How do you treat a small splenic injury in a patient with end-stage liver disease (ESLD)?

From the Guidelines

Management of a small splenic injury in a patient with end-stage liver disease (ESLD) typically requires a conservative, non-operative approach with close monitoring in an intensive care unit. This approach is supported by recent guidelines and studies, including the World Society of Emergency Surgery Nijmegen consensus practice 1, which emphasizes the importance of preserving splenic parenchyma and function. The use of non-operative management (NOM) has been shown to be effective in up to 90% of patients with splenic injury, with a success rate of over 80% in avoiding surgical intervention 1.

Key considerations in the management of small splenic injuries in ESLD patients include:

• Hemodynamic stabilization with careful fluid resuscitation using crystalloids and blood products as needed, while avoiding excessive volume that could worsen portal hypertension
• Strict bed rest for at least 24-48 hours, with frequent vital sign checks and serial hemoglobin measurements every 6-8 hours to detect ongoing bleeding
• Abdominal CT scans should be repeated at 24-48 hours to assess injury stability
• Correction of coagulation abnormalities with fresh frozen plasma, platelets (target >50,000/μL), and vitamin K (10 mg IV daily for 3 days) 1
• Pain management with acetaminophen (avoiding NSAIDs and opioids when possible) to prevent splenic blood flow increases from tachycardia

Surgery is generally avoided due to high mortality risks in ESLD patients from portal hypertension, coagulopathy, and poor hepatic reserve, but may be necessary for hemodynamic instability despite resuscitation 1. The WSES classification and guidelines for adult and pediatric patients with splenic trauma also support the use of NOM in hemodynamically stable patients, with a reported success rate of near 90% in high-volume centers with all facilities 1.

Overall, the conservative approach is preferred because ESLD patients have increased bleeding risk from portal hypertension and coagulopathy, while their compromised liver function reduces their ability to tolerate major surgical interventions.

From the Research

Treatment of Small Splenic Injury in Patients with End-Stage Liver Disease

• The treatment of small splenic injuries in patients with end-stage liver disease (ESLD) is complex and requires careful consideration of the patient's overall condition 2.
• Non-operative management (NOM) is the standard of care for hemodynamically stable patients with blunt splenic injury (BSI), but the presence of ESLD may increase the risk of bleeding and require a more cautious approach 3, 4.
• Angioembolization may be used to increase the success rate of NOM and reduce the risk of bleeding in patients with ESLD 3.
• The decision to operate or manage non-operatively should be based on the patient's hemodynamic stability, the severity of the splenic injury, and the presence of other injuries or comorbidities 4, 5.
• Close monitoring and regular follow-up are essential to ensure that the patient's condition does not deteriorate and that any complications are promptly addressed 6.

Considerations in Patients with ESLD

• Patients with ESLD are at increased risk of bleeding due to coagulopathy and thrombocytopenia, which may affect the management of splenic injuries 2.
• The presence of portal hypertension may also increase the risk of bleeding and require a more aggressive approach to management 2.
• The use of blood transfusions and other supportive measures may be necessary to manage bleeding and stabilize the patient 4, 5.

Clinical Algorithm

• A clinical algorithm can be developed to standardize the management of BSI in patients with ESLD, taking into account the patient's hemodynamic stability, the severity of the splenic injury, and the presence of other injuries or comorbidities 3.
• The algorithm should include criteria for NOM, angioembolization, and operative management, as well as guidelines for monitoring and follow-up 3, 4, 5.