The spectrum of splenic complications in patients with sickle cell disease in Africa: a systematic review.

The majority of the global population of sickle cell disease (SCD) patients resides in Africa. Individuals with this condition are at great risk of serious infections and early mortality secondary to splenic dysfunction without preventative measures. This review investigated the spectrum of splenic complications encountered in SCD among populations in Africa. We systematically searched several databases for all articles published through March 3, 2020. We included 55 studies from 14 African countries. This review reveals the difference in frequency of splenic complications in SCD in Africa when compared with their counterparts in the United State and Europe. While several studies (n = 45) described splenomegaly with a prevalence of 12% to 73% among children, and 4% to 50% among adults with HbSS, the reported prevalence for acute splenic sequestration crisis (n = 6 studies) and hypersplenism (n = 4 studies) was <10% and <5% respectively. A total of 30 surgical splenectomy was reported across eight studies. Only two (3.7%) studies provided data on spleen function. A conflicting pattern was observed amongst studies that evaluated the relationship between splenomegaly and the presence of bacterial and malaria infections. This review reveals the paucity of studies describing the role of SCD-induced splenic dysfunction in morbidity and infection related mortality in Africa.

Prospective observational study of dogs with splenic mass rupture suggests potentially lower risk of malignancy and more favourable perioperative outcomes.

Haemoperitoneum secondary to ruptured splenic tumours can be either benign or malignant in origin. The majority of previous studies of canine haemoperitoneum have been retrospective, which are associated with well-recognized biases, such as the potential to underappreciate the diversity of outcomes in a complex presentation such as haemoperitoneum. This study seeks to prospectively define perioperative morbidity and mortality of haemoperitoneum in dogs secondary to ruptured splenic masses. Forty dogs with haemoperitoneum secondary to a ruptured splenic mass met the inclusion criteria. As expected, the cohort predominately consisted of older large breed dogs. All dogs underwent preoperative staging and had a splenectomy performed. Histopathologic analysis was performed on the splenic mass, as well as any possible metastatic lesions that were noted intra-operatively. Perioperative care outside of splenectomy was delivered in specialty practices using current conventional approaches to care (eg, transfusions and anti-arrhythmic medications). Fifteen dogs (37.5%) had benign splenic tumours and were cured with surgery alone, whereas 62.5% had malignant disease (most often haemangiosarcoma [HSA]). Surgical outcomes were highly favourable in the vast majority of dogs. Indeed, 38 dogs (95%) survived and were discharged after a median hospitalization of 39.5 hours. Independent predictors of longer hospitalization times included receiving a transfusion and the development of an arrhythmia. Although small, this cohort defines distinctive and optimistic perspectives for dogs with haemoperitoneum from splenic tumour rupture. These favourable outcomes from this prospective study are sufficient to ask if larger prospective studies should be conducted to better inform owners during this challenging cancer emergency presentation.

Systematic review of spontaneous splenic rupture in dengue-infected patients.

Dengue infection varies from a mild febrile form to more severe disease with plasma leakage, shock, and multiorgan failure. Several serious complications such as cardiomyopathy, encephalopathy, encephalitis, hepatic damage, and neural manifestations cause organ damage in dengue infection. Splenic rupture, a less well known but life-threatening complication, can occur in dengue. The mechanism of splenic rupture in dengue is still unclear. Optimal therapeutic management is required to save the lives of patients with this complication. The objective of this study was to conduct a systematic review of studies documenting the development of spontaneous nontraumatic splenic rupture in patients with dengue infection. In March 2018, a search was conducted systematically in nine electronic databases, in addition to hand- searching. A total of 127 references were exported to Endnote; 47 references remained after removing duplicates. Finally, 16 reports met the inclusion criteria and represented 17 cases. All articles were evaluated and data extracted according to predefined criteria: number of cases, age, sex, severity of dengue disease, days of illness before admission, methods of definitive diagnosis, timing of the event, and management and outcome. A total of 17 individual patients including 13 males and four females were found. Most of the patients were young adults (ranging from 20 to 52 years) and diagnosed with computed tomography scan and managed with splenectomy. Four cases were fatal. Pathological splenic rupture in dengue is a rare, life-threatening condition where timely management can achieve a favorable outcome.

Babesiosis-associated Splenic Rupture: Case Series From a Hyperendemic Region.

BACKGROUND: Spontaneous splenic rupture is an increasingly reported complication of babesiosis and has been described as a severe complication. METHODS: We performed a retrospective chart review in a high-prevalence area to identify 7 cases of babesiosis-related splenic rupture between 2014 and 2016. RESULTS: Splenic rupture occurred in approximately 1% of babesiosis cases. Compared to cases without splenic rupture, these patients were younger (by >10 years), healthier (most with ≤1 comorbidity), had a lower degree of parasitemia (<10%), and were less likely to have end-organ dysfunction other than their splenic involvement. CONCLUSIONS: Younger, healthier patients may be more prone to develop splenic rupture, as splenic histiocytes engage in more robust erythrophagocytosis, leading to pathological mechanical strain and rupture.

Splenic Rupture in Children With Portal Hypertension.

INTRODUCTION: Massive splenomegaly from portal hypertension (PHTN) in children raises the specter of splenic rupture; however, the incidence, etiology, and risk of rupture have not been studied, nor have existing practices to reduce risk. We therefore performed an international survey to describe the splenic rupture cases in PHTN and to describe the existing empirical practice among hepatologists. METHODS: A questionnaire was constructed to elicit cases of splenic rupture and collect hepatologists' common practices for prevention of splenic rupture. Pediatric hepatologists working in selected tertiary academic centers in the United States, Canada, and the United Kingdom were contacted. RESULTS: Hepatologists from 30 of 35 centers who met the inclusion criteria replied to the survey. Thirteen cases of splenic rupture were described of which 11 resulted from trauma. In the opinion of the practitioners, high-risk activities were football, hockey, and wrestling. Sixty-one percent recommended total restriction from high-risk activities. Seventy-four percent stated that platelet count had no effect on this decision and 61% advised a spleen guard for certain activities. CONCLUSIONS: Splenic rupture in patients with PHTN and splenomegaly seems to be rare. The reported splenic rupture cases were mostly related to falling (and not to participation in sports). There was general agreement among hepatologists about restricting high impact sports. There was variation in recommendations regarding the use of a spleen guard. The authors recommend use of spleen guards in children with splenomegaly from PHTN for physical activities with risk of fall or blunt abdominal trauma.

Ten-year experience of splenic trauma in New Zealand: the rise of non-operative management.

AIM: The aim of this study was to describe the demographics, mechanisms of injury, management and outcomes in patients who suffered splenic trauma in Christchurch, New Zealand. METHODS: A retrospective study included all splenic injury patients admitted to Christchurch Public Hospital between January 2005 and August 2015. RESULTS: A total of 238 patients were included, with a median age of 26 years (4-88.7). Of these, 235 patients had blunt injuries. Eighty-nine had high-grade injuries. Yearly admissions of splenic trauma patients have gradually increased. A total of 173 (72.7%) patients were managed with observation; 28 patients (11.8%) had radiological intervention and 37 patients (15.5%) had splenectomy. Patients who died were significantly more likely to be older (median, 46.5 vs 25.2 years, p=0.04) and to have been admitted to ICU (100% vs 32%, p=<0.001). CONCLUSION: Splenic injuries have shown a steady increase in the last decade. Splenectomy rates have decreased in favour of non-operative techniques. Radiological intervention with splenic artery embolisation was successful in all selected patients with high-grade injuries.

A systematic review of splenic injuries during colonoscopies: Evolving trends in presentation and management.

INTRODUCTION: Although uncommon, the incidence of splenic injury from colonoscopy has been increasing significantly since first being reported in 1974. Early recognition is critical because mortality may be as high as 5%. METHODS: We systematically searched PubMed and EMBASE to identify English-language cases of splenic injury from colonoscopy from inception until January 26, 2015. We used descriptive statistics to characterize the identified cases. RESULTS: A total of 172 cases from 122 reports were included. The mean age was 64 years and 70.8% were females. Prior abdominal or pelvic surgeries were identified in 63.8%. 57.3% of patients underwent polypectomies or biopsies. There was a statistically significant increase in use of computerized tomography for diagnosis in the past 5 years (81.8% versus 65.2%). 76.1% patients received transfusions. Mean inpatient length of stay was 7.83 ± 5.32 days. A non-significant trend toward conservative management was noted in the past 5 years (37.7% versus 23.1%), and a non-significant drop in mortality was noted (4.9% versus 5.4%). DISCUSSION: Our data support prior literature suggesting a higher incidence of splenic injuries during colonoscopies in females, advanced age, prior history of abdominal/pelvic surgeries and biopsies/polypectomies during the procedure. CONCLUSIONS: Significant mortality associated with splenic injuries during colonoscopies warrants prompt recognition of this potentially life threatening, albeit uncommon, complication.

Characteristics of patients with spontaneous splenic rupture.

In the present study, we aim to share our clinical experience in patients with spontaneous splenic rupture. Splenic rupture without trauma is known as spontaneous splenic rupture. The major problems in the management of spontaneous splenic rupture are missed or delayed diagnosis due to the lack of trauma in most cases. The records of all patients, who were admitted to Cerrahpasa Medical Faculty, Istanbul University, were retrospectively reviewed from January 2000 to March 2013. Twelve patients were admitted to the emergency department and they were diagnosed with spontaneous splenic rupture. The mean age was 47.6 years. All patients had complaints of abdominal pain. The mean hematocrit value was 22%. Radiologic assessment revealed hemoperitoneum and/or subcapsular hematoma in 8 patients while splenic abscess was diagnosed in 2 patients. Eleven patients underwent splenectomy whereas one was managed conservatively. The most common cause of spontaneous splenic rupture was determined to be use of anticoagulants. Etiology was considered to be idiopathic in 1 patient. Two patients died in the postoperative period. Although rare, spontaneous splenic rupture must be suspected in emergency patients who have used especially anticoagulants and antiaggregants and who have had no recent history of trauma. One of the important causes of mortality is missed or delayed diagnosis.

Splenic injury during colonoscopy--a complication that warrants urgent attention.

INTRODUCTION: Colonoscopy is a safe procedure that is performed routinely worldwide. There is, however, a small but significant risk of splenic injury that is often under-recognized. Due to a lack of awareness about this injury, the diagnosis may be delayed, which can lead to an increased risk of morbidity as well as mortality. This paper presents a comprehensive review of the medical literature on colonoscopy-associated splenic injury and describes the clinical presentation and management of this rare but potentially life-threatening complication. MATERIALS AND METHODS: A comprehensive literature search identified 102 patients worldwide, including patients from our experience, with splenic injury during colonoscopy. A meta-regression analysis was completed using a mixed generalized linear model for repeated measures to identify risk factors for this rare complication. RESULTS: A total of 75 articles were identified and 102 patients were studied. The majority of the papers were in English (92 %). Only 23.4 % of patients (26/102) were reported prior to the year 2000. Among the patients reported after the year 2000, the majority (84.2 %, 64/76) were reported after 2005. There were more females (76.5 %), median age was 65 years (range, 29-90 years), and most of the colonoscopies were performed without difficulty (66.6 %). Nearly 67 % of patients presented within 24 h of colonoscopy with complaints ranging from abdominal pain to dizziness. The most common symptom was left upper quadrant pain (58 %), and CT scan was found to be the most sensitive tool for diagnosis. Seventy-three patients underwent operative intervention; 96 % of these were treated with splenectomy. Hemoglobin drop of more than 3 gm/dL was identified as the only significant predictor of operative intervention. The overall mortality rate was 5 %. CONCLUSION: Splenic injury during colonoscopy is rare; however, it is associated with significant morbidity and mortality. Splenic injury warrants a high degree of clinical suspicion critical to prompt diagnosis, and early surgical consultation is warranted.

The significance of pseudoaneurysms in the nonoperative management of pediatric blunt splenic trauma.

PURPOSE: Nonoperative management is the standard of care for hemodynamically stable pediatric and adult blunt splenic injuries. In adults, most centers follow a well-defined protocol involving repeated imaging at 24 to 48 hours, with embolization of splenic pseudoaneurysms (SAPs). In children, the significance of radiologically detected SAP has yet to be clarified. METHODS: A systematic review of the medical literature was conducted to analyze the outcomes of documented posttraumatic SAP in the pediatric population. RESULTS: Sixteen articles, including 1 prospective study, 4 retrospective reviews, and 11 case reports were reviewed. Forty-five SAPs were reported. Ninety-six percent of children were reported as stable. Yet, 82% underwent splenectomy, splenorrhaphy, or embolization. The fear of delayed complications owing to SAP was often cited as the reason for intervention in otherwise stable children. Only one child with a documented pseudoaneurysm experienced a delayed splenic rupture while under observation. No deaths were reported. CONCLUSIONS: There is no evidence to support or dispute the routine use of follow-up imaging and embolization of posttraumatic SAP in the pediatric population. At present, the decision to treat SAP in stable children is at the discretion of the treating physician. A prospective study is needed to clarify this issue.

Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?

BACKGROUND: Although blunt injury to the spleen and liver can lead to pseudoaneurysm formation, current surgical guidelines do not recommend follow-up imaging. Controversy exists regarding the clinical implications of these traumatic pseudoaneurysms as well as their management. METHODS: Retrospective review of children treated nonoperatively for isolated blunt liver and spleen trauma between 1991 and 2008 was undertaken. Patient demographics, grade of injury, and follow-up Doppler ultrasound results were obtained. RESULTS: Three hundred sixty-two children were identified. One hundred eighty-six of them had splenic injuries, and 10 (5.4%) developed pseudoaneurysms. They were associated with grade III (3/39 [8%]) and grade IV (7/41 [17%]) injuries. In 7 patients, the pseudoaneurysm thrombosed spontaneously. Angiographic embolization was required in 2 children, and one underwent emergency splenectomy for delayed hemorrhage. Of the 176 patients who had liver injuries, 3 (1.7%) developed pseudoaneurysms. All 3 were associated with grade IV injuries (3/11 [27%]). One child underwent early embolization, while 2 developed delayed hemorrhage requiring emergent treatment. CONCLUSIONS: Pseudoaneurysm development after blunt abdominal trauma is associated with high-grade splenic and liver injuries. Routine screening of this group of patients before discharge from hospital may be warranted because of the potential risk of life-threatening hemorrhage.

Rates and predictors of surgery for patients with blunt splenic trauma in a district general hospital of the UK.

OBJECTIVES: To describe the rates of surgery and nonoperative management (NOM) for patients with blunt splenic trauma in a district general hospital. METHODS: Retrospective review of 20 patients with blunt splenic trauma from 2004 to 2010. RESULTS: Six patients underwent immediate surgery. Fourteen (70%) patients entered a trial of NOM, of whom three failed the trial (21%) and required surgery. These three patients had significantly lower systolic blood pressures within 60 min of hospital arrival than those who succeeded NOM (90 vs. 113 mmHg, P=0.038). Final management strategy was operative in nine patients and nonoperative in 11 patients. These nine operative patients had significantly higher splenic injury grades, higher Injury Severity Scores and lower 60 min systolic blood pressures than those successfully treated with NOM. CONCLUSION: Rates of blunt splenic trauma in a district general hospital remain low with acceptable rates of NOM. Hypotension within 60 min of hospital arrival may be a useful predictor of the need for surgery.

Atraumatic splenic rupture: a 6-year case series.

Atraumatic splenic rupture is an uncommon but poorly defined clinical condition. Its diagnosis may be missed or delayed because of low clinical suspicion, especially in the absence of trauma. The primary aim of this study was to describe the experience with atraumatic splenic rupture in a district general hospital. Over a 6-year period (2004-2010), seven patients were identified, producing an incidence of 1.2/year. Computed tomography confirmed the diagnosis preoperatively in all the cases where it was performed (n=5). All patients required total splenectomy; indications included peritonitis, hypovolaemic shock and failed conservative treatment. Five splenectomies were performed within 24 h of admission. In four cases, no pathological abnormality was identified (atraumatic-idiopathic); abnormal pathologies (atraumatic-pathological) in the remaining three were amyloidosis, lymphoma and focal thrombosis. A high index of suspicion should be maintained by emergency physicians and surgeons during initial evaluation of these patients. Computed tomography scan facilitates the diagnosis and early total splenectomy is often needed.

Pathological rupture of the spleen in malaria: analysis of 55 cases (1958-2008).

BACKGROUND: Splenic rupture during acute malaria is rare but underreported. Because splenic rupture occurs mostly in non-immune adults, ongoing malaria elimination efforts may paradoxically increase the proportion of Plasmodium-infected patients suffering from this life-threatening complication. The pathogenesis and optimal patient management are still debated. METHOD: We collected and analysed reports of pathological rupture of the spleen associated with malaria published over the last 50 years in five languages. RESULTS: Fifty-five cases were reported, due to Plasmodium falciparum (n=26), Plasmodium vivax (n=23), Plasmodium ovale (n=2), Plasmodium malariae (n=2), or P. vivax-falciparum (n=2), and occurred in travellers (n=24), locals (n=21), expatriates (n=6) or migrants (n=4). Median age was 31.5 years and sex ratio M/F 3.2. Splenic rupture was complete with hemoperitoneum (n=50), or partial (n=5). Death occurred in 12 patients (22%), 8 of whom from early irreversible collapse (n=7) or unexpected death (n=1). Death rate was higher among travellers than in other patients (9/24, 38%, versus 3/31, 10%, p=0.01). Clinical features of P. falciparum- or P. vivax-associated splenic rupture were strikingly similar. Treatment included in-hospital medical observation without surgery (conservative management, n=14), immediate splenectomy (n=29), delayed splenectomy (n=4), or none (patients dying at admission, n=8). The type of treatment, conservative or not, had no influence on prognosis. The median duration of malaria symptoms before diagnosis was longer in our review (5-6 days) than in previous reports on imported malaria (3-4 days), suggesting that early diagnosis and therapy of malaria may reduce the incidence of splenic rupture. CONCLUSIONS: Abdominal pain, collapse, or fainting is warning symptoms. Fourteen published observations support conservative management in carefully selected patients. Spleen preservation likely reduces the risk of future severe malaria attacks in patients with potential further exposition to Plasmodium sp., and also that of overwhelming sepsis in all.

Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children.

OBJECTIVE(S): The current management of blunt spleen/liver injury in children requires a number of days of bed rest equal to the grade of injury plus 1. This protocol is used even when there is no clinical indication of ongoing bleeding. To establish a prospective protocol with an abbreviated period of bed rest, we conducted a retrospective review of our blunt spleen and liver trauma experience to examine the safety of such an attenuated protocol. METHODS: A retrospective analysis of our most recent 10-year experience (January 1996 to December 2005) with blunt spleen or liver injury was performed. Patient demographics, vital signs, hemoglobin levels, need for transfusion, operations, and outcomes were measured. An abbreviated protocol using 1 night of bed rest for grades 1 and 2 injuries and 2 nights of bed rest for higher grades was designed. This protocol was then applied to our patient population to assess its safety. Data are expressed as mean +/- SD. RESULTS: During the study period, 243 patients were admitted with blunt spleen and/or liver injury. The mean patient age was 9.0 +/- 4.6 years, and the mean weight was 35.3 +/- 19.3 kg. Sixty-three percent were male. The spleen was injured in 148 (61.2%) patients and the liver in 121 (50.0%), and 26 (10.6%) had both. The mean grade was 2.0 +/- 1.1, for which the mean bed rest was 3.5 +/- 1.1 days. This resulted in 5.6 +/- 6.5 days of hospitalization. There were 9 patients who died, 7 with severe brain injury and 2 with massive liver hemorrhage on presentation. No patient required an operation or transfusion after 2 nights of observation who did not have clinically obvious signs of ongoing blood loss. Implementation of the abbreviated protocol would have affected 65.8% of our patients and would have saved a mean of 2.0 +/- 1.5 hospital days per patient. CONCLUSIONS: According to our data, an abbreviated trauma protocol with overnight bed rest for grades 1 and 2 injuries and 2 nights for higher grades could be safely used. This protocol would immensely improve current resource use. Based on these retrospectively collected data, we have initiated a prospective consecutive controlled series to assess the safety of such an attenuated protocol.

Splenic rupture following colonoscopy: rare in the UK?

Splenic injury following colonoscopy is rare, with only 28 cases reported so far in the English language literature. Direct trauma during colonoscopy or traction on the spleno-colic ligament is the proposed mechanism of injury. Computed tomography (CT) of the abdomen is usually considered to be the most sensitive and specific modality for diagnosis. We report a case of a 56-year-old female, who was diagnosed having a splenic rupture following a routine colonoscopy for investigation of anaemia. She underwent an emergency laparotomy with splenectomy and made a satisfactory recovery post-operatively. We wish to highlight that there should be a high index of suspicion of splenic rupture in patients presenting with abdominal pain and demonstrating a positive Kehr's sign following colonoscopy. Only two case reports from the United Kingdom have been published, raising the possibility of under-reporting of such cases.

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization.

BACKGROUND: The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation. METHODS: The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications. RESULTS: One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications. CONCLUSIONS: Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.