From the Guidelines
The balance sign in splenic injury is a critical diagnostic finding that indicates the presence of both intraperitoneal and subcapsular hemorrhage, suggesting an unstable injury that may progress to complete rupture. This sign is characterized by the presence of blood collections both under the splenic capsule (subcapsular hematoma) and within the peritoneal cavity surrounding the spleen, appearing as a crescent-shaped fluid collection around the spleen with a visible interface between the two different blood collections on CT scans 1. The balance sign is clinically significant because it often corresponds to higher-grade splenic injuries (grade III or above) and may influence management decisions regarding the need for surgical intervention versus conservative management 1. Patients with a positive balance sign typically require closer monitoring as they have a higher risk of delayed splenic rupture, which can lead to life-threatening hemorrhage 1. Key considerations in managing patients with a balance sign include the use of angiography and angioembolization (AG/AE) in hemodynamically stable patients with moderate and severe lesions, as well as the presence of vascular injuries at CT scan 1. The reported success rate of non-operative management (NOM) with AG/AE ranges from 86 to 100%, with a success rate of AG/AE from 73 to 100% 1. Some studies suggest that AG/AE should be considered in all hemodynamically stable patients with high-grade splenic injuries, regardless of the presence of CT blush 1. However, controversies exist regarding which kind of lesions should be considered as “high-grade” and should undergo routine AG/AE 1. In general, the management of patients with a balance sign should be individualized, taking into account the severity of the injury, the presence of vascular injuries, and the patient's hemodynamic status 1.
From the Research
Balance Sign in Splenic Injury
The balance sign, also known as the "balance test" or "tilt test", is not explicitly mentioned in the provided studies as a diagnostic tool for splenic injury. However, the studies discuss various diagnostic methods for detecting intra-abdominal bleeding and splenic injury, including:
- Diagnostic Peritoneal Lavage (DPL) 2
- Ultrasonography 2, 3
- Computed Tomography (CT) scan 2, 3, 4
- Angiographic embolization (AE) 4
Diagnostic Methods
The studies highlight the importance of early diagnosis and monitoring of splenic injuries, and the choice of diagnostic method depends on the patient's condition and the availability of resources. For example:
- DPL is a simple and precise method for initial diagnosis of intra-abdominal bleeding, but it may not be suitable for haemodynamically unstable patients 2
- Ultrasonography is a non-invasive and useful method for monitoring intrasplenic and subcapsular hematomas, but it may not be applicable in disturbed and haemodynamically unstable patients 2, 3
- CT scan is a highly precise method for diagnosing splenic injuries and monitoring bleeding, but it can only be applied in haemodynamically stable patients 2, 3, 4
Key Findings
The studies also report on the outcomes of different treatment approaches for splenic injuries, including: