What Are the Most Common Causes of Spleen Pain?

According to the different causes of spleen injury, it can be divided into three categories: traumatic spleen injury, iatrogenic spleen injury and spontaneous spleen injury. Among them, more than 85% of spleen injury is caused by trauma, iatrogenic spleen injury and spontaneous spleen injury are insufficient. 15%.

Jiang Hongchi

(Chief physician)

The First Affiliated Hospital of Harbin Medical University

The spleen is located deep inside the ribs on the lower left side of the thorax, weighing about 75-150 grams and fragile. It is one of the most vulnerable organs in the abdominal organs. The incidence of spleen injuries can be as high as in various abdominal traumas. 40% -50%. The spleen rupture caused by a traffic accident is the first (about 50% -60%), and the others are fall injury, blow injury, bruise, knife injury, etc. in this order. Treatment shows that spleen rupture accounts for about 10% of developmental abdominal injuries, and spleen rupture accounts for about 20% -40% of closed abdominal injuries. The spleen rupture is more dangerous, and it is often associated with damage to other organs. The clinical manifestations are complex, requiring timely diagnosis and proper treatment, otherwise it can be life-threatening, and its mortality rate is 3% -23%. The mortality rate of patients with spleen pedicle or large blood vessel injury can reach 70%.

Western Medicine Name: Spleen injury
Affiliated Department: surgical-
Disease site: spleen

The main symptoms: Shock, abdominal pain, nausea, bloating, etc.
Main cause: Trauma, iatrogenic, etc.
Contagious: Non-contagious

Classification of Spleen Injury Diseases

Causes of spleen injury

(1) Traumatic spleen injury: According to different injury factors, traumatic spleen injury can be divided into two types: open spleen injury and closed spleen injury. Open spleen injury: It is mostly caused by stabbing, bullet penetration and explosion. Injuries of other organs are often combined, especially during wartime. Closed spleen injury: also known as blunt spleen injury, which mostly occurs in traffic accidents, followed by fall injury, left chest injury and left upper abdominal contusion. Abdominal trauma is the main cause in children.

(2) Spontaneous splenic injury: Spontaneous rupture of pathological spleen and normal spleen. The former is more common, such as malarial spleen or congestive splenomegaly. The original diseases of the spleen can be used as the internal cause of spontaneous spleen injury, while minor trauma and even daily activities may be the cause of spontaneous spleen injury. Such as fever, tiredness, cough, vomiting, sexual intercourse, sudden turn around, childbirth, etc. may cause spontaneous splenic injury.

(3) Iatrogenic spleen injury: It can be summarized as the following causes. Injury during surgery: It is the most common cause of iatrogenic spleen injury. It mostly occurs in the operation of organs and tissues near the spleen. Colon and kidney surgery are more common. Invasive operation and treatment: such as spleen biopsy, transsplenic liver portal vein angiography, splenic artery embolization, etc. Because of the spleen itself in these patients, pathological changes such as spleen congestion and swelling, poor coagulation mechanism, etc., can easily cause spleen injury. ^[1-2]

Pathophysiology of spleen injury

Pathology: Most of the spleen ruptures are split along the edge of the spleen. The lower spleen is the most common. This is because the lower spleen is poorly protected by the costal arch, and the spleen is fragile and vulnerable to damage. Most of the spleen injury does not involve the main large blood vessels in the spleen hilum. If the ruptured wound is along the direction of the spleen, there will be less rupture of the blood vessels in the spleen, and the bleeding will be slow and of short duration. If the slit crosses the spleen, the blood vessels are severely damaged, the amount of bleeding is large, and the duration is long. If the spleen pedicle and spleen hiatus are involved, a large amount of bleeding will occur in a short time, and hemorrhagic shock will occur, which is life-threatening.

Types of spleen injury and spleen rupture

1. Central rupture: refers to the rupture of the central region of the spleen, mostly localized bleeding, and often without clear blood loss. The prognosis of this kind of spleen rupture more than bleeding, hematoma keeps increasing, eventually causing rupture; secondary infection of hematoma; self-healing of hematoma absorption.

2. Subcapsular rupture: refers to a substantial laceration under the spleen capsule, but the capsule remains intact, more than a tension hematoma under the capsule. There is no clear clinical manifestation of abdominal hemorrhage in the clinic, and the pain in the left quarter costal region may not be obvious, so it is not easy to detect. If the bleeding stops, it can be gradually absorbed and healed by fibrosis. However, if bleeding persists, it may cause spleen rupture, leading to major bleeding, which can catch patients and doctors by surprise.

3. True rupture: refers to the simultaneous spleen parenchyma and capsular fissure with typical intra-abdominal bleeding. It is the most common type in clinical practice, and severe cases cause death in a short time.

4. Delayed rupture: Central rupture and subcapsular rupture can continue to develop, causing the parenchyma and the membrane to be ruptured, that is, true rupture.

Classification of spleen injury and spleen rupture

There are dozens of grading methods for traumatic spleen rupture at home and abroad. These grading systems are summarized on the basis of practice. Each of them reflects the characteristics and laws of spleen rupture from different aspects and to varying degrees. It is scientific and practical. The classification of the degree of spleen injury passed at the Sixth National Splenic Surgery Symposium by Chinese scholars is simple and practical. The level of spleen injury can be quickly judged based on this; it is comprehensive and involves from the capsule to the parenchyma and from the branch to the trunk

All vascular injuries; adapt to the characteristics of the common spleen injury mechanism in China. Has been widely adopted in China. The grading standard is specifically: spleen rupture grading level : splenic rupture or slight damage to the capsule and parenchyma, the length of spleen laceration seen during surgery 5.0cm, depth 1.0cm; grade : total length of spleen laceration> 5.0 cm, depth> 1.0cm, but the splenic hilum is not involved, or the blood vessels of the spleen are involved; Grade III: spleen rupture and spleen hilum or spleen separation, or blood vessels of the spleen lobe damaged; Grade : extensive spleen rupture, or The spleen pedicle and arteriovenous trunk were damaged. ^[3]

Clinical manifestations of spleen injury

(1) Symptoms: Hypotension and hemorrhagic shock: With the increase of blood loss, patients will experience symptoms of hemorrhagic shock such as irritability, thirst, palpitations, shortness of breath, pale skin, and cold limbs. Physical examination will show that the patient's blood pressure drops progressively, and the pulse is fast and weak. Post-traumatic stress and injury with other organs may have an impact on pulse and blood pressure. Such as duodenal rupture. The peritoneum is stimulated by the leakage of digestive fluid from the duodenum, and early symptoms such as hypotension and fast pulses can be improved after a short time, but then it will worsen. Abdominal pain is the most common symptom, mostly caused by trauma It is caused by abdominal soft tissue injury, etc., but the spleen capsule sensory nerve stimulation caused by spleen injury often does not attract patients' attention. If the severely injured person has sudden and severe abdominal pain, which extends from the left upper abdomen to the whole abdomen, this is caused by the spread of spleen rupture and bleeding to the abdominal cavity, which indicates that the condition is serious and the outcome is bad. Nausea and vomiting: more common, especially in the early stages. Mainly due to bleeding stimulating the peritoneal autonomic nerve. If the symptoms are significantly worse, it may also suggest gastrointestinal perforation and peritonitis. bloating: mostly caused by bleeding. A small amount of bleeding may not have obvious abdominal distension at an early stage, but with the extension of time, peritonitis can cause intestinal paralysis and increase abdominal distension.

(2) Signs: The patient bends and bends, is indifferent, the blood pressure drops, and the pulse speed increases. If there is a large amount of abdominal bleeding, it can be manifested as abdominal distension, meanwhile, there is abdominal tenderness, rebound pain and abdominal muscle tension. At the time of the percussion, there were moving dullness in the abdomen, and the bowel sounds weakened. Douglas was full on digital rectal examination. Sometimes the left shoulder is involved in pain due to blood irritation of the left diaphragm. When the breath is deepened, the involved pain is aggravated. This is the Kehr sign.

(3) Delayed splenic rupture: Hematomas formed by rupture of the spleen and a small number of true spleens are enclosed by surrounding tissues such as the omentum to form a localized hematoma. The spleen can break through the capsule and clot within 36-48 hours to cause typical bleeding And peritoneal irritation symptoms. Rupture usually occurs within 2 weeks, and a few cases can be delayed until several months later.

Diagnosis and identification of spleen injury

The diagnosis of traumatic spleen rupture is generally not difficult. According to the history of trauma, clinical manifestations and the results of abdominal puncture, the accuracy rate is as high as 90%. However, the amount of bleeding is small and the symptoms of spleen injury are easy to be ignored. In addition, the symptoms of multiple organ damage caused by trauma are not easy to distinguish from spleen rupture. Although the clinical manifestations of spontaneous spleen injury are similar to those of traumatic spleen injury, it is often not diagnosed before surgery because there is no obvious history of trauma. Therefore, if the condition permits, imaging examinations such as B-ultrasound and CT should be performed to further diagnose and dynamically observe the extent and scope of spleen injury. It should be noted that these objective indicators are also of great significance for clinical classification and grading, formulation of treatment plans and evaluation of curative effects.

Auxiliary examination of spleen injury

1. Laboratory tests: Routine blood red blood cell counts and hemoglobin are gradually decreased during spleen rupture and bleeding, and white blood cells may be slightly increased. Other tests such as electrolytes, coagulation function, blood type, and amylase are not specific to the diagnosis, but also Should be used as a routine examination of abdominal trauma to help differentiate and diagnose other combined injuries and determine the condition.

2. Diagnostic abdominal puncture and lavage: It is an invasive test with a positive rate of more than 90%, and it is very helpful for the diagnosis of organ damage and what kind of organ damage in the abdominal cavity. If the extracted fluid is fresh, non-coagulated or bloody fluid, it is proved that the internal organs have bleeding. If the extracted fluid is turbid, it is a characteristic of gastrointestinal rupture.

3. Ultrasound: It is the preferred method, which has the advantages of non-invasive, economical, and fast. It can show broken spleen, larger subcapsular hematoma, and hemorrhage in the abdominal cavity. It helps to observe the degree and classification of spleen injury, and can help to observe the development of the disease dynamically.

4. X-ray examination: It is helpful to judge the situation of abdominal hemorrhage and the damage of cavity organs such as gastrointestinal tract.

5. CT examination can clearly show the morphology and anatomical structure of the spleen, and it is very accurate for diagnosing spleen parenchyma or subcapsular hematoma.

6. Nuclide scanning can use 99m 99 colloidal sulfur scanning or gamma photography to diagnose spleen injury, the method is safe.

7. Selective abdominal angiography This is an invasive test, the operation is more complicated and there are certain risks. However, the accuracy of diagnosis of spleen rupture is quite high, and it can show the damaged arteries and parenchymal parts of the spleen. It is only used for closed injuries where the injury is stable and other methods have not been clearly diagnosed.

8. Magnetic resonance imaging: generally not used for emergency diagnosis, and is limited to patients with stable disease and difficult diagnosis. It has advantages in examining bleeding and hematoma.

9. Laparoscopy: Diagnosing is difficult and indications of laparotomy are unclear, can be used at the same time as a treatment.

10. Diagnostic laparotomy: In a few cases, neither external abdominal injury can be ruled out, nor can special examinations be performed. The condition is gradually worsening, and it is used for clear diagnosis and timely treatment.

Differential diagnosis of spleen injury

1. Liver rupture: It accounts for 15% -20% of various abdominal injuries. Right liver rupture is more common than left liver. The injury factors, pathological types and clinical manifestations of liver rupture are very similar to spleen rupture. Liver and spleen rupture are mainly manifested by intra-abdominal hemorrhage and hemorrhagic shock. When the spleen is ruptured, the signs of peritoneal irritation caused by bloody peritonitis are not obvious. However, bile may enter the abdominal cavity after liver rupture. Therefore, abdominal pain and peritoneal irritation are often more pronounced than those of spleen rupture. After liver rupture, blood sometimes enters the duodenum through the bile ducts, and the patient develops melena or vomiting. B-ultrasound is the first choice for diagnosis of liver and spleen rupture.

2. Left kidney rupture: Mainly manifested as pain in the left waist, occasionally no mass can be felt in the left waist, lumbar muscles are tense, hematuria is often found, X-rays are helpful for identification, and pyelography can confirm the diagnosis.

3. Pancreatic injury: It usually occurs in the body and tail of the pancreas. The increase in blood and urine amylase can help identification.

It should be emphasized that the above-mentioned injuries may sometimes coexist with spleen injury, so it is not possible to rule out the presence of the above-mentioned injury combined with spleen injury. In addition, intra-abdominal malignant tumor rupture and bleeding or ectopic pregnancy (ectopic pregnancy) rupture and bleeding often need to be distinguished from spleen rupture.

Treatment of Spleen Injury Diseases

In recent years, with the in-depth understanding of spleen function and the improvement and popularization of modern imaging technologies such as ultrasound and CT, the concept of diagnosis has also changed accordingly. The concept of modern spleen surgery has been formed. Instead of blindly removing the spleen, Based on the principle of "life first, spleen protection second" and individualized treatment principles, minor injuries can be treated conservatively, while heavier injuries require timely and effective surgical treatment. Surgical treatment must also be based on the patient For the specific situation, choose the most suitable technique.

Non-surgical treatment of spleen injury

(non-operative management, NOM):

Indications for NOM: Those who intend to implement NOM should generally meet the following conditions: Simple spleen rupture. Hemodynamic stability was stable after the injury, and the transfusion volume was not more than 2-4 units. Non-open injury. The patient's age is <50 years. Clinical symptoms gradually improved. From foreign experience, the indications for NOM are now gradually expanding: pathological spleen rupture, open spleen trauma, and elderly patients can be cured by NOM. As the direct evidence for choosing a treatment method, the imaging data provided by CT has been widely valued. We believe that under specific conditions, because doctors' grasp of monitoring indicators varies from person to person, patients of different ages and constitutions respond to the same N OM measure differently.Therefore, we must follow the general principles in clinical work. Under the premise of insisting on "individualized" solutions, it is not wise to rely too much on any quantitative indicators.

Specific measures of NOM: At present, the specific measures of NOM implemented at home and abroad are roughly the same, including absolute bed rest, strict ICU monitoring, fasting, fluid treatment, use of hemostatic drugs, prophylactic antibiotics, and CT or ultrasound follow-up. Treatment failure usually occurs within 96 hours, but it is not uncommon to occur within 6-20 days. Failure can be due to delayed bleeding, secondary infections, and so on. Delayed splenic rupture usually occurs within 2 weeks after injury. Therefore, bed rest should be strictly maintained for more than 2 weeks during non-surgical treatment. Cough, stool force and other factors that increase abdominal pressure should be avoided during non-surgical treatment. Vigorous activities should be avoided for 6-8 weeks. Physical contact sports should be avoided for at least 6 months or until CT showed that old lesions were fully absorbed. During the observation period, if one of the following conditions is found, surgery should be switched: abdominal pain and / or local peritoneal irritation continue to increase; blood transfusion volume> 4 units within 24 hours and vital signs are still unstable; hematocrit continues to decrease and blood transfusion is passed Can not be quickly corrected; observation can not rule out the damage to other organs in the abdomen.

Selective splenic vascular embolization is another effective and minimally invasive method. Its indications are relatively wide, and it also has a good effect on some injuries involving the splenic hiatus and spleen pedicle blood vessels, but it is necessary to maintain the patient's vital signs basically stable before surgery and to exclude severe extrasplenic organ damage. Its advantages are: it has the general characteristics of minimally invasive treatment, with less trauma and quick recovery; simultaneous diagnosis and treatment. Splenic arteriography can determine the location, extent, and speed of bleeding. Combined with CT, a comprehensive injury assessment can be obtained. After hemostasis by embolization, angiography can be performed again to determine the hemostatic effect. Due to the dual blood flow of the spleen, the necrotic spleen tissue can be regenerated after embolization, and the spleen function is well preserved.

Spleen Injury Surgery

Indications for surgical treatment: The indications for surgical treatment of spleen rupture proposed by Powell and others are still representative, including hemodynamic instability, intrasplenic and extrasplenic organ damage, and ISS (injur y severity score)> 15 , Adult AAST classification> III, CT showed indicators of massive abdominal hemorrhage, active bleeding, and high energy mechanisms. Cathey et al suggested that laparotomy should be performed in the following cases: systolic blood pressure <100mmHg, pulse> 100 beats / min, hematocrit <30, PT> 13 seconds, unconsciousness, advanced age, etc.

Surgical treatment methods: Since the 1970s, during the treatment of spleen rupture, the indications for splenectomy have been severely restricted; while spleen-preserving surgery is in the ascendant, showing a trend of diversification and minimally invasive. Each technique has its own scope of application, and how to make a reasonable choice has become a new topic in clinical work. We have proposed a corresponding treatment plan according to the degree of spleen injury and proved its feasibility in a large number of clinical practices: Grade : Non-surgical treatment, adhesive coagulation and hemostasis, suture repair; Grade : suture repair, Partial splenectomy, rupture banding, splenic artery ligation; Grade III: Partial splenectomy, splenic artery ligation; Grade IV: Total splenectomy + autologous splenic tissue transplantation. When implementing spleen-preserving surgery, there are two points to note: Four principles of spleen-preserving must be followed. That is to protect the spleen first, then give priority to the spleen at a young age, choose surgical methods and the combined application of various surgical methods according to the specific situation; pay attention to the technical points of various surgical methods. For the treatment of the spleen section, we have relatively mature experience: we can use suture plus mesh cover to compress the package, stuffing hemostasis, gluing method, physical hemostasis, and comprehensive bloodless technique. . There are many methods for autologous splenic slice transplantation after splenectomy. We have confirmed through observation that autologous spleen tissue transplantation in the omentum spleen decapsulated splenic mass can maintain the spleen function to the utmost, and it can function 2-3 months earlier than foreign reporters, and it has become a standardized operation. In addition, severe splenic laceration may bleed faster and more, and splenic artery ligation can be performed first to create conditions for subsequent operations. There are still surgical procedures for treating severe traumatic spleen rupture with autologous partial or hemi-spleen transplantation with vascular pedicles, but few have been carried out. For iatrogenic spleen injury, the above-mentioned grading method should also be used to determine the corresponding treatment. The principle of protecting the spleen as much as possible should be implemented without significantly prolonging the operation time and affecting the prognosis.

Brief introduction of several surgical treatment methods:

local adhesive: mainly used for spleen injury of grade , can also be used for splenic repair and partial splenectomy for mild bleeding.

Local coagulation and hemostasis: There are many coagulation methods, such as laser, infrared, high-heat air, etc. The coagulation method can be used to treat the wound first, and the local application of biological materials is effective.

splenic artery ligation: Ligation of the splenic artery does not cause necrosis of the spleen. At present, this procedure is mainly used in the treatment of spleen injury and bleeding, and it is effective in combination with other spleen-preserving operations. It is characterized by retaining the complete structure of the spleen. By ligating the main artery of the spleen, the blood flow of the spleen is reduced, while the volume and tension of the spleen are reduced, which is conducive to suture and repair of the spleen.

suture repair of spleen rupture: it belongs to spleen-preserving surgery, and the technique is relatively simple. When conditions are available and the surgical indications are met, it should be preferred.

Partial splenectomy: It is suitable for grade spleen rupture, and the damage is limited. It is difficult to stop the hemostasis or the damaged spleen tissue has lost vitality. After partial splenectomy, more than half of the spleen can be retained.

Total splenectomy: It is widely used in China. Although it has been recognized that a series of adverse consequences will occur after splenectomy, this classic technique still has irreplaceable advantages. It has rapid and thorough hemostasis and wide indications. Features, in some special cases, are still the only choice.

Total splenectomy + autologous spleen tissue omentum intracapsular transplantation: Since the 1980s, it has been generally considered as an effective method to compensate spleen function after total splenectomy. It not only meets the need to quickly cut the spleen to control bleeding and ensure the safety of patients' life, but also can safely and reliably compensate the spleen function.

Autologous spleen tissue transplantation with vascular pedicle: This operation is difficult, but the operation is reliable, and the spleen function recovers quickly after surgery. It can be a good treatment under the conditions that meet the indications and technical requirements. ^[4-7]

Prognosis of spleen injury disease

The prognosis of patients with spleen injury depends on the degree of spleen injury, whether the diagnosis is timely and the bleeding rate, the amount of blood loss, and the severity of the combined injury. Careful preoperative preparation, delicate surgical procedures, and the amount of spleen tissue retained also have a certain impact on the prognosis. If the spleen rupture is not treated in time, more than 90% of the spleen dies due to hemorrhagic shock due to heart, lung, kidney and other important organ failure. The death rate of spleen injury in China is 5%, and the more the combined organ injury, the higher the mortality rate.

Spleen injury diet note

Patients with spleen injury should follow the general postoperative diet and precautions for patients after total splenectomy. For patients undergoing non-surgical treatment, they should also pay attention to the following aspects: keep the mood peaceful, avoid emotional excitement, and stay in bed as directed by your doctor; If you have symptoms of vomiting, bloating, abdominal pain, fever, etc. after leaving the hospital, you should come to the hospital at any time; pay attention to rest and diet, non-smoking alcohol, eat light, digestible food, and avoid overeating; constipation, pay attention to Adjust your diet and keep your stools open. Those who are ineffective can take laxatives orally to avoid forced defecation.

Complications of spleen injury

The main complications of spleen injury are intra-abdominal hemorrhage, secondary spleen cyst, spleen abscess, and surgery-related complications, such as postoperative bleeding, abdominal infection, lung infection, pancreatic fistula, spleen fever, and dangerous infection after splenectomy.

Expert opinion on spleen injury

For surgeons and patients with spleen injury, the biggest problems are no more than spleen preservation and surgical options. The author believes that the following principles should be followed when performing spleen preservation surgery: save life first and then save spleen; the younger the age, the better the choice of spleen; choose the most suitable surgical method according to the degree and type of spleen injury; use several combinations if necessary Surgical procedures are safer; Pay close attention and follow-up of patients after spleen retention surgery; In case of elderly patients, major organ dysfunction or obstacles, severe infections, complex multiple abdominal injuries, prolonged prothrombin time, in order to avoid causing Unexpectedly, splenectomy can be considered.