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					                    WEST AFRICAN JOURNAL OF MEDICINE
                                                  ORIGINAL ARTICLE

  Management of Splenic Injuries in a University Teaching Hospital in Nigeria

       Gestion des blessures spléniques dans un hôpital d’enseignement universitaire au Nigéria

                                               P. E. Iribhogbe*, C. J. Okolo

ABSTRACT                                                            RÉSUMÉ
BACKGROUND: Management of spleen injuries has                       CONTEXTE: La gestion des blessures rate a subi une évolution au
undergone evolution over the past few decades.                      cours des dernières décennies.
OBJECTIVE: To assess the challenges of managing splenic             OBJECTIF: Évaluer les défis de la gestion des blessures spléniques
                                                                    au Nigeria.
injuries in Nigeria.
                                                                    MÉTHODES: Les dossiers médicaux de tous les patients adultes
METHODS: The medical records of all adult trauma patients
                                                                    présentant une lésion traumatismes documentés de la rate au cours
with documented injury of the spleen over a two-year period         d’une période de deux ans (2006–2008) ont été examinés. Les données
(2006-2008) were reviewed. Data collected included patient          recueillies comprennent les caractéristiques démographiques des
demographics, mechanism of injury, injury-arrival time,             patients, le mécanisme de la blessure, blessures heure d’arrivée,
Revised Trauma Score, abdominocentesis, abdominal                   Revised Trauma Score, abdominocentesis, une échographie
ultrasound and CT findings. Treatment received, outcome and         abdominale et les résultats de CT. Traitements reçus, les résultats et
length of hospital stay were also documented.                       la durée du séjour à l’hôpital ont aussi été documentés.
RESULTS: Twenty-three patients were managed for splenic             RÉSULTATS: Vingt-trois patients ont été gérés pour des blessures
injuries during the period under review. These consisted of 21      spléniques au cours de la période sous revue. Il s’agissait de 21
(91.3%) males and two (8.7%) females. The age range was             (91,3%) hommes et deux (8,7%) femmes. La fourchette d’âge est 16-
                                                                    58 ans (moyenne de 29,6 ± 12,2 ans). Accident de la route le mécanisme
16–58 years (mean of 29.6±12.2 years). The mechanism of
                                                                    de blessure n’a pas mâché dans 21 cas et pénétrant dans les deux cas
injury was blunt in 21 cases and penetrating in two cases with
                                                                    avec le moteur étant la cause la plus commune des blessures. La
motor vehicle accident being the most common cause of injury.       moyenne des blessures-heure d’arrivée était de 25,2 ± 26,5 heures.
The mean injury-arrival time was 25.2±26.5 hours. Eight             Huit patients ont subi avec succès la gestion non coopérative, tandis
patients successfully underwent non-operative management,           que 15 avaient intervention opératoire. Splénectomie a été la procédure
while 15 had operative intervention. Splenectomy was the most       la plus fréquemment effectuées. Défis identifiés dans la gestion des
frequently performed procedure. Challenges identified in the        patients souffrant de lésions spléniques au Nigeria comprennent
management of patients with splenic injuries in Nigeria include     retardé la présentation, sous-utilisation de la TDM, l’indisponibilité
delayed presentation, underutilization of CT, unavailability of     de la radiologie interventionnelle, les unités de soins intensifs
interventional radiology, inadequate ICUs, limited vaccination,     inadéquate, une vaccination limitée, la décharge contre avis médical
discharge against medical advice and poor follow up.                et les pauvres de suivi.
                                                                    CONCLUSION: La non-gestion coopérative des lésions à la rate
CONCLUSION: Non-operative management of injuries to the
                                                                    chez l’adulte semble prometteuse. Les défis identifiés doivent être
spleen in adults appears promising. The challenges identified
                                                                    traités afin d’assurer des soins optimaux pour les victimes de
need to be addressed in order to deliver optimal care for the       traumatismes rate. WAJM 2009; 28 (5): 308–312.
victims of spleen trauma. WAJM 2009; 28(5): 308–312.

Keywords: Spleen, injury, aetiology, Nigeria.                       Mots-clés: Spleen, le préjudice, l’étiologie, le Nigeria.

Department of Surgery, University of Benin Teaching Hospital, P. M. B 1111, Benin City, Nigeria.
*Correspondence: Dr P. E. Iribhogbe, Department of Surgery, University of Benin Teaching Hospital, P. M. B 1111, Benin City, Nigeria.
Phone: +234-8025853315, E-mail:
Abbreviations: AAST, American Association for the study of Trauma; ARDS, Adult Respiratory distress Syndrome; CT, computerized tomog-
raphy; DAMA, Discharge against medical advice; DPL, Diagnostic Peritoned Lavage; FAST, Focused, Assessment Using Sonograph Trauma;
ICU, intensive care unit; NOM, non-operative management; OM, Operative management; OPSI, overwhelming post splenectomy infection;
PCV, packed cell volume; RTS, Revised trauma score;USS, ultra sound scan.

                        West African Journal of Medicine Vol. 28, No. 5          September–October 2009
P. E. Iribhogbe and C. J. Okolo                                                      Challenges posed by Spleen Injuries in Nigeria

INTRODUCTION                                       Data collection included patient’s        had trauma laparotomy while eight were
      The spleen is the most frequently      demographics, mechanism of injury, time         successfully managed non-operatively
injured organ after blunt trauma of the      interval between injury and arrival in          out of 10 that qualified for NOM (success
abdomen.1–3 Management of injuries to        trauma unit (injury – arrival time), initial    rate 80%). The reasons for failure were
the spleen often involves a complex          pulse rate, initial blood pressure              persistent tachycardia, decreasing PCV
decision making process. On the one          recording (hypotension was defined as           and peritonitis in both patients. Injury –
hand haemorrhage from a traumatized          systolic blood pressure of 90mmHg or            arrival time varied from one hour to three
disrupted spleen can be lethal and timely.   less), initial packed cell volume (PCV),        weeks. One patient presented three
splenectomy may be life saving. On the       Revised trauma score (RTS), abdomino-           weeks post trauma with delayed rupture
other hand, many patients with injured       centesis, abdominal ultrasound scan as          of the spleen. Excluding her in the series
spleen can be treated with procedures        well as CT findings.                            the average injury – arrival time was 25.2
that accomplish splenic salvage and                Other data collected included the         ± 26.5 hours.
preserve the organ’s immunologic             management to which the patient was                   All the patients had a subnormal
function.4                                   subjected – Non Operative Management            initial PCV. Hypotension was present in
      Emphasis shifted towards non-          (NOM) or Operative Management (OM),             9 patients on presentation. However
operative management (NOM) since             use of blood products, presence of              comparing hypotensive to non hypo-
recognition of overwhelming post             associated injuries and in the case of OM       tensive patients the initial blood pressure
splenectomy infection (OPSI) several         the grade of splenic injury and the             was not statistically predictive of
decades ago.5–7 This trend was enabled       amount of haemoperitoneum. The length           operative intervention, ICU admission or
by the emergence of computerized             of ICU stay, length of hospital stay,           mortality (p values were 0.34, 0.42 and
tomography (CT) as an investigative tool     occurrence of complications, the outcome        0.61 respectively).
in the early 1980s which enabled more        of management and the length of follow                The most common associated injury
accurate diagnosis of blunt solid organ      up were also documented.                        was blunt chest trauma which occurred
injury.8                                           Statistical analysis was done using       in 12 patients with varying degrees of
      The success of NOM of spleen           Epi Info version 3.3.2. Continuous              fractured ribs, lung contusion and
injuries in selected patients has been
                                             variables are summarized using means            haemopneumothorax. Of the OM cases,
widely reported in developed countries.9-
                                             and standard deviation. Categorical             there were three diaphragmatic injuries,
   In developing nations however there
                                             variables are presented as frequencies          two liver injuries, one pancreatic injury
are several challenges in the management
                                             and percentages. Comparison between             and one cases of pelvic fracture.
of injuries to the spleen. This may be
                                             the operated and the non operated               Amongst the NOM cases it was difficult
responsible for the limited information on
                                             groups was performed with t-test for            to assess associated injuries as majority
NOM in developing nations. We present
                                             continuous variables and Fisher’s Exact         could not afford CT evaluation.
a two-year experience of splenic trauma
                                             test for categorical data. All tests are two-         The mean RTS in all patients was
at the University of Benin Teaching
                                             sided with a type one error rate of 5 %.        7.7392 ± 0.3136. Abdominocentesis (four
Hospital – a 650-bed hospital serving a
                                                                                             quadrant tap) was done in 15 patients and
population of over three million people
in the Mid Western region of Nigeria after   RESULTS                                         it was positive in all the cases (presence
the formal creation of a trauma unit. The         Twenty three adult trauma patients         of free flowing non–clotting blood).
trauma unit manages an average of 5000       were managed for splenic injuries during        Patients who had clear cut indication for
major trauma cases annually.                 the period under review. This consisted         laparotomy such as evisceration or who
                                             of 21(91.3%) males and two (8.7%)               came in with an ultrasound diagnosis of
SUBJECT, MATERIALS, AND                      females. The age range was 16–58 years          haemoperitoneum were not subjected to
METHODS                                      with a mean of 29.6 ± 12.2 years. The           abdominocentesis.
     The study was retrospective and         mechanism of injury was blunt in 21                   Sixteen patients had ultrasound
involved analysis of medical records of      (91.3%) cases and penetrating in two            evaluation of the abdomen performed by
patients. All adults 16 years or more in     (8.7%) cases (Table 1). Fifteen patients        either consultants or senior registrars in
age with documented splenic injury                                                           radiology department. Free fluid was
between February 2006 and March 2008         Table 1: Mechanism of splenic injuries          documented in 15 patients, splenic injury
were included in the study. Documen-                                                         in eight patients while it was negative in
tation of injury was based on abdominal      Mechanism                          Number       one patient. USS confirmed all the cases
ultrasound scan (USS) ± CT scan of the                                                       of haemoperitoneum diagnosed by
                                             Motor vehicle accident                  9
abdomen, or operative evidence of injury                                                     abdominocentesis. Only two patients had
                                             Motor bike accident                     6
to the spleen. Patients who had a                                                            CT evaluation of the abdomen. None had
                                             Pedestrian hit by car                   3
diagnosis of blunt abdominal trauma with                                                     angioembolization due to absence of the
                                             Blow to the abdomen                     2
suspected visceral injury but did not                                                        facility and interventional radiologists.
                                             Gunshot injuries                        1
undergo USS scan, CT evaluation or                                                           Patients who had successful NOM (n=8)
                                             Stab injuries                           1
trauma laparotomy were excluded from                                                         were compared with those who had OM
                                             Falling tree                            1
the study.                                                                                   (n=15) (Table 2). Patients who received

                        West African Journal of Medicine Vol. 28, No. 5 September–October 2009                                     309
P. E. Iribhogbe and C. J. Okolo                                                      Challenges posed by Spleen Injuries in Nigeria

Table 2: Splenic Injuries; Non operative Vs Operative Management                            Splenectomy was done for him and he
                                                                                            received seven units of blood intra-
                                             Non-Operative            Operative             operatively and one unit in the recovery
Number                                       8                        15                    room. He died in the ICU 24 hours after
Male: female ratio                           8:                       13:2                  admission from adult respiratory distress
Average age (years)                          35.6 ± 16.9              26.3 ± 7.6            syndrome (ARDS), pulmonary oedema
Average injury – arrival time (hours)        39.5 ± 33.1              17 ± 18.5             and respiratory failure.
Average RTS                                  7.84                     7.70                       Two patients in the NOM group
No with blood transfusion                    2                        12                    discharged themselves against medical
No. of units transfused                      4                        53                    advice (DAMA) while four patients did
ICU admission (n)                            0                        7                     not come for follow up following
Mortality (n)                                0                        1                     discharge from hospital. The others were
Average length of hospital stay (days)       8.4 ± 3.0                13.5 ± 4.6            followed up for varying periods between
                                                                                            four weeks and two years
RTS, Revised trauma score

OM were more likely to have blood             with increasing grade of spleen injury. In    DISCUSSION
transfusion compared to those receiving       grade one the average was 200ml, grade              The male preponderance of patients
NOM (p=0.02 Fisher’s Exact test). None        II 1000ml, grade III 1400ml, grade IV         with splenic injuries probably reflects the
of the NOM patients received ICU              2700ml while, grade V was 3000ml.             normal preponderance of males in trauma
admission. However, they received                  The common post operative                especially since majority of splenic
intensive care in the critical care bay       complications were post operative             injuries follow motor vehicle crashes or
section of the accident and emergency         pyrexia (n=5) and anaemia (n=4).              motorcycle accidents. Other workers
unit. Among the OM patients (n=15)                 Due to difficulty in obtaining           have made similar observations.14, 15 The
seven received ICU admission (Table 3).       vaccines only 10 patients received            average age of the patients is also in
Grade one injury occurred in two              meningococcal vaccines while two              keeping with observed trend in a previous
patients, grade II injury also in two         received pneumovax.                           study.5 Success rates of NOM have been
patients while grades III, IV and V                The average length of hospital stay      reported in literature as varying between
occurred in four, five, and two patients      for the patients with splenic injury was      80% and 93%. 16–20 The critical
respectively. In the two patients with        11.7 ± 4.8 days. One patient died in our      determinants of successful NOM in
grade one injury and one patient with         series (mortality of 4.3%). He was a 25       adults remain controversial21, 22 although
grade II injury, the spleen was left alone    year old male who fell from a moving bus      it is known that the most important
at operation. The other patient with grade    and presented after 16 hours of injury.       element for success is appropriate patient
II had a splenorrhaphy while 11 patients      His RTS on presentation was 7.55 while        selection. 23 Factors associated with
with varying degrees of grade III to grade    PCV was 29%. At laparotomy he was             failure include older age, haemodyanamic
V injury received total spenectomy. The       found to have a grade IV splenic injury       instability, large quantity of haemoperi-
amount of haemoperitoneum increased           with a haemoperitoneum of 4.5 litres.         toneum, severe or multiple injuries, and
                                                                                            higher grades of splenic injuries.20, 24, 25
Table 3: Characteristics of the Patients who received ICU Admission                         The two patients that failed to respond
                                                                                            to NOM in our series were due to
S/N Initial Initial     Grade of    Haemo-     Blood    Associated                  Days    continued bleeding and peritonitis. Both
    SBP     PCV         splenic     peri-      units    injuries/                    in     had an initial PCV below 30% while one
            (%)         injury      toneum     trans-    reason for                 ICU     had an episode of hypotension in the
                                    (mls)      fused    admission                           emergency department. At laparotomy
1     90      31        V           3000       4        Liver                        7      one had a grade II injury with a
2     120     29        IV          4500       8        ARDS/ pulm oedema,                  haemoperitoneum of 1.5litres while the
                                                        respiratory failure          1      other had a grade III injury with a
3     90      31        V           3000       9        Coagulopathy                 6      haemoperitoneum of three litres.
4     110     16        III         1600       5        Status asthmaticus           1            Laparotomy is indicated when there
5     140     37        I           200        –        Chest injury,                       is a significant haemoperitoneum, shock
                                                        haemopneumothorax            6      or persistent haemorrhage. Factors
6     110     36        II          400        –        Ruptured diaphragm,                 favouring surgery include suspected
                                                        liver, stomach, trans-              visceral injuries or serious brain injury
                                                        verse colon, omentum         4      that would be exacerbated by
7     120     38        I           150        –        Chest injury,                       hypotension.
                                                        ruptured diaphragm           1            There was significant delay in
                                                                                            presentation at our trauma centre
SBP, Systolic BP mmHg                                                                       following injury. This is due to absence

310                     West African Journal of Medicine Vol. 28, No. 5            September–October 2009
P. E. Iribhogbe and C. J. Okolo                                                         Challenges posed by Spleen Injuries in Nigeria

of pre hospital teams and organized             Increased blood transfusion in the OM           4.    x Richard S, Mangus NCM, William W
trauma system.26, 27 Some of the patients       group as we found has been the                        et al. Statewide variation in the
had presented either in private hospitals       experiences of some workers.15 Increased              treatment of patients hospitalized with
                                                                                                      spleen injury. Arch Surg 1999; 134:
or lower levels of care which may be far        length of stay in the OM group has been
away from the University Teaching               similarly documented.5, 13
                                                                                                5.    x Gregory AW, Matthew RR,, Mazen
Hospital. Often times there may be                   Intensive care unit (ICU) admission              SZ et al. Non operative management of
delayed recognition of the injury by the        was influenced by injury grade, amount                severe blunt splenic injury: Are we
attending physician leading to a delayed        of haemoperitoneum, transfusion                       getting better? J. Trauma 2006; 61:
referral. At other times the patients           requirements, presence of coagulopathy,               1113–1119.
present to alternative medical care such        associated injuries or presence of              6.    Singer DB. Post splenectomy sepsis.
as the herbalist especially in gunshot          comorbidity.                                          Perspect Pediatr Pathol 1973; 1: 285–
injury where futile efforts at magical bullet        Mortality following splenic injuries             311.
                                                                                                7.    Holdsworth RJ, Irving AD, Cuschieri
extraction are often undertaken.                is quoted as being between three and
                                                                                                      A. Post splenectomy sepsis and its
      Abdominocentesis has been                 23%. 29 Adult respiratory distress
                                                                                                      mortality rate: actual versus perceived
criticized for poor sensitivity. However        syndrome (ARDS) accounted for the                     risks. Br J Surg. 1991; 78: 1031–1038.
with good patient selection and                 mortality in our series. Hildebrard et al 30    8.    Schroeppel TJ, Croce MA. Diagnosis
technique it could be very useful in the        in a review of blunt abdominal trauma                 and management of blunt abdominal
determination of haemoperitoneum in             found the most frequent reasons for                   solid organ injury. Current Opinion in
centres where Focused Assessment                death as haemorrhagic shock, ARDS and                 Critical Care 2007; 13: 399–404.
using Sonography in Trauma (FAST) or            head trauma.                                    9.    x Crawford RS, Tabbara M, Sheridan R
Diagnostic peritoneal lavage (DPL)                   Self discharge by patient against                et al. Early discharge after non-
                                                medical advice is a recognized problem                operative management for splenic
facilities are unavailable provided it is
                                                                                                      injuries: increased patient risk caused
borne in mind that a negative tap does          in Nigeria and this is rampant, especially
                                                                                                      by late failure: Surgery 2007; 142: 337–
not exclude haemoperitoneum. In all the         amongst trauma patients.31–33 Similarly,
cases subjected to abdominocentesis it          poor follow up visits after discharge from      10.   x Kornprat P, Urannes S, Salehi B et al.
was positive and this was confirmed             hospitals remain a cause for concern.                 Preliminary results of a prospective
either by USS or at operation. The poor         These issues are often the results of                 study of non operative management of
use of CT scan amongst the patients was         poverty, long distance from trauma centre             splenic injuries caused by blunt
due to the high cost. An abdominal CT           and ignorance.                                        abdominal trauma. European Surgery
scan costs 40000. In a country with a                In conclusion we have presented                  Acta Chirurgica Austriaca 2007; 39: 33
                                                our experience of splenic trauma. Non-                – 38.
monthly minimum wage of 7500 and a
                                                operative management of injuries to the         11.   x Harbrecht BG, Zenati MS, Ochoa JB
weak Health Insurance Scheme the
                                                spleen in adults appears promising.                   et al. Evaluation of a 15-year experience
affordability crisis is understandable.                                                               with splenic injuries in a state trauma
      It is recommended that patients for       Major challenges in the current manage-
                                                                                                      system. Surgery 2007; 141: 229–238.
NOM should be admitted in the ICU.28            ment of this injury in Nigeria include          12.   Leung E, Wong L, Taylor J. Non
However with limited ICU bed space in           delayed presentation, absence of FAST,                operative management for blunt splenic
our hospital these patients received            underutilization of CT, unavailability of             trauma in children: An updated literature
intensive care in the critical care bay of      interventional radiology, inadequate                  review. Surgical Practice 2007; 11: 29–
the accident and emergency department.          ICUs, limited vaccination, discharge                  35.
All the patients that successfully under-       against medical advice (DAMA) and               13.   x Caddedu M, Garnett A, Al-Anezi K
                                                poor follow up. These issues need to be               et al. Management of spleen injuries in
went NOM had normal RTS but the
                                                address, in order to deliver optimal trauma           the adult trauma population. A ten year
average RTS in the OM group was below                                                                 experience. Can J Surg 2006; 49: 386–
normal. The earlier presentation noted in       care for the victims of splenic injuries.
the OM group may be due to increased                                                            14.   x Brady RRW, Bandari M, Kerssens JJ
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312                      West African Journal of Medicine Vol. 28, No. 5              September–October 2009