IJGII Inernational Journal of Gastrointestinal Intervention

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Case Report

Int J Gastrointest Interv 2024; 13(2): 41-45

Published online April 30, 2024 https://doi.org/10.18528/ijgii230056

Copyright © International Journal of Gastrointestinal Intervention.

Grade IV splenic injury: When to consult interventional radiology-a case report and review of management protocols

Madhukar Dayal1,* , Pratik Pandey1 , and Abhay Kumar2

1Department of Radiology, Nalanda Medical College & Hospital Patna, Bihar, India
2Department of Surgery, Big Apollo Spectra Hospital, Bihar, India

Correspondence to:*Department of Radiology, Nalanda Medical College & Hospital, Agam Kuan Flyover, Sadikpur, Patna, Bihar 800007, India.
E-mail address: Dayal.madhukar@gmail.com (M. Dayal).

Received: October 17, 2023; Revised: January 15, 2024; Accepted: January 21, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The spleen is one of the organs most commonly affected by blunt abdominal trauma. Splenectomy is often indicated for high-grade post-traumatic injuries and in patients who are hemodynamically unstable, while non-operative management (NOM) is considered for the remaining cases. Patients who have undergone splenectomy are at an increased risk of overwhelming post-splenectomy infection, leading to a shift in the consensus toward managing splenic trauma with spleen-preserving NOM approaches, such as splenic artery embolization, when possible. Patients with grade IV and V splenic injuries who are hemodynamically stable and do not have an active bleed are often candidates for prophylactic angioembolization. This intervention reduces the risk of re-bleeding, preserves splenic function, and decreases the likelihood of requiring a splenectomy. However, not all facilities have access to interventional radiology (IR). Through this case report, we emphasize the importance of using the period of conservative management to either consult with an IR specialist or transfer the patient to a center equipped with IR, given the high risk of re-bleeding or delayed rupture of the spleen. An additional unusual finding in our case was a re-bleed occurring beyond the typical interval for NOM as reported in most literature.

Keywords: Conservative treatment, Radiology, interventional, Splenectomy, Splenic artery, Splenic rupture

The spleen is one of the organs most commonly injured by blunt trauma, accounting for approximately one-third of abdominal organ injuries.1,2 The identification and grading of splenic injuries are crucial in guiding patient management.3 Over the last few decades, the management of splenic trauma has undergone significant changes, with a marked shift toward non-operative management (NOM). NOM strategies vary from observation and monitoring alone to the use of angiography/angioembolization to preserve splenic function.4 Hemodynamic stability is the key factor in determining the appropriate management approach.

Concerns persist regarding NOM for high-grade splenic injuries due to its high failure rate.5 Splenic trauma may lead to delayed post-traumatic splenic rupture, which carries a significantly higher mortality rate. Therefore, diligent follow-up is crucial, particularly for hemodynamically stable patients with severe splenic injuries. Our practice adheres to the World Society of Emergency Surgery (WSES) guidelines for the management of patients with splenic trauma. In most hospital settings, strict adherence to protocols is essential, particularly when not all facilities are available on-site. This adherence is necessary to make informed decisions and provide appropriate follow-up, ultimately aiming to reduce mortality, management costs, and the duration of hospital stays.

Computed tomography (CT) is the standard method for grading splenic injuries according to the American Association for the Surgery of Trauma (AAST) splenic injury scale. Injuries classified as grade IV and V are considered high-grade and carry a higher risk of delayed splenic rupture and increased bleeding potential. Typically, these injuries are confirmed via CT scan in patients who are hemodynamically stable. Conversely, hemodynamically unstable patients may be taken directly to surgery. In cases where patients with high-grade splenic injuries remain stable, there may be uncertainty about whether to proceed with surgery or opt for NOM, particularly in facilities that offer endovascular treatment options. Timely follow-up and appropriate intervention are crucial to prevent delayed complications such as re-bleeding in a stable patient. Angioembolization is a significant aspect of NOM. Numerous studies have shown that early embolization can improve the likelihood of preserving the spleen following a traumatic injury.6,7

A 47-year-old man presented at our hospital complaining of pain in the left hypochondrium for the past 5 hours. The patient had sustained blunt abdominal trauma in a pedestrian road traffic accident 1 day prior, after which he received local treatment. Before his arrival at our hospital, he was managed locally, and a focused assessment with sonography in trauma was performed, revealing minimal fluid collection on the day of the injury. However, due to the worsening pain, he was admitted to our hospital for further evaluation. Upon examination, the patient was stable, with the following vital signs: blood pressure of 118/70 mmHg, heart rate of 110 bpm, respiratory rate of 20 breaths per minute, no fever, and a hemoglobin level of 10.2 g/dL. There was moderate tenderness over the left hypochondrium, but bowel sounds were normal.

On the first day of admission, the patient underwent a CT scan of the abdomen (Fig. 1), revealing a grade IV splenic injury characterized by multiple deep lacerations extending to the hilum, along with an associated subcapsular hematoma. There was no indication of active bleeding or pseudoaneurysm, even in the delayed phase images.

Figure 1. Non-contrast computed tomography (CT) axial image of abdomen on day 1 of admission (initial CT image) showing hematoma (asterisk) around the spleen (s) with lacerations (arrow) in the parenchyma.

Both embolization and conservative management were recommended, with close monitoring of vital signs and the potential need for a splenectomy if indicated. After reaching a common consensus, NOM was chosen, taking into account the patient’s socioeconomic status and understanding. From days 2 to 7, the patient showed improvement and a resolution of his primary concern, which was pain. However, on day 9, as discharge was being considered, he developed sudden moderate-grade pain in the left hypochondrium, accompanied by signs of vital parameter derangement and hemodynamic shock, with his hemoglobin level dropping to 8.2 g/dL. Within a few hours, the patient was stabilized. He remained conscious and oriented, prompting a call to the surgical team and interventional radiology (IR). A repeated contrast-enhanced CT examination revealed an enlarged hematoma around the spleen, with more pronounced lacerations (Fig. 2). Coronal reconstruction of the CT images showed the development of a left-sided moderate pleural effusion (Fig. 3). Surprisingly, there was still no direct evidence of active bleeding or a pseudoaneurysm on the repeated CT examination. Given the patient’s hemodynamic stability and declining laboratory parameters, embolization was planned, and the patient was transferred to the angiosuite. A written consent was taken from the patients attendant.

Figure 2. Repeated computed tomography (CT) on day 9 of admission, after re-bleeding event (follow-up contrast-enhanced CT image). Axial image showing more pronounced lacerations (arrow) and an increase in the size of the hematoma (asterisk).

Figure 3. Coronal image of contrast-enhanced computed tomography of the abdomen on day 9 of admission showing the peri-splenic hematoma (asterisk) and left sided pleural effusion (#).

During the selective splenic angiogram (Fig. 4) and subsequent superselective angiograms, no active bleeding or pseudoaneurysm was identified. A few abnormal late arterial dot-like blushes were noted at the upper pole of the spleen (Fig. 5), but no active bleeding was observed. A gel foam slurry was injected into the bed, targeting the area of a larger laceration. To preserve splenic parenchymal function, proximal splenic artery embolization using coils was also performed. Two 35-5-5 coils (Cook Medical) were placed distal to the origin of the dorsal pancreatic artery (Fig. 6), and the post-coil embolization angiogram was satisfactory. The patient was then transferred to the high-dependency unit for further monitoring.

Figure 4. Digital subtraction angiography of the splenic artery (arrow) showing parenchymal blush defects in the region of the lacerations at upper pole with no active contrast extravasation.

Figure 5. Late arterial phase of the splenic angiogram showing irregular branches and late parenchymal blush (encircled area) with no active extravasation.

Figure 6. Post-proximal coil embolization angiogram shows no parenchymal staining of the spleen and preserved parenchymal blush of the distal pancreas (arrow).

Post-embolization, the patient remained stable and was discharged 4 days later. He returned to the surgical outpatient department for a follow-up 1 week later and was stable, with only mild pain in the left abdominal quadrant.

The spleen and liver are the organs most frequently injured in both penetrating and blunt abdominal trauma.8 Recognition of the spleen’s role in the immune response, along with the awareness of overwhelming post-splenectomy infection after splenectomy,911 has significantly altered the treatment of splenic trauma over the past century. The approach has shifted from surgical intervention to NOM. Currently, NOM, with or without angioembolization, is the preferred treatment for traumatic splenic injuries in hemodynamically stable patients.4

According to the current WSES guidelines, splenectomy is considered only when the patient is hemodynamically unstable or in case of failure of NOM.4 The ASST classification divides splenic injury into five grades, and the WESE classification divides splenic injuries into minor, moderate, and severe.4 American guidelines propose choosing angioembolization in patients with more than grade III splenic injury, the presence of contrast blush on CT, moderate hemoperitoneum, or evidence of ongoing splenic bleeding.

NOM for high-grade (AAST grade IV–V) splenic injuries remains controversial due to the high failure rates reported, which is pertinent to our case.12 A review article by Meira Júnior et al13 posits that NOM may be appropriate for all hemodynamically stable patients, assuming the availability of adequate resources. It is crucial to identify the primary predictors of NOM failure once this management route is chosen. The article also recommends tailoring treatment to the strongest available evidence.13 Several authors have advocated for the use of prophylactic angioembolization in cases of high-grade splenic injury.1416 While angioembolization can improve the outcomes of NOM, its availability is currently limited to select centers. The most significant benefit of this procedure is the preservation of some functional splenic parenchyma.

Complications of splenic injury include pseudocysts, abscesses, pseudoaneurysms, and delayed splenic rupture.17 Delayed post-traumatic rupture of the spleen is an unusual outcome and is defined as bleeding that occurs more than 48 hours after blunt trauma.18,19 The asymptomatic period before the delayed rupture is also known as the latent period of Baudet. A high index of suspicion is crucial for the early detection of delayed splenic rupture. Additionally, patients with high-impact injuries or damage to surrounding organs should be considered for follow-up multidetector CT scans 2 to 3 days after trauma or before discharge.20 CT scans provide comprehensive information about the parenchymal and vascular status, contributing to the final decision-making process.17 In cases of definite evidence of vascular injury, such as active extravasation or pseudoaneurysm, NOM is not appropriate, and immediate endovascular treatment or surgery should be considered. However, if no definite vascular injury is identified on a CT angiogram, a careful decision regarding NOM should be made.

The incidence of delayed splenic rupture is approximately 1%, typically occurring between 4 and 8 days post-injury.21 In our case, the patient presented with delayed splenic rupture at an unusually late time point. The significance of delayed splenic rupture is underscored by its substantially higher mortality rate of 5%–15%, compared to the 1% overall mortality associated with acute splenic injuries.19 Basukala et al22 emphasized in their case report that clinicians must evaluate the entire clinical scenario when deciding between operative management and NOM, rather than relying solely on the CT injury grade. In a review, Olthof et al23 have reported that factors such as the severity of splenic injury, the presence of a large hemoperitoneum, contrast extravasation, a high Injury Severity Score > 25, systolic hypotension, the need for transfusion of more than one unit of packed red blood cells, and concomitant traumatic brain injury increase the risk of NOM failure which has to be taken into consideration.

Angioembolization is a critical element of NOM, and the time elapsed from injury to intervention is crucial. Research has shown that facilities with prompt access to angiographic procedures have higher rates of splenic preservation.6,7 Therefore, an immediate referral to IR is essential in cases of high-grade splenic trauma, which proved beneficial in our case. Our institution also adheres to the WSES guidelines, offering prophylactic splenic artery embolization to patients when appropriate. However, the high costs associated with this procedure and the generally poor socioeconomic status of patients in our area sometimes necessitate a more conservative approach.

In conclusion, high-grade splenic injuries are common and the critical care team is typically the first to assess them. The decision to pursue conservative management, surgery, or minimally invasive intervention is based on the patient’s hemodynamic stability. However, challenges such as poor socioeconomic conditions and a limited understanding of the disease process by patients often necessitate adherence to NOM, especially when the patient is stable. Additionally, not every medical facility has access to IR services. Therefore, the time between diagnosing the grade of splenic injury and initiating NOM should be used to arrange for IR consultation and, if necessary, transfer patients to a facility with dedicated IR capabilities for optimal care. This is due to the documented risk of NOM failure, as evidenced by our case report. Our findings underscore the importance of timely communication with the IR team in cases of high-grade splenic injury (grade IV, as in our case), to ensure they are prepared for any required interventions.

We also emphasize that delayed re-bleeding of high-grade splenic injuries can occur beyond the expected time frame, as noted in our case. Prophylactic embolization is a safe and valuable intervention for preventing life-threatening complications from splenic trauma in high-risk patients, while also preserving functional splenic tissue.24 The systematic approach and availability of all modalities, including IR as in our case, were instrumental in optimal patient management, which may not be available at most centers.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

No potential conflict of interest relevant to this article was reported.

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