RICE & MICE: Spleen injuries

Just a month ago, Dallas Cowboys tight end, Jason Witten had suffered a lacerated spleen  in a preseason football game that threatened his ability to play this season. Fortunately, his spleen laceration was not severe enough to require surgery and he was able to recover in an extraordinarily fast time in order to play in the season opener just 23 days later.

Of course, I ended up having a great conversation with a patient about why they didn’t operate on Jason Witten’s lacerated spleen.

The spleen is located in the upper left side of the belly and sits snugly behind the stomach and tucked up under the ribs. Though seemingly well-protected by the ribs, the spleen is the most commonly affected organ when there is blunt trauma to the abdomen. Sources of blunt trauma are falls, car accidents, and, of course, sports.

Even though the spleen is not vital for survival, it does have some important responsibilities and functions. It’s similar in structure to a lymph node but, much larger in size, and filters blood similar to the way lymph nodes filter blood. It helps filter infections by removing antibody covered bacteria and acts as a recycling plant for old or damaged red blood cells. It also stores red blood cells (as much as 30% of the total red blood cells) as well as white blood cells, or lymphocytes. It also produces lymphocytes. An average red blood cell only lives for 120 days, however in some blood disorders, this life span is shorter which causes the spleen to work a bit harder and it becomes enlarged.

Splenomegaly, or enlarged spleen, is caused by conditions such as cancer, blood disorders and certain types of anemia, viral infections, like infectious mononucleosis, and some bacterial and parasitic infections. Still, in other cases, the spleen can go haywire and collect normal cells for reasons that we just don’t know. In a condition called, idiopathic thrombocytopenic purpura (ITP) the spleen collects healthy platelets, cells that clot the blood, and there is risk of easy bleeding.

You may recall that fomer Flyer Peter Zezel had a blood disorder called hemolytic anemia. Hemolytic literally means breakdown of blood cells and this condition results in the body breaking down red blood cells faster than it can produce new ones.  In some forms of hemolytic anemia, the red blood cells are broken down and recycled in the spleen faster than they are replaced, causing the spleen to enlarge. In May, 2009 Zezel was scheduled to have a splenectomy when complications arose that caused him to slip into a coma and was subsequently taken off of life support.

A normal sized spleen is usually not felt when examining the abdomen, however when enlarged the spleen can get big enough become palpable. Enlargement also increases susceptibility to injury from blunt trauma or sudden deceleration (as seen in car accidents and falls).

Injuries to the spleen are considered a hematoma or a laceration and are graded on a scale of 1-5 based on severity, 1 being the least severe and 5 being a total destruction of the spleen. Since we know that  the spleen can store blood and that it can enlarge in certain conditions, an injury to the spleen can result in serious internal bleeding. In the past injuries to the spleen were treated by removing the spleen, however our understanding of the spleen and how to treat injuries to it has led to more conservative management when possible. Nowadays, most injuries to the spleen can heal without surgery. This can take from six weeks to months after the injury depending on how badly the spleen was injured. There is a small chance that the spleen laceration may bleed again after discharge from the hospital, so rest is very important.

Sometimes, spleen injuries aren’t immediately apparent, especially with the less severe grades of injury. In most cases, the patient will complain of left upper abdominal pain and tenderness. There may also be referred pain to the left shoulder due to irritation of the nerves that supply the diaphragm. If these symptoms are present in light of a history of abdominal trauma, an ultrasound or CT scan can be used to confirm suspected spleen injuries.

The grading scale above is based on CT scan findings. Injuries that cause more severe bleeding will cause subtle signs of early shock, such as a fast heartbeat, rapid shallow breathing, anxiety and restlessness, as well as pallor. Severe bleeding from a spleen injury will cause overt shock, including low or dropping blood pressure and altered mental status, abdominal distension and abdominal pain, tenderness or rigidity. Low blood pressure in a patient with suspected spleen injury is a surgical emergency and should prompt immediate surgical evaluation and intervention.

If a patient is in shock, but can be stabilized, then a method to stop the bleeding, called arterial embolization, can be used, rather than an open surgical procedure. Arterial embolization is the selective blocking of arteries by purposely introducing emboli, or foreign bodies through a catheter that block blood flow. In other cases, the best management is rest and observation.

Because of its role in fighting infections, when the spleen is removed, people become vulnerable to these infections the post-splenectomy patient should receive pneumococcal, meningococcal, and haemophilus influenzae (Hib) vaccinations.

NHLers that have injured their spleens, in no particular order:

Sean Avery: Spleen laceration, April 2008, Treated non-operatively, however he was observed in the hospital for 5 days.

Matt Hunwick: Ruptured spleen, April 2009. Treated non-operatively after initial evaluation and CT scan that showed a lacerated spleen, observed in hospital for 24 hours, then sent home, worsening pain led to a second evaluation and CT scan that showed a ruptured spleen and was thus treated surgically with splenectomy.

Peter Forsberg: Ruptured spleen, May 2001 treated operatively with splenectomy

Sami Lepisto: lacerated spleen, April 2009, treated non-operatively

Francois Beauchemin: lacerated spleen, December 2006, treated non-operatively

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