From the Guidelines
Computed tomography (CT) with intravenous contrast is the best imaging modality for suspected splenic rupture. When a patient presents with left upper quadrant pain following trauma or with signs of hemodynamic instability, a contrast-enhanced CT scan should be performed promptly to evaluate for splenic injury, as recommended by the World Journal of Emergency Surgery in 2017 1. The CT scan should include portal venous phase imaging, which allows for accurate assessment of splenic parenchymal injury, active bleeding, hemoperitoneum, and associated injuries to other abdominal organs.
Key Points to Consider
- CT scan is the gold standard in hemodynamically stable or stabilized trauma patients, with a sensitivity and specificity for splenic injuries near to 96–100% 1.
- E-FAST is effective and rapid to detect free fluid, but it lacks the sensitivity and specificity to fully characterize splenic injuries 1.
- Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization and in follow-up, but they are not the primary diagnostic modality for suspected splenic rupture 1.
- The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient, with CT scan being the preferred modality in hemodynamically stable patients 1.
Clinical Considerations
- In hemodynamically unstable patients, bedside ultrasound may be used as the initial diagnostic modality to identify the need for emergent laparotomy, but CT scan should be performed as soon as the patient is stabilized 1.
- The presence of contrast blush, pseudo-aneurysms, and arterio-venous fistula on CT scan are indicators of vascular injuries and may require angiography and angioembolization 1.
- The grade of splenic injury, as determined by CT scan, directly influences management decisions ranging from observation to surgical intervention 1.
From the Research
Imaging Modalities for Suspected Splenic Rupture
The best imaging modality for suspected splenic rupture can be determined based on various studies that have evaluated the effectiveness of different imaging techniques.
- Ultrasound: Ultrasound is a commonly used initial imaging modality for suspected splenic rupture, especially in emergency settings 2, 3. It is non-invasive, quick, and can be performed at the bedside. However, its accuracy may be limited in certain cases, such as in patients with significant abdominal gas or in those with subtle injuries.
- Computed Tomography (CT): CT is considered the gold standard for evaluating splenic injuries 4, 5. It provides detailed images of the spleen and surrounding structures, allowing for accurate assessment of the extent of injury. CT can also help identify other potential injuries or complications.
- Contrast-Enhanced Sonography: Contrast-enhanced sonography has been shown to be a promising tool in the assessment of splenic trauma 2. It can provide additional information about the extent of injury and help identify injuries that may not be visible on unenhanced sonography.
Factors Influencing Imaging Modality Choice
The choice of imaging modality may depend on various factors, including:
- Clinical Stability: Hemodynamically unstable patients may require immediate imaging with CT or ultrasound to quickly assess the extent of injury and guide management decisions 4, 5.
- Injury Severity: Patients with severe injuries may require CT to accurately assess the extent of injury and identify potential complications 4, 5.
- Availability of Resources: The availability of imaging modalities and expertise may influence the choice of imaging modality in certain settings.
Follow-Up Imaging
Follow-up imaging may not be necessary in all cases of suspected splenic rupture, especially in clinically stable patients with low-grade injuries 6. However, follow-up imaging may be useful in certain cases, such as in patients with high-grade injuries or in those with concerns about potential complications.