Spleen Injury (Ruptured Spleen)

What the spleen does

The spleen filters the blood, removes old red blood cells, stores platelets and blood, and helps fight infections, particularly from encapsulated bacteria such as pneumococcus, meningococcus and Haemophilus influenzae. It has a rich blood supply, which is why injuries can bleed heavily.

Causes

• motor vehicle crashes, the most common cause of abdominal trauma
• falls, including from bikes and horses
• contact sports: football, hockey, rugby, skiing collisions
• assaults and direct blows
• broken lower left ribs puncturing the spleen
• an enlarged spleen (splenomegaly) from mononucleosis, malaria, liver disease or blood cancers, which can rupture with minor trauma or even spontaneously

Symptoms

• pain or tenderness in the left upper abdomen, under the ribs
• pain in the left shoulder tip, caused by blood irritating the diaphragm (Kehr's sign)
• bruising over the left lower ribs or abdomen
• dizziness, lightheadedness or fainting
• rapid heartbeat, rapid breathing
• pale, cold, clammy skin
• confusion and signs of hemorrhagic shock with severe bleeding

Symptoms may be delayed for hours or, rarely, days, if bleeding is slow or contained under the spleen's capsule before it ruptures.

Grades of spleen injury

The American Association for the Surgery of Trauma grades splenic injuries from I to V:

Higher grades and active bleeding seen on CT increase the likelihood of needing intervention.

Diagnosis

• FAST ultrasound in the emergency room quickly detects blood in the abdomen
• CT scan with contrast: the main test in stable patients, showing the grade and any active bleeding
• blood tests: hemoglobin, repeated to track blood loss; blood type and crossmatch
• monitoring of heart rate, blood pressure and urine output

Treatment

Nonoperative management

Most stable adults and nearly all children with spleen injuries are treated without surgery:

• admission to hospital for monitoring
• bed rest and serial blood tests and exams
• blood transfusion if needed
• gradual return to activity

Angiographic embolization

An interventional radiologist passes a catheter through a blood vessel to block the bleeding artery. This preserves the spleen and avoids surgery in many people with higher-grade injuries or active bleeding.

Surgery

Emergency surgery is needed for people who are unstable from bleeding or fail nonoperative management. Options are repairing the spleen (splenorrhaphy), removing part of it, or removing it entirely (splenectomy).

Recovery

• hospital stay of a few days for monitoring
• avoid contact sports, heavy lifting and strenuous activity for typically 4 to 12 weeks or longer depending on grade; follow your surgeon's advice
• report new belly pain, shoulder pain, dizziness or fainting immediately during recovery, as delayed bleeding can occur

Living without a spleen

After splenectomy, the risk of serious infection (overwhelming post-splenectomy infection) is lifelong. Precautions include:

• vaccines against pneumococcus, meningococcus (including group B), Haemophilus influenzae type b, and yearly flu shots
• seeking urgent care for any fever
• sometimes daily or standby antibiotics
• carrying a medical alert card
• taking malaria precautions when traveling

Spleen injury and mononucleosis

The spleen enlarges in most people with mononucleosis, making it fragile. Athletes are generally advised to avoid contact sports for at least 3 to 4 weeks from the start of symptoms, and often longer, until cleared by a doctor.

Frequently asked questions

What are the symptoms of a ruptured spleen?

Pain in the left upper belly, pain in the left shoulder tip, tenderness, dizziness, fainting, a fast heart rate and pale, clammy skin after an injury. These signs of internal bleeding need emergency care.

Can a ruptured spleen heal on its own?

Many spleen injuries, especially lower grades, heal without surgery with monitoring in hospital and activity restrictions. Some need embolization or surgery if bleeding continues or the person becomes unstable.

Why does a spleen injury cause shoulder pain?

Blood from the injured spleen can irritate the diaphragm, which shares nerve pathways with the left shoulder. This referred pain in the left shoulder tip is called Kehr's sign and is an important warning sign.

How long after a spleen injury can I play sports?

It depends on the grade and treatment. Many people are advised to avoid contact sports for 6 to 12 weeks or longer. Your surgeon will guide your return, sometimes with a follow-up scan.

Can you live without a spleen?

Yes. Other organs take over most of its functions, but you will be more vulnerable to some serious infections for life. Vaccinations, prompt treatment of fever and sometimes preventive antibiotics greatly reduce that risk.