appear as hypoechoic masses. Surrounding fluid collections are recognized as perisplenic hematomas, whereas hemoperitoneum is identified as free peritoneal fluid. However, although it has portable capability and is not significantly degraded by patient motion, ultrasonography had n o t been p e r f o r m e d a c u t e l y frequently when local pain and tenderness were present. 13,25,3o,32 A TRUE ENTITY The incidence of delayed splenic rupture has declined from about 15% to 1.5% due, in particular, to liberal use of peritoneal lavage and CT scan in p o t e n t i a l l y splenic-injured patients. The question now is whether true delayed splenic rupture exists at all. We found eight cases from the recent literature (see below) that support delayed splenic rupture as a true e n t i t y , Is,31, 33-36 based on the sensitivity of presently available technology. We propose the t e r m " d e l a y e d splenic rupture" be reserved for only those cases where initial imaging of the spleen, properly interpreted, was negative and the diagnosis was determined 48 hours or more after trauma by surgery or imaging. For the purpose of clarity, these will be labeled "true delayed splenic ruptures." In our review of the literature, patients with an initial negative peritoneal lavage were excluded because this procedure cannot detect subcapsular or intrasplenic bleeding. In 1980, Berlatzky et al reviewed 293 cases of blunt splenic injuries. 4 They found 12 cases of delayed recognition beyond 48 hours, the result of diagnostic error, and three cases that were termed "true delayed hemorrhage," 19:4 April 1990
in accord with McIndoe's definition. 6 Because no initial imaging was performed, those three cases cannot be regarded as true delayed ruptures. The next year, Toombs et al reported one case of a patient with abdominal trauma who had a normal CT scan at the time of admission. 33 Follow-up CT demonstrated a hemoperitoneum but no splenic laceration. However, splenic rupture was f o u n d at surgery. G r u e n b e r g and Horan presented in 1983 the case of a 49~year-old man who was involved in a m o t o r vehicle accident and required an emergency splenectomy 25 days after the event. 34 His initial peritoneal lavage and angiogram were n e g a t i v e , and his a b d o m e n was a s y m p t o m a t i c for more than three weeks. Taylor and Rosenfield reported the following year a 39-yearold man who fell 25 ft and required an emergency splenectomy ten days after the fallA 5 He had an initial contrast-enhanced abdominal CT scan that was negative for splenic injury and hemoperitoneum. In 1985, Schultz and Froelich described a young man who had significant thoracoabdominal trauma but an initial normal liver-spleen scint i g r a p h y and b e n i g n h o s p i t a l course. 31 Twenty-three days after the trauma, he developed an acute abdomen and at laparotomy was found to have a ruptured spleen. Similarly, in the same year, Fagelman et al presented the case of an 83-year-old w o m a n who was admitted after a motor vehicle accident. 3s The postt r a u m a t i c liver-spleen scan at six h o u r s and c o n t r a s t - e n h a n c e d CT scan at one day revealed a normal spleen. Twenty-one days after admission, a drop in hematocrit was found to be due to a subcapsular hematoma by CT scan. In 1987, Pappas et al reviewed three patients who had normal contrast-enhanced high-resolution abdominal CT studies immediately after blunt abdominal trauma, all of whom went on to become symptomatic for splenic injury as documented by repeat CT scans. 36 In the preceding cases, it is conceivable that a small intrasplenic tear was initially present without associated hematoma or hemoperitoneum and could not be identified by scintigraphy, angiography, or CT scan, that is, it was beyond the resolution of presently available radiologic imAnnals of Emergency Medicine
aging techniques. It could be argued that this concept, in fact, negates a "delayed" rupture because a lesion was present from the start but was not or could not be detected. The 1987 report by Sutton and Haaga added credibility to this argument by providing previously unreported signs of limited splenic trauma in a patient who required a splenectomy on the third day. 37 CLINICAL CONSIDERATIONS The incidence of 14% previously quoted for delayed splenic rupture could be due to inconsistencies and variations in the clinical findings at both the initial event and the secondary internal hemorrhage, particularly at a time when peritoneal lavage and splenic i m a g i n g were n o t w i d e l y used. Benjamin et al reviewed 302 cases of blunt splenic injuries; only 186 patients presented with a tender abdomen, guarding, and distension, s Tachycardia and blood pressure of less than 100 m m Hg were found in 107 patients. In 1966, Sizer et al reviewed 312 cases of delayed splenic rupture. 3s They concluded that there were no reliable early or late signs and symptoms for diagnosis; left upper quadrant pain was present secondarily only in 53 of 306 cases (17%). Furthermore, it is unusual but not rare for delayed splenic rupture to present without a clear history of previous trauma. In 1983, Campbell described a 21year-old w o m a n whose chief complaint was increasing right iliac fossa pain for six hours. 39 She was preoperatively diagnosed to have acute appendicitis but at surgery was discovered to have a ruptured spleen. In 1986, Sujka et al reported delayed splenic rupture (seven days after the patient's initial diving catch while playing baseball) in a patient presenting with a scrotal hematoma. 4o The c l a s s i c c i r c u m s t a n c e s for splenic injury are blunt trauma to the anterior abdomen or to the left flank from motor vehicle or motorcycle accidents, falls, or sport and fighting injuries, especially when there are objective signs of trauma such as local ecchymoses, abrasions, seat belt imprints, or tire markings. Rosoff et al divided the clinical manifestations of traumatic splenic rupture into two parts - the systemic syndrome of acute internal hemorrhage and the local peritoneal irritation in the area 401/95
SPLENIC RUPTURE Dang et al
of the spleen. 41 Fractures of the lower ribs on the left raise the possibility of a splenic injury in adults; rib fractures in children may not be present because the chest wall is extremely pliable. In McIndoe's series of 45 patients, ten had fractured ribs. 6 Zabinski and Harkins noted 11 instances of left rib fracture in their report, z T r u n k e y mentioned that fractures of any one or combination of the eighth, ninth, and tenth ribs are associated with a 20% chance of splenic rupture. 42 The presence of a left pleural effusion unexplained by thoracic pathology also is a strong indicator for further evaluation of s p l e n i c injury. 36 O t h e r r a d i o l o g i c s i g n s of p o s s i b l e splenic injury that could sometimes be f o u n d o n a p l a i n f i l m of t h e abdom e n are e n l a r g e m e n t of t h e s p l e n i c s h a d o w , m e d i a l d i s p l a c e m e n t of t h e g a s t r i c gas b u b b l e , d i l a t e d s t o m a c h with a serrated greater curvature, o b l i t e r a t i o n of t h e left p s o a s s h a d o w , d e p r e s s i o n of t h e s p l e n i c f l e x u r e of the colon, elevated left hemid i a p h r a g m , a n d e v i d e n c e of i n t r a p e r i t o n e a l h e m o r r h a g e (fluid b e t w e e n a d j a c e n t l o o p s of b o w e l i n t h e p e l v i s or i n t h e c o l o n i c gutter). 32 A d i s e a s e d a n d e n l a r g e d s p l e e n , as c o u l d be s e e n in patients w i t h malaria, sarcoidosis, infectious mononucleosis, and many of t h e h e m a t o l o g i c d i s o r d e r s , c a n predispose to splenic rupture.
SUMMARY The concept of delayed splenic rupture is an evolving one. The cases reviewed have led us to reserve the term "delayed splenic rupture" for the situation in which early posttraumatic imaging of the spleen is normal and is followed by the diagnosis of splenic hemorrhage 48 or more hours after the initial insult. Post-traumatic splenic evaluation is indicated when the mechanism of injury is likely to injure the spleen, there is unexplained hypovolemia, or the patient complains of left upper quadrant pain or tenderness. Peritoneal lavage is indicated when hypovolemia is the main manifestation. R a d i o n u c l i d e s t u d y is u s e d for screening isolated splenic or hepatic injury when the suspicion is low. Reduced availability of visceral angiogram has resulted in CT scan becoming the main diagnostic modality. When a patient presents with 96/402
blunt abdominal trauma, awareness of t h e p r o b l e m of s p l e n i c r u p t u r e a n d active diagnostic approach may help reduce the morbidity and mortality associated with splenic hemorrhage, e i t h e r i m m e d i a t e or d e l a y e d .
19. Leppaniemi A, Haapiainen R, Standert~ skjold-Nordenstam CG, et al: Delayed presentation of blunt splenic injury. A m J Surg 1988;155:745-749. 20. Buntain WL, Gould HR, Maull KI: Predictability of splenic salvage by computed tomography. J Trauma 1988;28:24-34.
REFERENCES 1. Olsen WR, Polley TZ Jr: A second look at delayed splenic rupture. Arch Surg 1977; 112:422-425.
21. Sortland O, Nerdrum HJ, Solheim K: Computed tomography and scintigraphy in the diagnosis of splenic injury. Acta Chir Scand t986;152:453-461.
2. Ballance CA: On splenectomy for rupture without external wound. Practitioner 1898; 60:347-358.
22. Berger PE, Kuhn JP: CT of blunt abdominal trauma in childhood. A m J Radiol 1981; 136:105-110.
3. Baudet R: Ruptures de ]a rate. Med Praet 1907;3:565-567.
23. Filler RM: Experience with the management of splenic injuries. A u s t N Z J Surg 1984; 54:443-445.
4. Berlatzky Y, Shiloni E, Anner H, et aI: "Delayed rupture of the spleen" or delayed diagnosis of the splenic injury? Isr J Med Sei 1980;16:659-664.
24. Girvan DP: Radionuclide scintigraphy: A valuable diagnostic aid in children with splenic trauma. Can J Surg 1984;27:539-541.
5. Benjamin CI, Engrav LH, Perry JF Jr: Delayed rupture or delayed diagnosis of rupture of the spleen. Surg Gynecol Obstet 1976;142:171-172.
25. Erasmie U, Mortensson W, Persson U, et al: Scintigraphic evaluation of traumatic splenic lesions in children. Acta Radiol 1988;29:121-125.
6. McIndoe AH: Delayed hemorrhage following traumatic rupture of the spleen. Br J Surg 1932;20:249-268.
26. Sziklas JJ, Spencer RP, Rosenberg RJ: Delayed splenic rupture: A suggestion for "predictive monitoring." J Nucl Med 1985;26:609-611.
7. Zabinski EJ, Harkins HN: Delayed splenic rupture: A clinical syndrome following trauma. Arch Surg 1943;46:186-213.
27. Fisher RG, Foucar K, Estrada R, et al: Splenic rupture in blunt trauma: Correlation of angiographic and pathologic records. Radio1 Clin North Am 1981;19:141-165.
8. Olsen WR: Delayed rupture of the spleen as an index of diagnostic accuracy. Surg Cynecol Obstet 1974;138:82. 9. Hertzanu Y, Mendelsohn DB: Delayed splenic rupture: A true entity. Clin Radiol 1984;35:393-396. 10. Fabian TC, Mangiante EC, White TJ, et al: A prospective study of 91 patients undergoing both computed tomography and peritoneal lavage following blunt abdominal trauma. J Trauma 1986;26:602-607. 11. Uthoff LB, Wyffels PL, Adams CS, et al: A prospective study comparing nuclear scintigraphy and computerized axial tomography in the initial evaluation of the trauma patient. Ann Surg 1983;198:611~616.
28. Gold RE, Redman HC: Splenic trauma: Assessment of problems in diagnosis. Am J Roentg 1972;116:413-418. 29. Papua New Guinea Splenic Injury Study Group: Ruptured spleen in the adult: An ac k count of 205 cases with particular reference to non-operative management. Aust N Z J Surg 1987;57:549-553.
30. Froelich JN, Simeone JF, Mckusick KA, et al: Radionuclide imaging and ultrasound in liver/spleen trauma: A prospective comparison. Radiology 1982;145:457-461. 31. Schultz DA, Froelich JW: Delayed rupture of the spleen: A case report. Cliu Nucl Med 1985;10:642-645.
12. Jeffrey RB, Laing FC, Federle MP, et al: Computed tomography of splenic trauma. Radik ology 1981;141:729-732. 13. Kaufman RA, Towbin R, Babcock DS, et al: Upper abdominal trauma in children: Imaging evaluation. A m J Radiol 1984;142:449-460.
32. Bundy AL, Scott M, Druckman D, et al: Delayed and occult splenic rupture. Comput Radiol 1985;9:299-305.
14. IYderle MP, Jeffrey RB: Hemoperitoneum studied by computed tomography. Radiology 1983;148:187-192.
34. Gruenberg JC, Horan DP: Delayed splenic rupture: The phoenix. J Trauma 1983;23: t59-160. 35. Fagelman D, Hertz MA, Ross AS: Case report: Delayed development of splenic subcapsular hematoma: CT evaluation. J Comput Assist Tomogr 1985;9:815-816.
15. Taylor CR, Rosenfield AT: Limitations of computed tomography in the recognition of delayed splenic rupture. ] Comput Assist Tomogr 1984;8:1205-1207. 16. Mall JC, Kaiser JA: CT diagnosis of splenic laceration. Am J Radio] 1980;134:265-269. 17. Nelson EW~ Holliman CJ, Juell BE, et al: Computerized tomography in the evaluation of blunt abdominal trauma. A m J Surg 1983; 146:751-754. 18. Sherck JP, McCort JJ, Oakes DD: Computed tomography in thoracoabdominal trauma. J Trauma 1984;24:1015-1021.
Annals of Emergency Medicine
33. Toombs BE), Lester RG, Ben-Menachem Y, et al: Computed tomography in blunt trauma. Radiol Clin North Am 1981~19:17-35.
36. Pappas D, Mirvis SE, Crepps JT: Splenic trauma: False-negative CT diagnosis in cases of delayed rupture. A m J Radiol 1987;149:727-728. 37. Sutton CS, Haaga JP: CT evaluation of lhnited splenic trauma. J Comput Assist Tomogr 1987;11:167-169. 38. Sizer JS, Wayne ER, Frederick PL: Delayed rupture of the spleen: Review of the literature
19:4 April 1990
and report of six cases. Arch Surg 1966; 92:362-366. 39. Campbell WB: Delayed rupture of the sp]een can masquerade as appendicitis. Ann R Coll Surg Engl 1983;65:396.
19:4 April 1990
40. Sujka SK, Evans EJ, Nigam A: Delayed rupture of the spleen presenting as a scrotal hematoma. J Trauma 1986;26:85-86. 41. Rosoff L, Cohen JL, Telfer N, et ah Injuries of the spleen. Surg Clin North A m 1972;
Annals of Emergency Medicine
52:667-685. 42. T r u n k e y DD: Spleen, in Blaisdel FW, Trunkey DD (eds): Trauma Management, Volume I: Abdominal 2):auma. New York, ThiemeStratton Inc, 1982, p 185-197.
403/97
Delayed Rupture of the Spleen [Dang C, Schlater T,, Bui H, Oshita T: Delayed rupture of the spleen. Ann Emerg Med April 1990;19:399-403.] INTRODUCTION The term "delayed splenic rupture" is analyzed and clarified, and modalities for the determination of splenic injury in the emergency department setting are evaluated. HISTORIC BACKGROUND In 1977, Olsen and Polley credited Evans with describing, in 1866, delayed splenic rupture from blunt abdominal injury for the first time.l He reported a 63-year-old dustman who died five days after blunt abdominal trauma. After he reviewed the autopsy report of an intrasplenic hematoma and a capsule laceration, Evans concluded that the capsule tear most likely occurred on the fourth day after the blunt trauma to the abdomen. In 1898, Ballance proposed that the splenic capsular tear occurs at the onset of injury rather than some time later. ~ Hemorrhage from the initial splenic rupture is stopped with a contained perisplenic hematoma and followed later by serious secondary hemorrhage. In 1907, Baudet called attention to an interval of quiescence between the injury and the delayed rupture. 3 This interval, which lasts more than 48 hours and during which the patient is nearly free of symptoms, has become known as the "latent period of Baudet."
Chat Dang, MD* Theodore Schlater, MDt Los Angeles, California Hum Bui, MD:~ Patton, California Takashi Oshita, MD Los Angeles, California From the Departments of Emergency Medicine* and Surgery, I- King/Drew Medical Center, Los Angeles, California; and Patton State Hospital, Patton, California.:~ Received for publication October 24, 1988. Revisions received May 25, and September 18, 1989. Accepted for publication December 12, 1989. Address for reprints: Chat Dang, MD, Department of Emergency Medicine, King/ Drew Medical Center, 12021 South Wilmington Avenue, Los Angeles, California 90059.
THE CONTROVERSY Surgical literature defines delayed splenic rupture as splenic rupture occurring 48 hours after the trauma.4, s This definition is based only on the temporal relationship to the initial injury rather than on the underlying pathological process. Indeed, there are three possible mechanisms for delayed splenic rupture: contained, slowly expanding subcapsular hematoma with eventual sudden rupture of the capsule; primary splenic rupture with a nonexpanding perisplenic hematoma followed by secondary hemorrhage; and continued slow bleeding into the peritoneal cavity from an undetected primary laceration with delayed recognition. Using presently available diagnostic modalities, the term "true delayed splenic rupture" should be used only when the initial splenic imaging is negative. Once an initial splenic injury is missed, the distinction between delayed splenic rupture and delayed diagnosis of an initial rupture is academic as there is no therapeutic difference. In 1932, McIndoe studied 46 cases of "delayed hemorrhage following traumatic rupture of the spleen. ''6 His choice of words was careful and accurate. He considered the splenic injury to have occurred as a result of trauma and the cessation of initial bleeding to have accounted for the latent interval. McIndoe arbitrarily chose a latent period of at least 48 hours before the renewal of profuse secondary hemorrhage as the inclusion criterion for his review. Subsequently, the term "delayed splenic rupture" was loosely used for circumstances of slow but progressive clinical deterioration until internal hemorrhage was clinically recognized. In 1943, Zabinski and Harkins reviewed cases from the literature of 175 patients and cases of four of their own patients, seeking the condition of 19:4 April 1990
Annals of Emergency Medicine
399/93
SPLENIC RUPTURE Dang et al
original injury, insidious latent period, and f u l m i n a t i n g s e c o n d a r y hemorrhage, z They provided a detailed analysis of 72 cases, 16 of which would have been excluded by McIndoe because they occurred within 48 hours (14) or because of progressive clinical d e t e r i o r a t i o n (two). Based on an average of five studies, they concluded that delayed rupture represented about 14% of all splenic ruptures (15 of lll cases). This percentage has been often cited in the surgical literature. In 1974, Olsen stated that the 14% incidence was "an expression of past diagnostic limitations. ''8 Based on his study of 154 patients with splenic injury, 152 patients (98.7%) were found to have hemoperitoneum at the initial peritoneal lavage. There was one falsenegative lavage. Thus, only one of 154 patients (0.6%) had "true delayed splenic rupture." Based on their studies with peritoneal lavage, visceral angiography, and isotope scan, Benjamin et al s in 1976 and Olsen and Polley I in 1977, independently concluded that usually, delayed splenic rupture is actually a delay in diagnosis of the condition. Benjamin et al's s retrospective investigation revealed that his hospital had a 2% incidence rate of delayed rupture (six of 302) using peritoneal lavage as the only diagnostic procedure. Olsen and Polley arrived at an incidence rate of 1% (three of 314). 1 They used peritoneal lavage in the initial assessment of all patients with more than trivial blunt abdominal trauma, resorting to angiography only when more precise information was needed. Occasionally they performed radionuclide scans, usually in children. They concluded that because subcapsular hematomas of the spleen were infrequent, peritoneal lavage could be trusted in the detection of most splenic injuries. DIAGNOSTIC CONSIDERATIONS Several diagnostic techniques have been used extensively in the detection of blunt splenic injury. They are indicated whenever the possibility of a splenic injury is present, but immediate surgery is not warranted. The i n d i c a t i o n s for e v a l u a t i o n of a splenic injury include mechanism of injury likely to injure the spleen; pain or tenderness over the left upper abdomen or lower chest; discomfort 94/400
in the left shoulder or scapula (referred pain from diaphragmatic irritation); evidence of direct trauma to the left thoracoabdominal area in the form of local bruises, abrasions, seatbelt imprints, or tire markings; direct or indirect thoracoabdominal trauma in a patient with a depressed sensorium or spinal cord injury; or unexplained post-traumatic hypovolemia. Since its introduction in 1965, peritoneal lavage has probably been the main investigational tool used, with a reported accuracy in the detection of hemoperitoneum of 95% to 99%.l,5,9 In a 1986 prospective study of 91 patients undergoing both computed tomography (CT) and peritoneal lavage after blunt abdominal trauma, Fabian et al reported four patients with normal initial CT interpretations who required splenectomy or splenorrhaphy. 1° The preliminary readings were performed by available radiology staff (attending and/or resident). When reviewed by experienced tomographers, the interpretations were found to be false-negatives. Besides errors due to the limited experience of the staff making the initial diagnosis, other sources of CT falsenegatives could be artifacts due to an internal metal hemoclip 11 or ribs or to air contrast interfaces within the stomach;12A3 failure to scan affected areas;14 intrasplenic or perisplenic hemorrhage isodense with contrastenhanced spleen; 15 and a n a t o m i c variants such as congenital clefts and lobulations. 12 Despite these shortcomings, CT has become popular in the evaluation of splenic and other intra-abdominal injuries.~A 6-2° CT offers several advantages over other diagnostic modalities. With more mobile CT units available, CT is easier to obtain as it does not require the technical skills of an angiographer. CT provides det a i l s on t h e a m o u n t of h e m o peritoneum, the extent of the splenic laceration and hematoma, and any associated intraperitoneal or retroperitoneal injuries. These data are invaluable in the selection of conservative treatment for blunt abdominal trauma. 14,2o-22 The sensitivity, specificity, and accuracy of CT diagnosis after blunt a b d o m i n a l t r a u m a have been reported by Fabian et al to be 85%, 100%, and 97%, respectively. 1° For splenic trauma, rates of CT accuracy Annals of Emergency Medicine
exceeded 95% for Jeffrey et a112 and Buntain et al. 2° Sortland et al reported a sensitivity of 96% and a specificity of 100% for CT diagnosis of splenic injury. 21 The results of CT should not lull emergency physicians or surgeons into a false sense of security. 13 A negative CT does not mean that the patient can be discharged; rather, a negative CT scan should combine with appropriate clinical circumstances to lead to discharge. Visceral angiography and radionuclide studies have had good results in the evaluation of splenic injuries in adult and pediatric patients. 11,23,24 In 1984, Filler 23 reviewed the cases of 127 pediatric patients treated for blunt splenic trauma between 1972 and 1981; all were less than 16 years old. The diagnosis was established by spleen scan and angiography in the 71% clinically stable patients who had been treated nonoperatively. The diagnoses were confirmed at surgery in the 29% of the patients who required surgery. No delayed splenic rupture occurred in the nonoperative group, and the spleen was preserved in three fourths of the surgical cases. Additional studies of the use of scintigraphy in splenic trauma reported a sensitivity of about 90% and specificity of about 80%. 11,21,25 The main advantage of scintigraphy is the ability to provide a better examination without sedation in uncooperative adults and children. 21 However, liver-spleen scintigraphy is organ specific and does not provide information on the rest of the abdomen. It may be used as a screening test acutely and for follow-up of splenic injuries treated conservatively. 26 Computed scintigraphic tomography or computed emission tomography (CET) uses a higher dose of t e c h n e t i u m - 9 9 m sulfur or stannous colloid, m o r e s c i n t i g r a p h i c views of the spleen, and a computer to reconstruct the image in a transverse plane. CET has not been proved superior to the classic vertical plane scintigraphy in the evaluation of splenic trauma. 2s Angiography could be considered the standard for m a n y diagnoses, based on the interpretation of the anatomy of the vascular tree (eg, normal, stretched, displaced, occluded, compressed, or leaking contrast material). Fisher et al 2z published a detailed classification of angiographic findings in splenic trauma based on 19:4 April 1990
their experience with 102 patients. However, a negative angiogram finding does not exclude splenic injury if bleeding spontaneously stopped and no hematoma resulted. Other problems in diagnosis occur in patients with a n a t o m i c variations such as deep lobulation and multiple spleens. 28 The required skills of an angiographer have made the procedure less readily available. Laparoscopy allows direct visualization of the spleen but is rarely used. 29 Ultrasound has also been advocated for splenic injury. 9A9,3°,3[ Real-time sonography provides multiorgan imaging without the need for contrast injection. Splenic hematomas appear as hypoechoic masses. Surrounding fluid collections are recognized as perisplenic hematomas, whereas hemoperitoneum is identified as free peritoneal fluid. However, although it has portable capability and is not significantly degraded by patient motion, ultrasonography had n o t been p e r f o r m e d a c u t e l y frequently when local pain and tenderness were present. 13,25,3o,32 A TRUE ENTITY The incidence of delayed splenic rupture has declined from about 15% to 1.5% due, in particular, to liberal use of peritoneal lavage and CT scan in p o t e n t i a l l y splenic-injured patients. The question now is whether true delayed splenic rupture exists at all. We found eight cases from the recent literature (see below) that support delayed splenic rupture as a true e n t i t y , Is,31, 33-36 based on the sensitivity of presently available technology. We propose the t e r m " d e l a y e d splenic rupture" be reserved for only those cases where initial imaging of the spleen, properly interpreted, was negative and the diagnosis was determined 48 hours or more after trauma by surgery or imaging. For the purpose of clarity, these will be labeled "true delayed splenic ruptures." In our review of the literature, patients with an initial negative peritoneal lavage were excluded because this procedure cannot detect subcapsular or intrasplenic bleeding. In 1980, Berlatzky et al reviewed 293 cases of blunt splenic injuries. 4 They found 12 cases of delayed recognition beyond 48 hours, the result of diagnostic error, and three cases that were termed "true delayed hemorrhage," 19:4 April 1990
in accord with McIndoe's definition. 6 Because no initial imaging was performed, those three cases cannot be regarded as true delayed ruptures. The next year, Toombs et al reported one case of a patient with abdominal trauma who had a normal CT scan at the time of admission. 33 Follow-up CT demonstrated a hemoperitoneum but no splenic laceration. However, splenic rupture was f o u n d at surgery. G r u e n b e r g and Horan presented in 1983 the case of a 49~year-old man who was involved in a m o t o r vehicle accident and required an emergency splenectomy 25 days after the event. 34 His initial peritoneal lavage and angiogram were n e g a t i v e , and his a b d o m e n was a s y m p t o m a t i c for more than three weeks. Taylor and Rosenfield reported the following year a 39-yearold man who fell 25 ft and required an emergency splenectomy ten days after the fallA 5 He had an initial contrast-enhanced abdominal CT scan that was negative for splenic injury and hemoperitoneum. In 1985, Schultz and Froelich described a young man who had significant thoracoabdominal trauma but an initial normal liver-spleen scint i g r a p h y and b e n i g n h o s p i t a l course. 31 Twenty-three days after the trauma, he developed an acute abdomen and at laparotomy was found to have a ruptured spleen. Similarly, in the same year, Fagelman et al presented the case of an 83-year-old w o m a n who was admitted after a motor vehicle accident. 3s The postt r a u m a t i c liver-spleen scan at six h o u r s and c o n t r a s t - e n h a n c e d CT scan at one day revealed a normal spleen. Twenty-one days after admission, a drop in hematocrit was found to be due to a subcapsular hematoma by CT scan. In 1987, Pappas et al reviewed three patients who had normal contrast-enhanced high-resolution abdominal CT studies immediately after blunt abdominal trauma, all of whom went on to become symptomatic for splenic injury as documented by repeat CT scans. 36 In the preceding cases, it is conceivable that a small intrasplenic tear was initially present without associated hematoma or hemoperitoneum and could not be identified by scintigraphy, angiography, or CT scan, that is, it was beyond the resolution of presently available radiologic imAnnals of Emergency Medicine
aging techniques. It could be argued that this concept, in fact, negates a "delayed" rupture because a lesion was present from the start but was not or could not be detected. The 1987 report by Sutton and Haaga added credibility to this argument by providing previously unreported signs of limited splenic trauma in a patient who required a splenectomy on the third day. 37 CLINICAL CONSIDERATIONS The incidence of 14% previously quoted for delayed splenic rupture could be due to inconsistencies and variations in the clinical findings at both the initial event and the secondary internal hemorrhage, particularly at a time when peritoneal lavage and splenic i m a g i n g were n o t w i d e l y used. Benjamin et al reviewed 302 cases of blunt splenic injuries; only 186 patients presented with a tender abdomen, guarding, and distension, s Tachycardia and blood pressure of less than 100 m m Hg were found in 107 patients. In 1966, Sizer et al reviewed 312 cases of delayed splenic rupture. 3s They concluded that there were no reliable early or late signs and symptoms for diagnosis; left upper quadrant pain was present secondarily only in 53 of 306 cases (17%). Furthermore, it is unusual but not rare for delayed splenic rupture to present without a clear history of previous trauma. In 1983, Campbell described a 21year-old w o m a n whose chief complaint was increasing right iliac fossa pain for six hours. 39 She was preoperatively diagnosed to have acute appendicitis but at surgery was discovered to have a ruptured spleen. In 1986, Sujka et al reported delayed splenic rupture (seven days after the patient's initial diving catch while playing baseball) in a patient presenting with a scrotal hematoma. 4o The c l a s s i c c i r c u m s t a n c e s for splenic injury are blunt trauma to the anterior abdomen or to the left flank from motor vehicle or motorcycle accidents, falls, or sport and fighting injuries, especially when there are objective signs of trauma such as local ecchymoses, abrasions, seat belt imprints, or tire markings. Rosoff et al divided the clinical manifestations of traumatic splenic rupture into two parts - the systemic syndrome of acute internal hemorrhage and the local peritoneal irritation in the area 401/95
SPLENIC RUPTURE Dang et al
of the spleen. 41 Fractures of the lower ribs on the left raise the possibility of a splenic injury in adults; rib fractures in children may not be present because the chest wall is extremely pliable. In McIndoe's series of 45 patients, ten had fractured ribs. 6 Zabinski and Harkins noted 11 instances of left rib fracture in their report, z T r u n k e y mentioned that fractures of any one or combination of the eighth, ninth, and tenth ribs are associated with a 20% chance of splenic rupture. 42 The presence of a left pleural effusion unexplained by thoracic pathology also is a strong indicator for further evaluation of s p l e n i c injury. 36 O t h e r r a d i o l o g i c s i g n s of p o s s i b l e splenic injury that could sometimes be f o u n d o n a p l a i n f i l m of t h e abdom e n are e n l a r g e m e n t of t h e s p l e n i c s h a d o w , m e d i a l d i s p l a c e m e n t of t h e g a s t r i c gas b u b b l e , d i l a t e d s t o m a c h with a serrated greater curvature, o b l i t e r a t i o n of t h e left p s o a s s h a d o w , d e p r e s s i o n of t h e s p l e n i c f l e x u r e of the colon, elevated left hemid i a p h r a g m , a n d e v i d e n c e of i n t r a p e r i t o n e a l h e m o r r h a g e (fluid b e t w e e n a d j a c e n t l o o p s of b o w e l i n t h e p e l v i s or i n t h e c o l o n i c gutter). 32 A d i s e a s e d a n d e n l a r g e d s p l e e n , as c o u l d be s e e n in patients w i t h malaria, sarcoidosis, infectious mononucleosis, and many of t h e h e m a t o l o g i c d i s o r d e r s , c a n predispose to splenic rupture.
SUMMARY The concept of delayed splenic rupture is an evolving one. The cases reviewed have led us to reserve the term "delayed splenic rupture" for the situation in which early posttraumatic imaging of the spleen is normal and is followed by the diagnosis of splenic hemorrhage 48 or more hours after the initial insult. Post-traumatic splenic evaluation is indicated when the mechanism of injury is likely to injure the spleen, there is unexplained hypovolemia, or the patient complains of left upper quadrant pain or tenderness. Peritoneal lavage is indicated when hypovolemia is the main manifestation. R a d i o n u c l i d e s t u d y is u s e d for screening isolated splenic or hepatic injury when the suspicion is low. Reduced availability of visceral angiogram has resulted in CT scan becoming the main diagnostic modality. When a patient presents with 96/402
blunt abdominal trauma, awareness of t h e p r o b l e m of s p l e n i c r u p t u r e a n d active diagnostic approach may help reduce the morbidity and mortality associated with splenic hemorrhage, e i t h e r i m m e d i a t e or d e l a y e d .
19. Leppaniemi A, Haapiainen R, Standert~ skjold-Nordenstam CG, et al: Delayed presentation of blunt splenic injury. A m J Surg 1988;155:745-749. 20. Buntain WL, Gould HR, Maull KI: Predictability of splenic salvage by computed tomography. J Trauma 1988;28:24-34.
REFERENCES 1. Olsen WR, Polley TZ Jr: A second look at delayed splenic rupture. Arch Surg 1977; 112:422-425.
21. Sortland O, Nerdrum HJ, Solheim K: Computed tomography and scintigraphy in the diagnosis of splenic injury. Acta Chir Scand t986;152:453-461.
2. Ballance CA: On splenectomy for rupture without external wound. Practitioner 1898; 60:347-358.
22. Berger PE, Kuhn JP: CT of blunt abdominal trauma in childhood. A m J Radiol 1981; 136:105-110.
3. Baudet R: Ruptures de ]a rate. Med Praet 1907;3:565-567.
23. Filler RM: Experience with the management of splenic injuries. A u s t N Z J Surg 1984; 54:443-445.
4. Berlatzky Y, Shiloni E, Anner H, et aI: "Delayed rupture of the spleen" or delayed diagnosis of the splenic injury? Isr J Med Sei 1980;16:659-664.
24. Girvan DP: Radionuclide scintigraphy: A valuable diagnostic aid in children with splenic trauma. Can J Surg 1984;27:539-541.
5. Benjamin CI, Engrav LH, Perry JF Jr: Delayed rupture or delayed diagnosis of rupture of the spleen. Surg Gynecol Obstet 1976;142:171-172.
25. Erasmie U, Mortensson W, Persson U, et al: Scintigraphic evaluation of traumatic splenic lesions in children. Acta Radiol 1988;29:121-125.
6. McIndoe AH: Delayed hemorrhage following traumatic rupture of the spleen. Br J Surg 1932;20:249-268.
26. Sziklas JJ, Spencer RP, Rosenberg RJ: Delayed splenic rupture: A suggestion for "predictive monitoring." J Nucl Med 1985;26:609-611.
7. Zabinski EJ, Harkins HN: Delayed splenic rupture: A clinical syndrome following trauma. Arch Surg 1943;46:186-213.
27. Fisher RG, Foucar K, Estrada R, et al: Splenic rupture in blunt trauma: Correlation of angiographic and pathologic records. Radio1 Clin North Am 1981;19:141-165.
8. Olsen WR: Delayed rupture of the spleen as an index of diagnostic accuracy. Surg Cynecol Obstet 1974;138:82. 9. Hertzanu Y, Mendelsohn DB: Delayed splenic rupture: A true entity. Clin Radiol 1984;35:393-396. 10. Fabian TC, Mangiante EC, White TJ, et al: A prospective study of 91 patients undergoing both computed tomography and peritoneal lavage following blunt abdominal trauma. J Trauma 1986;26:602-607. 11. Uthoff LB, Wyffels PL, Adams CS, et al: A prospective study comparing nuclear scintigraphy and computerized axial tomography in the initial evaluation of the trauma patient. Ann Surg 1983;198:611~616.
28. Gold RE, Redman HC: Splenic trauma: Assessment of problems in diagnosis. Am J Roentg 1972;116:413-418. 29. Papua New Guinea Splenic Injury Study Group: Ruptured spleen in the adult: An ac k count of 205 cases with particular reference to non-operative management. Aust N Z J Surg 1987;57:549-553.
30. Froelich JN, Simeone JF, Mckusick KA, et al: Radionuclide imaging and ultrasound in liver/spleen trauma: A prospective comparison. Radiology 1982;145:457-461. 31. Schultz DA, Froelich JW: Delayed rupture of the spleen: A case report. Cliu Nucl Med 1985;10:642-645.
12. Jeffrey RB, Laing FC, Federle MP, et al: Computed tomography of splenic trauma. Radik ology 1981;141:729-732. 13. Kaufman RA, Towbin R, Babcock DS, et al: Upper abdominal trauma in children: Imaging evaluation. A m J Radiol 1984;142:449-460.
32. Bundy AL, Scott M, Druckman D, et al: Delayed and occult splenic rupture. Comput Radiol 1985;9:299-305.
14. IYderle MP, Jeffrey RB: Hemoperitoneum studied by computed tomography. Radiology 1983;148:187-192.
34. Gruenberg JC, Horan DP: Delayed splenic rupture: The phoenix. J Trauma 1983;23: t59-160. 35. Fagelman D, Hertz MA, Ross AS: Case report: Delayed development of splenic subcapsular hematoma: CT evaluation. J Comput Assist Tomogr 1985;9:815-816.
15. Taylor CR, Rosenfield AT: Limitations of computed tomography in the recognition of delayed splenic rupture. ] Comput Assist Tomogr 1984;8:1205-1207. 16. Mall JC, Kaiser JA: CT diagnosis of splenic laceration. Am J Radio] 1980;134:265-269. 17. Nelson EW~ Holliman CJ, Juell BE, et al: Computerized tomography in the evaluation of blunt abdominal trauma. A m J Surg 1983; 146:751-754. 18. Sherck JP, McCort JJ, Oakes DD: Computed tomography in thoracoabdominal trauma. J Trauma 1984;24:1015-1021.
Annals of Emergency Medicine
33. Toombs BE), Lester RG, Ben-Menachem Y, et al: Computed tomography in blunt trauma. Radiol Clin North Am 1981~19:17-35.
36. Pappas D, Mirvis SE, Crepps JT: Splenic trauma: False-negative CT diagnosis in cases of delayed rupture. A m J Radiol 1987;149:727-728. 37. Sutton CS, Haaga JP: CT evaluation of lhnited splenic trauma. J Comput Assist Tomogr 1987;11:167-169. 38. Sizer JS, Wayne ER, Frederick PL: Delayed rupture of the spleen: Review of the literature
19:4 April 1990
and report of six cases. Arch Surg 1966; 92:362-366. 39. Campbell WB: Delayed rupture of the sp]een can masquerade as appendicitis. Ann R Coll Surg Engl 1983;65:396.
19:4 April 1990
40. Sujka SK, Evans EJ, Nigam A: Delayed rupture of the spleen presenting as a scrotal hematoma. J Trauma 1986;26:85-86. 41. Rosoff L, Cohen JL, Telfer N, et ah Injuries of the spleen. Surg Clin North A m 1972;
Annals of Emergency Medicine
52:667-685. 42. T r u n k e y DD: Spleen, in Blaisdel FW, Trunkey DD (eds): Trauma Management, Volume I: Abdominal 2):auma. New York, ThiemeStratton Inc, 1982, p 185-197.
403/97
