WEST AFRICAN JOURNAL OF MEDICINE
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
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
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: email@example.com
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
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or lower levels of care which may be far length of stay in the OM group has been
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Abdominocentesis has been 23%. 29 Adult respiratory distress
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with good patient selection and mortality in our series. Hildebrard et al 30 8. Schroeppel TJ, Croce MA. Diagnosis
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not exclude haemoperitoneum. In all the amongst trauma patients.31–33 Similarly,
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was positive and this was confirmed hospitals remain a cause for concern. Preliminary results of a prospective
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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
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