What are the treatment options for a diseased or injured spleen?

Treatment Options for Diseased or Injured Spleen

Non-operative management (NOM) is the first-line treatment for hemodynamically stable patients with splenic injuries, regardless of injury grade, while operative management is indicated for hemodynamically unstable patients or those with associated injuries requiring surgical exploration. 1

Assessment and Diagnosis

• Hemodynamic status is the primary determinant of treatment approach:

  • Stable: Consider non-operative management
  • Unstable: Proceed to operative management

• Diagnostic imaging:

  • E-FAST (Extended Focused Assessment with Sonography for Trauma): Rapid detection of free fluid 1
  • CT scan with IV contrast: Gold standard for hemodynamically stable patients to define anatomic injury and identify associated injuries 1
  • Doppler US and contrast-enhanced US: Useful for evaluating splenic vascularization and follow-up 1

Treatment Algorithm

1. Non-Operative Management (NOM)

NOM is recommended for:

• Hemodynamically stable patients
• Absence of peritonitis
• No hollow organ injuries requiring surgery
• No bowel evisceration or impalement 1

NOM includes:

• Close clinical observation
• Hemodynamic monitoring in ICU/high dependency environment
• Serial clinical examinations and laboratory tests
• Immediate access to diagnostics, interventional radiology, and surgery
• Immediate availability of blood products 1

Angiography/Angioembolization (AG/AE)

• Consider as first-line intervention in stable patients with:

  • Arterial blush on CT scan
  • Pseudo-aneurysms
  • Arteriovenous fistula
  • WSES grade III lesions (regardless of CT blush)
  • Signs of persistent hemorrhage 1

• Proximal or combined AG/AE recommended for:

  • Multiple splenic vascular abnormalities
  • Severe lesions 1

2. Operative Management (OM)

OM is indicated for:

• Hemodynamically unstable patients
• Peritonitis
• Associated hollow organ injuries requiring surgery
• Bowel evisceration or impalement
• Failed NOM with AG/AE
• Centers without intensive monitoring capabilities or AG/AE availability 1

Surgical options include:

• Splenectomy: When NOM fails and patient remains unstable or requires continuous transfusions 1
• Partial splenic salvage: Attempted in 50-78% of cases 1
• Splenorrhaphy: Rarely used (only 1-6% of cases) 1
• Laparoscopic splenectomy: Only for stable patients with low-moderate grade injuries 1, 2

Special Considerations

Pediatric Patients

• NOM is strongly preferred in hemodynamically stable children 1
• Splenectomy should be avoided when possible 1
• The presence of contrast blush on CT is not an absolute indication for splenectomy or AG/AE in children 1

Patients with Severe Traumatic Brain Injury

• In WSES class II-III splenic injuries with severe traumatic brain injury:
  • NOM only if rescue therapy (OR and/or AG/AE) is rapidly available
  • Otherwise, splenectomy should be performed 1

Post-Treatment Management

Follow-up for NOM

• Bed rest for 48-72 hours in moderate and severe lesions 1
• Consider repeat CT scan for:
  • Moderate and severe lesions
  • Decreasing hematocrit
  • Presence of vascular anomalies
  • Underlying splenic pathology
  • Coagulopathy
  • Neurologically impaired patients 1
• Activity restriction: 4-6 weeks for minor injuries, 2-4 months for moderate/severe injuries 1

Thromboprophylaxis

• Mechanical prophylaxis is safe and recommended 1
• LMWH-based prophylactic anticoagulation may be safe in selected patients with blunt splenic injury 1

Post-Splenectomy Care

• Vaccination: Required against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis) 1, 3

  • Start no sooner than 14 days after splenectomy or total vascular exclusion
  • If discharged before 15 days, vaccinate before discharge 1
  • Annual influenza vaccination recommended 1

• Antibiotic prophylaxis: Consider for any sudden onset of fever, malaise, or chills 1

• Patient education: Inform about increased infection risk and need for prompt medical attention for fevers 3

Complications to Monitor

• Overwhelming post-splenectomy infection (OPSI) 3, 4
• Postoperative bleeding (1.6-3% incidence with 20% mortality) 1
• Portal hypertension in chronic liver disease patients with splenomegaly 5

Pitfalls and Caveats

1. Don't miss associated injuries: 20-30% of splenic trauma cases have multiple injuries 1

2. Beware of delayed splenic rupture: Can occur days to weeks after initial injury

3. Consider underlying splenic pathology: Conditions like sickle cell disease can affect splenic function and healing 6

4. Avoid non-operative management in inappropriate settings: NOM should only be attempted in centers with proper monitoring capabilities and immediate access to surgery 1

5. Recognize hyposplenism early: Proper management of asplenia is crucial to prevent overwhelming infections through vaccination and antibiotic prophylaxis 3