[Splenic rupture following colonoscopy: report of an unusual case in the absence of underlying splenic disease]

Splenic injury following colonoscopy is rare and, to our knowledge, 18 cases only have been reported so far in the literature. The presumed mechanisms for splenic injury during colonoscopy are direct trauma to the spleen or excessive traction of the splenocolic ligament this latter mechanism being due to decreased mobility between the spleen and the colon secondary to adhesions. Splenomegaly or underlying splenic disease are two conditions which are considered to be predisposing factors to splenic injury. We report one case of splenic rupture which was due to colonoscopy in the absence of any underlying splenic disease. This case was diagnosed and monitored by computed tomography, thus avoiding unnecessary splenectomy.

Occult splenic rupture: a case report

We present a case of an atraumatic, occult rupture of the spleen. It is only in a distinct minority of cases, that the splenic capsule remains intact, thereby preventing intraperitoneal bleeding. Nevertheless, this condition can be accompanied by a severe loss of blood. A nonoperative management can be considered. Reviewing the literature on splenic rupture, the lack of uniformity in nomenclature is striking. The etiological and morphological classifications are reviewed.

Partial splenic resection using the TA-stapler

Since 1987, we have used the TA-stapler for 15 partial resections of the spleen. The cases included 5 second- to third-degree traumatic ruptures, 4 splenic cysts, 3 injuries resulting from accidents during upper-abdominal surgery, 2 diagnostic resections, and 1 intralienal pancreatic cyst. The TA-55 stapler was used 14 times and the TA-90 once. No patient developed postoperative bleeding or required further surgery. Postoperative laboratory chemistry and scintigraphy findings were within the limits indicative of normal function in all cases. The TA-stapler expands the technical possibilities for organ-conserving splenic surgery.

Delayed rupture of the spleen--myths, facts, and their importance: case reports and literature review

Over a 1-year period, three patients were seen in our trauma service with delayed bleeding (> or = 7 days) from an initially inapparent splenic injury. This entity was defined as a late occurrence of signs and symptoms attributed to splenic injury not detected by diagnostic computed tomographic (CT) scanning during the initial examination. We believe that this represents an "injury in evolution" minor enough to go undetected on initial CT scans of the abdomen. A high index of suspicion and liberal utilization of imaging techniques are essential for the identification of delayed splenic rupture. Further multicenter studies are required to delineate the true incidence of its occurrence and its clinical significance. We conclude that "delayed rupture" of the spleen is a true clinical entity. The occurrence of a delayed rupture may prove hazardous to patients discharged early from the hospital after blunt abdominal injury. A classification system to assess this type of injury is suggested.

[The forensic medical evaluation of subcapsular splenic injuries]

Data on 63 cases of subcapsular spleen lesions are analyzed. Circumstances of trauma infliction period of the 2-nd stage of spleen capsule rupture, morphological types of subcapsular spleen lesions, microscopic changes in different posttraumatic periods are presented.

[Atraumatic rupture of the spleen. A proposal of new attitudes. Apropos a case in brucellosis]

A case of spontaneous spleen rupture during acute brucellosis, followed by clinical and ultrasound examinations until the natural resolution of the subcapsular hematoma, is presented. The causes of this complication are reviewed and a new classification is proposed, creating 3 groups of nontraumatic ruptures: spontaneous, with basal splenic disease and associated to other pathology. We highlight the several states of spleen ruptures--some with spontaneous resolution--and the utility of the radiological techniques to carry out a follow-up on them, which can in some cases help avoid surgical intervention.

Hypotension and bleeding with various anatomic patterns of blunt splenic injury in adults

A retrospective study of 112 consecutive adult patients with blunt splenic lacerations was performed. All of the patients had operative grading of the splenic injuries according to a prospective protocol. Data on preoperative hypotension (systolic blood pressure of less than 100) and intraoperative splenic bleeding were collected from hospital records. Patients with subcapsular hematomas were excluded. Over-all, 55.4 per cent of the patients with splenic lacerations were hypotensive preoperatively and 76.6 per cent were noted to be bleeding from the spleen at operation. For injuries not involving the hilum, seven of 22 of the patients with Grade I injuries were hypotensive preoperatively versus 19 of 29 of the patients with Grade IV injuries (p = 0.025). Fourteen of 21 patients with Grade I injuries were noted to be bleeding at operation. Seventeen of 23 with Grade IV injuries were noted to be bleeding. This difference was not significant. Of the patients with injuries involving the hilum, 25 of 38 were hypotensive preoperatively and 25 of 29 were noted to be bleeding at operation. No difference in the incidence of hypotension or bleeding was found between superficial and deep hilar injuries. No significant difference was found between the active bleeding with hilar and nonhilar injuries (p = 0.19). For isolated splenic injuries (N = 36), the incidence of hypotension was 39 per cent. However, 79 per cent of the patients with isolated splenic injuries were noted to be bleeding at operation. Of 49 patients with nonisolated splenic injuries who had been hypotensive preoperatively, 72.9 per cent were found to be bleeding at operation. Of the 27 patients never hypotensive preoperatively, 78 per cent were noted to be bleeding at operation (NS). For isolated splenic injury also, no relationship was found between preoperative hypotension and the presence of operative bleeding. No significant correlation was found between preoperative hypotension or the anatomic grade of splenic injury and the incidence of bleeding found at operation. Even if computed tomographic scans can reliably grade splenic injuries, anatomic grade may not be a predictor of clinical behavior. Hypotension also failed to predict the occurrence of continued splenic bleeding.

Evaluation of splenorrhaphy: a grading system for splenic trauma

Since April 1977, we have used splenorrhaphy as the procedure of choice for splenic trauma. To evaluate the efficacy of this procedure, we graded splenic injury based upon the extent of splenic repair in 77 patients with blunt abdominal trauma. This grading system is as follows: Grade 1-capsular treatment (five patients); Grade 2-capsular or parenchymal injuries requiring topical hemostatic agents (13 patients); Grade 3-parenchymal injuries requiring suture repair (nine patients); Grade 4-parenchymal injuries requiring partial splenic resection (seven patients); Grade 5-total splenic devascularization or uncontrollable bleeding from the splenic pedicle requiring splenectomy (43 patients). Twenty-nine patients had associated orthopedic injuries, and 42 patients had associated intra-abdominal or thoracic injuries. Mean operative time was 130 +/- 10 minutes. Operative time increased with severity of associated intra-abdominal injuries. Mean operative transfusion requirement was 500 +/- 100 cc of packed red blood cells. Transfusion requirements were not related to the severity of splenic injury. Twenty-three patients developed complications. Pancreatitis occurred in three patients, atelectasis of pneumonitis in eight patients, ten developed wound infections, and two patients required reoperation for small-bowel obstruction. Complication rates were not related to the degree of splenic injury. The grading system described herein provides a framework for sound clinical judgment and comparison of results in the management of splenic injuries.