The right waist is empty when lying on the left side, and the left waist is dull when lying on the right side

Introduction Traumatic spleen rupture can be found in the abdominal wall with general tenderness and muscle rigidity, the most significant left upper abdomen. The spleen voiced area of the left rib also often increases. If there is a lot of blood accumulation in the abdomen, it can also be found to have mobile dullness. However, because there are often clots around the spleen, the left waist can be empty when the patient is lying on the left side, but the left waist is often fixed when lying on the right side. Voiced sound, called Balllance sign.

Cause

(1) Causes of the disease

The spleen is very fragile and rich in blood supply. When subjected to external forces, it is easy to cause rupture and bleeding. Clinically, spleen injury or rupture caused by direct or indirect external force is called traumatic or damaging spleen rupture. Traumatic spleen rupture can be divided into open and closed. There are also spontaneous spleen rupture and iatrogenic spleen rupture.

Traumatic spleen rupture is caused by knife or shrapnel, often accompanied by other visceral injuries, while closed persons are caused by direct or indirect violence such as dumping, boxing, car accidents, etc. One of the most common types of abdominal injuries.

(two) pathogenesis

The high incidence of spleen trauma 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 blow can cause spleen trauma. The tight binding of the spleen to the stomach wall and the tight fixation of the surrounding ligaments limit 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 so that the spleen is easily traversed. At the time of trauma, the pressure in the spleen and the pressure in the stomach increase, and the increase in blood storage in the spleen increases the likelihood of injury.

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 the ligament tension that is radially distributed on the surface of the spleen can also cause spleen damage. This injury mechanism can explain spleen damage during rapid deceleration of the body. Direct trauma, such as trauma to the left upper abdomen, is secondary to the cause of spleen trauma. In the case of trauma, the spleen is prone to trauma at the moment of inhalation, and the spleen moves to the caudal and ventral sides, leaving the surrounding area. The thorax is protected and is in the direction of the force, and the left rib arch contraction contuses the spleen. Under normal circumstances, only the flexible thorax of children and young people can occur, and often combined with rib fractures, rib fragments can also directly stab the spleen.

Compared with blunt abdominal injuries, the chance of spleen trauma caused by penetrating injuries such as abdominal scratches, stab wounds and gunshot wounds is much smaller. All wounds below the sixth rib on the left side, including the entrance or exit of the bullet, should take into account the possibility of 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 farther under the skin or under the fascia when entering the abdominal cavity. The warhead with higher kinetic energy is often surrounded by the surrounding. Tissue (such as peritoneal tissue) turns and a completely unexpected process occurs that can 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 by the degree of damage, ranging from a small laceration of the spleen capsule to a complete rupture of the spleen. Only 1/3 of the lacerations occur in the spleen convex surface. Other traumas often have spleen injury. The spleen concave laceration is often more dangerous than the facial laceration. This is because the spleen is covered with thick spleen and Spleen blood vessels.

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, and a large amount of blood is accumulated in the abdominal cavity. If the spleen envelope can withstand stress, the hematoma will slowly absorb and form a fibrous scar or pseudocyst.

Some small lacerations often stop on their own, and the spleen concave and large blood vessel lacerations often have a large amount of abdominal hemorrhage, which can be quickly diagnosed due to the acute blood volume decline and shock symptoms. However, such bleeding or rupture of larger blood vessels can occasionally stop on their own, which may be due to the following reasons: decreased spleen vascular pressure and circulating blood pressure, formation of blood clots, occlusion of the omentum, and intima of the blood vessels. Retraction and intravascular thrombosis. The re-distribution of blood flow in the spleen may also play a role, as it has been found that there are diversions of the arteries and veins.

Sometimes, especially after spleen injuries in children and young people, it is often found that bleeding has stopped during surgery. Therefore, although the spleen is extensively damaged, there may be an illusion that the circulation is relatively stable, but rebleeding may occur at any time, especially after a large amount of fluid replacement.

Spleen rupture classification

(1) Central rupture: the deep rupture of the spleen parenchyma, the superficial parenchyma and the spleen capsule are intact, and the hematoma is formed in the spleen marrow, causing the spleen to gradually enlarge and slightly bulge. There are three such spleen ruptures. One is bleeding, the hematoma is increasing, the rupture is so severe that it is ruptured, the second is hematoma secondary infection, and the third is that the hematoma can be gradually absorbed or mechanized.

(2) subcapsular rupture: the part of the spleen parenchyma is ruptured under the capsule, and the capsule is still intact, causing blood to accumulate under the capsule.

(3) true rupture: the spleen capsule and the parenchyma rupture at the same time, intra-abdominal hemorrhage occurs, the most common rupture, accounting for more than 85% of spleen rupture.

2. Spleen rupture grading is to deal with different degrees of damage more consistently.

(1) According to ultrasound, CT, intraoperative DSA and clinical manifestations, the American Society of Traumatic Surgery (AAST) published the classification criteria for organ damage in 1989, and divided the spleen rupture into the following five levels:

Grade 1: Hematoma under the capsule, does not expand, the surface area is less than 10%, the tear of the capsule is not bleeding, and the depth is less than 1cm.

Grade 2: subcapsular hematoma, no expansion, surface area 10% to 50%, or parenchymal hematoma does not expand, hematoma diameter is less than 5cm, there is active bleeding in the tear of the capsule, or the depth of the parenchyma is 1~3cm, but not Injury to the spleen vascular.

Grade 3: subcapsular hematoma is extensible, or surface area greater than 50%, subcapsular hematoma rupture and active bleeding, parenchymal hematoma greater than 5cm, or extensibility, parenchymal laceration depth greater than 3cm or injury spleen The blood vessels of the spleen did not lose blood supply to the spleen.

Grade 4: The hematoma in the parenchyma is ruptured and there is active bleeding. The laceration involves the spleen segment or the spleen and blood vessels, resulting in the loss of blood supply to the large spleen tissue (more than 25%).

Level 5: The spleen is completely ruptured, the spleen is damaged, and the whole spleen loses blood supply.

(2) The 6th National Symposium on Splenic Surgery held in Tianjin in September 2000 passed the grading standard for spleen injury. The Spleen Surgery Group and the Collaborative Group of the Chinese Society of Surgery recommended the national standard.

Grade 1: The spleen was ruptured under the capsule or the membrane and the parenchyma were slightly damaged. The length of the spleen injury seen in the operation was 5 cm and the depth was 1 cm.

Grade 2: The total length of the spleen laceration is 5 cm, and the depth is 1 cm, but the spleen is not involved, or the spleen is damaged.

Grade 3: rupture of the spleen and separation of the spleen or spleen, or damage to the spleen and blood vessels.

Grade 4: The spleen is extensively ruptured, or the spleen pedicle, spleen arteriovenous trunk is damaged

an examination

Related inspection

Abdominal vascular ultrasound examination of gastric ultrasound

1. Symptoms and signs of spleen rupture have different manifestations with the number 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 pain in the left upper abdomen, which can be exacerbated during breathing; 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. The performance of other internal bleeding also does not exist. If not completely ruptured, once it becomes completely ruptured, acute symptoms will appear rapidly and the condition will deteriorate rapidly.

Once a complete rupture occurs, there will first be symptoms of peritoneal irritation. If the bleeding is slow and the amount is not much, abdominal pain can be limited to the left quarter rib; if the bleeding is more scattered and the whole abdomen, it can cause diffuse abdominal pain, but still the most significant left rib. Reflex vomiting is common, especially in the early stages of onset. Sometimes the blood stimulates the left diaphragm, which can cause pain in the left shoulder (the distribution of the fourth cervical nerve), and often worsens in deep breathing, called the Kehr sign. Subsequently, the patient may have obvious symptoms of internal bleeding in a short period of time, such as thirst, palpitation, palpitations, tinnitus, weakness of the limbs, shortness of breath, decreased blood pressure, unconsciousness, etc.; in severe cases, excessive bleeding, circulatory failure in a short period of time And die.

Physical examination revealed general tenderness and muscle rigidity in the abdominal wall, with the left upper abdomen being the most significant. The spleen voiced area of the left rib also often increases. If there is a lot of blood accumulation in the abdomen, it can also be found to have mobile dullness. However, because there are often clots around the spleen, the left waist can be empty when the patient is lying on the left side, but the left waist is often fixed when lying on the right side. 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 in clinical practice:

(1) Immediate spleen rupture: the spleen rupture, which is commonly called clinically, accounts for 80% to 90% of traumatic spleen rupture. It is spleen rupture, intra-abdominal hemorrhage, hemorrhagic shock immediately after trauma, 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, and even no clear history of trauma can be traced, the diagnosis is not easy to be sure. Anemia, left upper abdominal mass, spleen pseudocyst or rupture, and intra-abdominal hemorrhage are diagnosed. This type is rare and occurs less than 1% in closed spleen rupture.

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. This period varies from 3 to 4 hours, usually from 10 to 3 to 5 days. Individual diseases such as subcapsular hemorrhage or minor laceration can also last for 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 pain, tenderness, and tendon in the left rib, only the local part has a subtle lumps, and the abdomen is slightly bulging; Radiation pain in the left shoulder is not common. However, if the diagnosis cannot be made in time, it is the main reason for the poor prognosis of most patients. Therefore, it should be done cautiously. The history of trauma is not clear. The patient's condition is still good. There is no obvious internal bleeding symptoms. There is no typical The Kehr sign or the Balllance sign is numb 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, and bullets or shrapnel can hurt the spleen no matter where it enters the abdominal cavity. These open injuries are often accompanied by other visceral injuries, requiring early laparotomy; it is difficult or unnecessary to diagnose spleen rupture before surgery. It should be noted that abdominal injuries with symptoms of internal bleeding are more urgent than those of simple hollow organs.

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. For such suspicious cases, only vigilance and close observation can not delay the disease. Pay attention to whether the pain range is widened, whether the abdominal wall tension is increased, whether there is pain in the left shoulder, whether the abdomen has bulging, whether the bowel sounds are weakened, whether the pulse is gradually increasing, whether the red blood cells and hemoglobin are continuously decreased, and whether the bowel or the hemoglobin is continuously decreased. Internal bleeding. And timely X-ray, B-ultrasound, CT and other examinations, in the diagnosis of difficulty, MRI, selective celiac angiography, hepatosplenic nucleus 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.

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