Tag Archives: spleen

Pop Quiz: Interesting Case!

A 16 year old male was thrown against the handlebars during a motorcycle crash at about 40 mph. He dusted himself off and went home for a few hours. Unfortunately, he slowly developed some abdominal pain.

He presented to an ED several hours later. He was found to have mild, diffuse abdominal pain, normal vital signs, and a positive abdominal FAST exam. CT scan showed a grade IV spleen injury and a grade II liver injury in the right lobe with no extravasation or pseudoaneurysm noted. He was successfully treated nonoperatively and was sent home.

One month later he returns to the ED complaining of a single episode of hematochezia (approximately 200cc). He has an entirely normal exam and vital signs.

Here are my questions for you:

  • Was the initial management appropriate?
  • Should anything additional have been done during the first admission?
  • What is the diagnosis now?
  • What diagnostic or therapeutic maneuvers are indicated now?

Please tweet your guesses, or leave comments below. Hints tomorrow and answers on Friday. Good luck!

Patient not treated at Regions Hospital

Angiography And Splenic Salvage

Variations in the way we deal with trauma can have a significant impact on patient outcome. This has been documented most recently in the use of angioembolization when dealing with patients with spleen injuries. The first paper presented at EAST 2013 looked at outcomes at hospitals that use angio more heavily vs those who don’t.

They analyzed 1275 patients presenting to 4 Level I trauma centers. Two centers were high-use (11% and 19% usage) and the other 2 were low-use (1% and 4%). The outcomes studied were the splenic salvage rate and success in nonoperative management. And although patients at the low angio use centers had a higher ISS, the splenic injury grade was the same.

Interesting findings included:

  • Admission splenectomy rate was the same, meaning that both types of centers used the same criteria when the patient rolled through the door
  • High angio use centers had higher overall salvage rates (82% vs 77%)  and greater success with nonoperative managment (96% vs 92%)
  • In high grade injury (grade 3 and 4) the salvage rate was still better (67% vs 56%) and nonop success rates were much better (92% vs 80%)
  • In patients who were initially managed nonoperatively, use of angio was associated with salvage
  • Patients in high angio centers were more likely to leave the hospital with their spleen where it should be
  • There was no analysis of complications from angiography
  • There was no comment on how these patients were managed on a day to day basis

Bottom line: There is a considerable amount of variation in how trauma centers use angiography for spleen injury. Unfortunately, this variability is allowing people to lose their spleens at centers who don’t use it as much. The overall success rate in managing spleen injury (all comers) has historically been about 93%. More aggressive use of angiography is now shown to improve that to 97%. Given this new data, angio needs to be considered in patients with grade 3+ injury and in any with contrast extravasation. And the overall management should be standardized as well.

Reference: Variation in splenic artery embolization and spleen salvage: a multicenter analysis. Paper 1, EAST annual scientific assembly, Jan 15, 2013.

Post-Embolization Syndrome?

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I’ve seen a number of trauma patients who have developed pain and elevated WBC after embolization of solid organs for trauma. For kidneys and main splenic artery embolization, it’s fairly common in my experience. Turns out, this phenomenon was described in 2007-2008 in patients undergoing embolization of hepatic tumors and uterine fibroids. It was termed post-embolization syndrome, and consists of pain, fever, nausea and ileus.

An article was just published in the Journal of Trauma describing this syndrome in children after splenic embolization for blunt trauma. The authors looked at their own trauma registry over a 12 year period. Yes, it took that long to find 448 children with blunt splenic injury. Of those, only 11 underwent arterial embolization (sigh of relief).

The average age was about 13 and ISS was 16 in both groups. Kids who underwent embolization were more likely to spend some time in the ICU, had a longer hospital stay (8 vs 5 days(!)), and took longer to resume their diet (5 vs 2 days). These differences occurred despite the fact that most of the embolized children had isolated splenic injuries. Additionally, the embolized children were more likely to receive blood (3 units vs none) and plasma.

My first question about this paper is, why? Broken spleens in children do not act like broken spleens in adults. The vast majority of the cases of contrast extravasation in children stops on its own without intervention. So why did we even have to find out that post-embolization syndrome occurs in children? They shouldn’t be going through this procedure anyway! Fortunately, a deeper read of the paper provides the answer. The indication for angio was splenic pseudoaneurysm in 2, and ongoing hemorrhage in the other 9. In the case of these latter 9, it did keep the children from having their spleens operated on.

Bottom line: In general, don’t send kids for splenic angiography (99.3% of kids in this study did not have it). Ongoing hemorrhage (prior to hypotension, which is an absolute indication for OR) is probably the only indication I can think of. Pseudoaneurysm and extravasation of contrast are not indications like they are in adults. But if you do have to send them, just be aware that they may develop pain, fever and ileus that will keep them in the hospital and/or ICU for a few extra days.

Reference: Transarterial embolization in children with blunt splenic injury results in postembolization syndrome: A matched case-control study. J Trauma 73(6):1558-1563, 2012.

Contrast Blush in Children

A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush.

Splenic contrast blush

This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!

Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!

Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. A recently released paper confirms these findings.

The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).

Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.

Spleen Embolization After Trauma

Angioembolization of the spleen (AES) is part of our armementarium in the management of spleen and liver trauma. However, there are no good guidelines to help us decide exactly which patients would benefit from it. An abstract to be presented at the EAST meeting in January 2013 gives us a little more information on the actual benefits of this procedure.

The authors did a retrospective review of the management of blunt splenic injury at four busy Level I trauma centers. They looked at 1275 injured patients over a 3 year period. Here are the interesting tidbits from the study:

  • There was considerable variation in the use of AES at the 4 centers, ranging from 1% of patients to 14%. This should be no surprise because there is no real guidance available yet.
  • There was also a large degree of variation between the number of initial splenectomy performed at these centers
  • Centers that used AES more frequently had lower initial splenectomy rates
  • Patients at centers with high AES rates were 3 times more likely to leave with their spleen intact

Bottom line: This abstract correlates with my own personal experience: judicious use of angioembolization saves spleens. The real question is about which patients are best served by it. Our protocol is to strongly consider it in all high grade spleen injuries (Grade 4 and 5), and to always do it if a blush or extravasation is present. Our success rate for nonoperative management currently stands at about 94%.

Related posts:

Reference: Variation in splenic artery embolization a spleen salvage: a multicenter analysis. EAST Annual Scientific Assembly, Paper #1, to be presented January 2013.