traumatic splenic rupture
Introduction
Introduction to traumatic spleen rupture Traumatic spleen rupture, common in wartime and peacetime, can occur in closed abdominal injury (abdominal skin integrity, abdominal cavity without the wound to communicate with the outside world), can also occur in open abdominal injury (abdominal skin loss of integrity) The abdominal cavity communicates with the outside through the wound). basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: rib fractures, kidney injury, spinal cord injury, liver injury, lung injury, craniocerebral injury, gastric injury
Cause
Causes of traumatic spleen rupture
Spleen trauma (35%):
The high incidence can be explained by the mechanism of trauma. In 1965, Gieseler's experiment proved that not only the direct trauma of the left abdomen can cause spleen injury, but also the indirect injury can cause spleen trauma, tight joint of the spleen and stomach wall and tight fixation of the surrounding ligament. Limits the sudden movement of the spleen, especially when the pressure in the abdominal cavity increases drastically, the upper and lower poles of the spleen are very narrow, and the sacral surface is curved into an extremely convex shape, and the bottom is overstretched to make the spleen extremely easy to traverse. In the case of trauma, the pressure in the spleen and the pressure in the stomach increase, and the increase in blood storage in the spleen leads to an increased likelihood of injury.
Indirect impact (25%):
Indirect impact during pregnancy may also cause sudden injury to the spleen. Even a small hematoma may cause rupture of the spleen parenchyma in the later stages of pregnancy. The expansion of the uterus increases the pressure in the abdominal cavity, and the spleen is further raised, while being surrounded by the surrounding ligaments. Tightly fixed, in this case, a slight increase in abdominal pressure may cause the spleen to bend or rupture more.
Extreme changes in ligament tension on the surface of the spleen can also lead to spleen injury. This injury mechanism can explain spleen injury during rapid deceleration of the body. Direct trauma, such as trauma to the left upper abdomen, is secondary to the cause of spleen trauma. To be in a position, if a trauma occurs, at the moment of inhalation, the spleen is prone to trauma, the spleen moves to the caudal and ventral sides, is separated from the protection of the surrounding thorax, and is in the direction of the force, and the left rib arch contracts. The spleen is contused. In general, only the elastic thorax of children and young people can occur. At the same time, rib fractures are often combined, and rib fragments can directly stab the spleen.
Compared with blunt abdominal injuries, the chances of spleen trauma caused by penetrating injuries such as abdominal scratches, stab wounds and gunshot wounds are much smaller. All wounds below the sixth rib on the left side, including the entrance or exit of the bullet, should be considered. Spleen injury and other organ damage in the abdomen, the entrance and exit of the gunshot wound may be spleen trauma even if it is far from the left upper abdomen. The decelerated warhead can often travel far under the skin or under the fascia when entering the abdominal cavity. The distance, the warhead with higher kinetic energy often turns due to the surrounding tissue (such as peritoneal tissue), and a completely unexpected process occurs, which may damage the spleen or other organs.
Most spleen lacerations are perpendicular to the spleen axis, along the edge between the spleen segments, it is not easy to damage the large blood vessels near the spleen, and there are few spleen vascular injuries. This lateral laceration usually has moderate bleeding volume and bleeding time. Also shorter, longitudinal lacerations span the boundaries between the spleen segments, often with more severe bleeding, and 40% of spleen trauma is multiple spleen laceration.
Spleen trauma is classified according to its degree of injury, ranging from small laceration of the spleen capsule to complete rupture of the spleen. Only 1/3 of the lacerations occur in the spleen convex surface. Other traumas often have spleen injury, and the spleen concave laceration often It is more dangerous than a laceration of the face, because the spleen is covered with thick spleen and spleen.
Injury of the spleen parenchyma (20%):
If the spleen parenchyma is damaged and the spleen capsule is still not broken, a subcapsular hematoma will occur and it will not be easily detected until the spleen is damaged. A large amount of blood is accumulated in the abdominal cavity. If the spleen capsule can withstand the pressure, the hematoma will be slow. Slowly absorbed to form fibrous scars or pseudocysts.
Some small lacerations often stop on their own, and spleen concave and large blood vessel lacerations often have a large amount of abdominal hemorrhage, which can be quickly diagnosed due to acute blood volume decline and shock symptoms. However, such bleeding or Larger blood vessels rupture and bleeding, and occasionally can stop on their own, which may be due to the following reasons: spleen vascular pressure and decreased circulating blood pressure, blood clot formation, omental occlusion, endovascular retraction and vascular lumen Internal thrombosis, etc., the re-distribution of blood flow in the spleen may also play a role, as it has been found that there are movements and venous shunts.
Sometimes, especially after spleen injury in children and young people, it is often found that bleeding has stopped during surgery. Therefore, although the spleen is extensively damaged, sometimes a circumstance of relatively stable circulation may occur, but rebleeding may be in any Time occurs, especially after a lot of fluid replacement.
Prevention
Traumatic spleen rupture prevention
1. Develop good habits, stop smoking and limit alcohol. Smoking, the World Health Organization predicts that if people no longer smoke, after five years, the world's cancer will be reduced by 1/3; secondly, no alcohol. Smoke and alcohol are extremely acidic and acidic substances. People who smoke and drink for a long time can easily lead to acidic body.
2. Don't eat too much salty and spicy food, don't eat food that is overheated, too cold, expired and deteriorated; those who are frail or have certain genetic diseases should eat some anti-cancer foods and high alkali content as appropriate. Alkaline foods maintain a good mental state.
Complication
Traumatic spleen rupture complications Complications rib fracture kidney injury spinal cord injury liver injury lung injury craniocerebral injury gastric injury
Spleen rupture can be combined with a variety of multiple injuries. According to statistics, closed abdominal or lower chest injury, only 30% of the injured spleen; at the same time injured other organs or tissues are more common, combined with multiple injuries can occur in In the abdominal cavity, it can also occur in the abdominal cavity. The incidence is in descending order for the chest (including rib fracture), kidney, spinal cord, liver, lung, craniocerebral, small intestine, large intestine, pancreas, stomach, etc., spleen rupture combined with multiple injuries misdiagnosed The rate is 11% to 66%, and the injury is more serious, complicated, with many complications and high mortality. According to statistics, the mortality rate of spleen rupture alone is 10%; the combined with other organ injuries is 25%; multiple injuries are 4 The organ is 45.5%; more than 5 organs are 100%.
Symptom
Traumatic spleen rupture symptoms common symptoms abdominal pain shock blood pressure drop tinnitus breath rapid reflex vomiting limbs weakness circulatory failure palpitations
1. Symptoms and signs of spleen rupture
With the amount and speed of bleeding, the nature and extent of rupture, and the presence or absence of combined injuries or multiple injuries in other organs, only patients with subcapsular rupture or central rupture, mainly manifested as left upper abdominal pain, Breathing can be aggravated; at the same time, the spleen is swollen and tender, and the abdominal muscle tension is generally not obvious, and there is no nausea or vomiting. Other internal bleeding also does not exist, such as incomplete rupture once it is completely ruptured. Acute symptoms will appear rapidly and the condition will deteriorate rapidly.
Once the complete rupture occurs, there will be symptoms of peritoneal irritation first, and the bleeding is slow and the amount is not much. The abdominal pain can be limited to the left rib; if the bleeding is more scattered and the whole abdomen, it can cause diffuse abdominal pain, but still The left rib is the most prominent, and reflex vomiting is common, especially in the early stage of onset, sometimes due to blood stimulation of the left diaphragm, which can cause pain in the left shoulder (the distribution of the fourth cervical nerve), and often Deep breathing, aggravated, known as Kehr sign, then patients in a short period of time can appear obvious symptoms of internal bleeding, such as thirst, palpitation, palpitations, tinnitus, limb weakness, shortness of breath, blood pressure, unconsciousness, etc.; In the short term, he died due to excessive bleeding and circulatory failure.
During the physical examination, it can be found that the abdominal wall has universal tenderness and muscle rigidity. The left upper abdomen is the most prominent. The spleen voiced area of the left rib also often increases. For example, there is a lot of blood accumulation in the abdomen, and there are also mobile dullness. However, due to the presence of blood clots around the spleen, the left waist of the patient may be empty when lying on the left side, and the left lumbar part of the left side is often fixed voiced sound, called Balllance sign.
2. Classification
In addition to the so-called spontaneous spleen rupture, general traumatic spleen rupture can be roughly divided into three types:
(1) Immediate spleen rupture: the spleen rupture, which is commonly referred to in the clinic, accounts for 80% to 90% of traumatic spleen rupture. It is rupture of the spleen immediately after trauma, intra-abdominal hemorrhage, hemorrhagic shock, and severe cases may be acute. Hemorrhage and death in a short period of time.
(2) Delayed (late) spleen rupture: a special type of traumatic spleen rupture, accounting for about 10% of closed spleen rupture, with asymptomatic period of more than 48h between trauma and spleen rupture and bleeding (Baudet incubation period).
(3) Occult spleen rupture: only subcapsular hemorrhage or minor laceration after spleen trauma, the symptoms are not obvious, even no clear history of trauma can be traced, the diagnosis is not easy to be sure, in the presence of anemia, left upper abdominal mass, spleen pseudocyst Or rupture, intra-abdominal hemorrhage, etc. are diagnosed. This type is rare, and the incidence in closed spleen rupture is less than 1%.
3. Generally speaking, patients with ruptured spleen can have the following three processes in clinical practice.
(1) Early shock stage: It is a kind of reflex shock after abdominal trauma.
(2) Mid-term concealment stage: the patient has recovered from early shock, and the symptoms of internal bleeding are not obvious. The length of this period is different. The short is 3 to 4 hours, usually 10 hours to 3 to 5 days. Individual diseases such as under the capsule Bleeding or minor laceration can also last up to 2 to 3 weeks before entering the obvious bleeding stage. During this period, the patient's mild shock has passed, and severe bleeding symptoms have not yet appeared, so the situation is mostly good; except for the left quarter rib There are pain, tenderness, and tendon. There are only partial lumps in the abdomen, and the abdomen is slightly bulging. The radiation pain in the left shoulder is not common. However, if the diagnosis cannot be made in time, it is the main cause of poor prognosis in most patients. Should be cautious, the history of trauma is not clear, the patient's condition is still good, no obvious internal bleeding symptoms, no typical Kehr sign or Balllance sign and paralyzed or wrong.
(3) Late bleeding stage: There is no doubt in this stage of diagnosis, bleeding symptoms and signs have been very obvious, the patient's condition has deteriorated, and the prognosis is more serious.
Open injuries caused by sharps are more common in wartime. Bullets or shrapnel may injure the spleen wherever they enter the abdominal cavity. These open injuries are usually accompanied by other visceral injuries. Early laparotomy is required. Surgery; whether the spleen rupture has been diagnosed before surgery is difficult or unnecessary. It should be noted that abdominal injuries with symptoms of internal bleeding are more urgent than those of simple hollow organs.
Examine
Traumatic spleen rupture
Blood routine tests of red blood cells and hemoglobin often have a progressive decline, while white blood cells can be increased to about 12 × 109 / L, the response to acute bleeding.
1. Abdominal X-ray examination
Traumatic patients can take abdominal X-ray films, observe the spleen contour, shape, size and position changes, accompanied by rib fracture imaging, is very helpful for the diagnosis of spleen trauma.
2. Abdominal ultrasound examination
When the spleen is damaged, the spleen contour is not neat, the image is interrupted, the subcapsular hematoma is suspected, and the spleen is progressively enlarged and the double contour image is displayed. At the same time, the effusion of more than 100 ml in the abdominal cavity can be displayed. When the spleen capsule is broken, it can be seen. The surface of the spleen is not smooth and tidy, the continuity is interrupted, and the dark band of the cord can be detected. The echo of the spleen is still uniform. The spleen and the left and right armpits can be explored with different liquid dark areas. When the capsule is spleen At the same time of rupture, the spleen capsule is broken, and one or more irregular hypoechoic areas can be detected in the spleen parenchyma. The spleen, the liver, the liver and the kidney, and the left and right armpits can detect a large number of liquid dark areas. When the delayed spleen ruptures, multiple ultrasound examinations are required to detect substantial rupture.
3. Abdominal CT examination
CT can determine the presence of spleen injury and its extent of damage, with very high sensitivity and specificity. The subcapsular hematoma of the spleen appears as a localized subcapsular hemorrhage, resembling a crescent or half-moon shape with corresponding substantial The pressure is flat or jagged. The density of the initial hematoma is similar to the density of the spleen. The CT value of the hematoma over 10 days gradually decreases, which is lower than the spleen parenchyma density. Enhanced CT shows that the spleen parenchyma strengthens and the hematoma does not change. Density difference is an important supplementary examination for hematoma on the flat scan. The hematoma in the spleen parenchyma is usually round or oval in the same density or low density area, and the single spleen tears in the enhanced spleen parenchyma. Inside the low-density area of the line, multiple spleen tears often appear as comminuted spleen, showing multiple low-density areas, usually invading the spleen capsule, as well as with abdominal hemorrhage, spleen not enhanced, suggesting damage Or supply arterial embolization of the spleen segment.
Spleen laceration showed spleen banding, patchy or irregular low-density shadow, with multiple signs of abdominal hemorrhage, spleen hematoma density changes with time, fresh hematoma is equal or slightly higher density, with time The prolongation, hemoglobin lysis and hematoma water volume increase, the hematoma density gradually decreases, easy to diagnose, CT of the subcapsular hematoma of the spleen shows equal or slightly higher than the spleen density shadow, and the same density hematoma in the spleen, CT scan is easy to miss diagnosis, It is necessary to do CT enhancement to confirm the diagnosis. The literature suggests that about 1% to 15% of patients with spleen injury will see normal CT scan immediately after injury, and CT scan will reveal signs of spleen injury after 48 hours, usually around 3 weeks, a few incubation periods. In months or years, CT scans are not only sensitive and specific for the diagnosis of spleen injury, but also can further estimate the degree of injury, thereby guiding the development of clinical treatment plans and predicting the prognosis of patients.
4. Diagnostic abdominal puncture lavage
Although it can not indicate the location of the injury, it can not explain the degree of injury, but it is helpful to determine the indication of laparotomy. The diagnostic accuracy rate is over 90%. Due to the wide application of ultrasound and CT, abdominal puncture seems to be limited.
5. Radionuclide imaging examination
MRI is not used for emergency patient examination because of the long imaging time, some rescue equipment is difficult to access MRI machines, etc., but MRI is a kind of comparison when the condition is stable, or when the condition is complicated, especially when checking bleeding and hematoma. Effective examination methods, various pathological changes after spleen trauma are reflected in the MRI image and CT performance is basically the same, while MRI can be coronal and sagittal imaging, showing the overall change and other organ damage related to abdominal trauma The CT is more comprehensive. The change of MRI signal intensity of hemorrhage is related to the bleeding time. The intrasplenic hemorrhage and hematoma formation are early, the T1 weighting of the hemorrhage area is equal signal, the T2 weighting is the low signal area, and the bleeding is 3~14 days, the T1 weighted image is White high-intensity signals also show high-intensity images on T2-weighted images.
6. Selective celiac angiography
This is an invasive examination with a high degree of specificity and accuracy. It can be used to specifically diagnose and simultaneously perform superselective splenic embolization.
Diagnosis
Diagnosis and diagnosis of traumatic spleen rupture
diagnosis
Closed spleen rupture according to the obvious left upper abdomen or left rib traumatic history, and may have local soft tissue contusion and rib fracture, as well as peritoneal irritation and internal bleeding symptoms after injury, the general diagnosis is not difficult, especially in the abdomen Those with mobile dullness can puncture in the left lower abdomen, and the diagnosis can be confirmed when the blood can be aspirated.
Incomplete or only mild laceration and rupture of the spleen that has been blocked by the clot, the diagnosis is not easy, the patient recovers from early shock and the internal bleeding is not significant, and the diagnosis is difficult. Such suspicious cases, only to increase vigilance, close observation, in order to not delay the disease, pay attention to whether the scope of pain has expanded, whether the abdominal wall tension has increased, whether there is pain in the left shoulder, whether the abdomen has bulging, whether the bowel sounds are weakened, and whether the pulse is gradually accelerating Whether the determination of red blood cells and hemoglobin continues to decline, generally can detect the presence or absence of internal bleeding in time, and timely X-ray, B-ultrasound, CT and other examinations, in the diagnosis of difficulty, MRI, selective celiac angiography, hepatic and spleen nucleus Visual imaging, etc., or laparotomy.
Differential diagnosis
Traumatic spleen rupture should be differentiated from liver, kidney, pancreas, mesenteric vascular rupture, left rib fracture and ectopic pregnancy, and should be differentiated from certain medical diseases such as acute gastroenteritis and even myocardial infarction.
