Spleen & Diaphragmatic trauma By AMGAD FOUAD Professor Of Surgery Gastroenterology Center

2. Spleen & Diaphragmatic trauma By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Mansoura University.

3. INTRODUCTION • Abdominal injuries are common in patients who sustain major trauma. • Unrecognized abdominal injuries are frequently the cause of preventable death. • Approximately one-fifth of all traumatized pt requiring operative intervention have sustained trauma to the abdomen.

4. Abdominal trauma • Abdominal trauma is an injury to the abdomen. It may be blunt or penetrating and may involve damage to the abdominal organs.

5. TYPES OF INJURIES • Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Blunt trauma: liver …spleen (most common). • Penetrating:liver, small bowel and stomach. Penetrating: present with single or multiple injuries

6. Penetrating abdominal trauma (PAT) is usually diagnosed based on clinical signs, blunt abdominal trauma is more likely to be missed because clinical signs are less obvious. • Penetrating trauma is further subdivided into stab wounds and bullet wounds, which have different treatments.

7. Key responses to decrease mortality and morbidity include • Aggressive Resuscitation Efforts, • Adequate Volume Replacement, • Early Diagnosis Of Injuries, And • Surgical Intervention If Warranted

8. ORGANS Solid Organs Liver Spleen Kidneys Pancreas Hollow Organs Stomach Small bowel Large bowel Bladder

9. Spleen InjuriesContusion, Laceration

10. Abdominal Quadrants • Right Upper • Liver, Pancreas, Kidney, and Lung • Right Lower • Appendix, Ureter, Bladder, Colon, and Gonads • Left Upper • Heart, Spleen, Kidney, Stomach, and Lung • Left Lower • Ureter, Bladder, Colon, and Gonads

11. Spleen Function • The primary filtering element for the blood. Acts as a filter against foreign organisms that infect the blood stream. • The site of red blood cell and platelet storage. • Filters out old red blood cells and recycles them.

12. More About The Spleen • The spleen is the organ most often damaged in cases of abdominal trauma. • Any injury to the spleen can cause severe internal hemorrhage and shock. • If surgically removed, the liver and red bone marrow can take over the functions normally carried out by the spleen.

13. Still More About That Wonderful Spleen • During periods of high infection, the spleen may become enlarged, increasing its ability to become injured. • Infectious mononeucleosis is the most likely cause of spleen enlargement.

14. Method of Injury • Blunt trauma • Infection causes spleen to swell • Increasing chance of contusion to spleen 

15. Signs & Symptoms • History of blow to upper left quadrant • Pale skin • Light headed • Blood pressure low • Heart rate up • Nausea • Abdominal rigidity • Pt tender in upper left quadrant but less tender if muscles are tense • KEHR's sign-pain in left shoulder

16. What is a spleen laceration? • A significant tear that involves the main blood vessels to the spleen which causes complete destruction of the spleen.

17. Spleen Laceration • External lateral view of a spleen. • Notice the normal slate-gray color of the spleen. • Towards the right of this specimen, extending from the very top diagonally across to the bottom of the specimen, is a large tear in the capsule of the spleen, exposing the pulp. • Splenic lacerations are common in automobile accidents and are particularly common if the spleen has undergone enlargement due to some reason.

18. Treatment • Monitor even if just had wind knocked out • See MD if symptoms persist • Nonoperative treatment is recommended with a week of hospitalization.  • No activity for three weeks.  Can resume light activity at three weeks to full recovery at four weeks.  • If surgical repair is needed, then will require 3 months to recover, whereas spleen removal will require six months before the athlete can return to activity

19. Diaphragmatic Injuries

21. Etiology • Penetrating trauma • Blunt trauma. • Iatrogenic injury. • Spontaneous rupture during pregnancy. • Unexplained Spontaneous rupture. Two categories: • Recognition during initial hospitalization • Late Recognition

22. Recognition During Initial Hospitalization • Blunt Diaphragmatic Trauma • Incidence of 3% in severe blunt trauma • Most commonly occurs in the left leaf. • The ratio of rupture of the left versus the right hemidiaphragm>>5: 1

23. Various Reports of laterality incidence • 34% incidence of right-sided rupture. • The left diaphragm in 68.5% of cases. the right in 24.2%. • Other types of injury • Bilateral –Pericardial- Central tendon rupture • Avulsion

24. On the left side the organs most commonly herniated into the chest are the stomach, spleen, large bowel, liver, small intestine and omentum. • On the right when herniation occurs the liver is always present and the colon is occasionally herniated. Vascular injuries (tears of the juxtahepatic vena cava and hepatic vein injuries) as well as lacerations of the liver frequently are associated Pathology

25. Recognition during initial hospitalizationblunt diaphragmatic trauma Symptomatology • Respiratory distress, Cardiac disturbances, Deviated trachea. • Bowel sounds in the chest >>in the inority • Symptoms that are present are related to other organ injuries, such as those to the heart, lungs, or spleen, or are due to the presence of hypovolemic shock.

26. Blunt Diaphragmatic Trauma-Methods of Diagnosis • History& Physical exam • Chest X Ray • Sonography • CT Scan • MRI • Contrast Studies • Laparoscopy • Thoracoscopy • Operative Intervention DPL?

28. Several normal variants may lead to diagnostic confusion: • Incidental poster lateral diaphragmatic defects (0.17% to 6% of otherwise normal patients) • Areas of apparent discontinuity can be seen where the diaphragm inserts on the costal margins • There may be areas of marked localized thinning (ie, eventration ) • Advancing age also predisposes to increasing areas of nodularity and contour irregularity

29. Blunt Diaphragmatic Trauma-Methods of Diagnosis Chest radiography • Supine positioning, portable technique, and reduced patient cooperation can limit diagnostic quality • Serial radiographs may be particularly useful in ventilated patients in whom positive-pressure support overcomes the natural negative pressure gradient that normally would facilitate herniation

30. Concurrent abnormalities, such as • Pulmonary contusion • Atelectasis • Pleural effusion may mask diaphragm injury

31. Specific radiographic signs of diaphragm injury include: • Intrathoracic location of abdominal viscera, with or without a site of focal constriction (ie, “collar sign”) • Clear demonstration of a nasogastric tube tip above the left hemidiaphragm

32. Highly suggestive sign: • Elevation of the left hemidiaphragm (>4 cm than the right) without associated atelectasis • In 90 % of normal patients, the left diaphragm dome is 1 to 3 cm lower than the right marked

33. Other sensitive, but nonspecific, findings: • Obscuration or distortion of the diaphragm margin • Diaphragm elevation with contralateralmediastinal shift • Elevation of the right diaphragm apex

34. Blunt Diaphragmatic Trauma-Methods of Diagnosis CT • Helical CT and the newer, multidetector CT (MDCT) are mainstays in the assessment of the polytrauma Patient • Because associated visceral injuries are the immediate concern, intravenous contrast is administered routinely (150 mL of iohexol [300 mgI/ mL] at 3 mL/sec with a 45-sec scan delay). Typically, oral contrast is administered, although it is not mandatory.

35. Signs of diaphragm injury : • Direct visualization of injury • Segmental diaphragm nonvisualization, • Intrathoracicherniation of viscera • The collar sign • The dependent viscera sign • Diaphragm thickening • Peridiaphragmatic active contrast extravasation

36. Segmental diaphragm nonvisualization • This sign must be used with caution when seen in isolation, especially in the elderly, in whom it can be a normal variant • In the absence of visceral herniation, hemothorax and atelectasis may blur the diaphragm margins, and thereby, yield a false positive examination • The usefulness of this sign increases when other signs of injury are present

37. Intrathoracicherniation of viscera • Factors that may hinder intrathoracicherniation: • The presence of intrathoracic space-occupying abnormalities, such as a large hemothorax • Increased intrathoracic pressure secondary to positive pressure ventilation

38. Herniation through torn hemidiaphragm. Hemothorax secondary to bleeding herniated omentum.

42. Signs of diaphragm injury COLLAR SIGN • If an abdominal structure herniates through a diaphragm rent, the free edges of the diaphragm can constrict the herniated organ, and thereby, result in a “collar.”

43. DEPENDENT VISCERA SIGN • Normally, the intact diaphragm prevents the upper abdominal viscera from contacting the posterior chest wall in the supine patient. When the diaphragm is torn, its constraints are released, and the viscera may lie “dependent” against the posterior chest wall.

44. ABNORMALLY THICK DIAPHRAGM • In the presence of injury, intramuscular hematoma or edema or muscle retraction accounts for the abnormallythick diaphragm

45. Diaphragm injury DIAGNOSTIC PITFALLS OF CT • Failure to recognize normal variations • Overemphasis of nonspecific signs of injury • Failure to recognize subtle signs of injury • Scanning artifacts • Repeat scanning with oral contrast and thinner image reconstruction, or follow-up scanning after several days, may improve diagnostic confidence

46. MR IMAGING • Provide direct sagittal and coronal images • Imaging the entire diaphragm • Excellent contrast resolution • Clear discrimination between the diaphragm and adjacent structures, such as the liver and atelectatic lung

47. The limitations of MR imaging in the setting of acute trauma • Currently available MDCT technology and videoscopic techniques • In cases of suspected delayed presentation or equivocal diagnosis by CT, MR imaging can play a valuable role as a noninvasive means to assess diaphragm integrity.

48. Other imaging modalities • Hepatobiliary scanning • Barium studies • Fluoroscopy • Given current CT and MR imaging technology, none plays an active role in the acute management

49. Sonographic signs of diaphragm injury • Herniation of viscera through the diaphragm • Diaphragm disruption • Diaphragm nonvisualization • Absent diaphragm excursion during the respiratory cycle

50. Ultrasound assessment of the diaphragm can be compromised by: • Pulmonary aeration • Gastric and colonic gas • Subcutaneous emphysema • Bandages and support appliances • Abdominal pain • Obesity