The spleen is a soft, highly vascular organ tucked away in the upper left abdomen, safely positioned beneath the ribcage and diaphragm. It acts primarily as a sophisticated blood filter, removing old, damaged, or abnormal red blood cells from circulation. The spleen also maintains a blood reserve and plays an active role in the immune system by housing white blood cells that fight off certain types of bacteria and infections. A ruptured spleen is a serious medical emergency, typically caused by blunt force trauma to the abdomen, resulting in rapid internal bleeding due to the organ’s rich blood supply.
Recognizing the Signs of Injury
A rupture demands immediate medical attention, with symptoms ranging from localized discomfort to signs of severe blood loss. The most common complaint is sharp pain and tenderness in the upper left quadrant of the abdomen. This pain may worsen when the area is touched or when the patient takes a deep breath.
A particularly telling symptom is pain that radiates upward to the left shoulder, known as Kehr’s sign. This referred pain occurs because blood leaking from the injured spleen irritates the diaphragm, which shares nerve pathways with the phrenic nerve. As bleeding continues, the patient may show signs of internal hemorrhage and shock, including lightheadedness, confusion, a rapid heart rate, and paleness. Low blood pressure is a late sign of significant blood loss, confirming a life-threatening situation.
Diagnosis and Severity Grading
Once a patient arrives, the medical team quickly assesses for internal bleeding to confirm a suspected rupture. A Focused Assessment with Sonography for Trauma (FAST) exam uses ultrasound to rapidly check for free fluid, which indicates blood in the abdominal cavity. Blood tests are also performed to measure hemoglobin and hematocrit, which indicate the extent of active blood loss.
For hemodynamically stable patients, a computed tomography (CT) scan with intravenous contrast dye is the gold standard for defining the full extent of the injury. Radiographic images allow physicians to classify the damage using the American Association for the Surgery of Trauma (AAST) grading system. This system assigns a grade from I (minor laceration or small hematoma) to V (shattered spleen or active, uncontained bleeding) based on the depth of the laceration and the size of the hematoma. The AAST grade dictates the course of medical management.
Treatment Options
The management of a ruptured spleen is determined primarily by the patient’s hemodynamic status and the AAST grade. For stable patients, especially those with lower-grade injuries, Non-Operative Management (NOM) has become the standard of care. This approach involves close observation, often in intensive care, with mandatory bed rest and frequent monitoring of vital signs to ensure the bleeding has stopped.
The goal of NOM is splenic salvage, which avoids the long-term immunological risks associated with organ removal. In some cases, splenic artery embolization (SAE) is used as part of NOM, where interventional radiologists thread a catheter to block blood flow to the injured area, effectively stopping the hemorrhage. NOM is highly successful in 60 to 90 percent of cases, especially for low-grade injuries.
Surgical intervention is required for patients who are hemodynamically unstable, have high-grade injuries, or fail observation. Surgeons first attempt to repair the organ (splenorrhaphy) or perform a partial splenectomy to remove only the damaged portion. However, if the bleeding is uncontrollable, the damage is too extensive, or the spleen is shattered (AAST Grade V), a complete removal of the organ (splenectomy) becomes necessary to save the patient’s life.
Long-Term Recovery and Precautions
If a patient retains their spleen, whether through NOM or surgical repair, recovery involves restricted physical activity, including avoiding contact sports, to allow the organ to fully heal. When a splenectomy is performed, the long-term focus shifts to managing the increased infection risk. The spleen’s absence leaves the body vulnerable to encapsulated bacteria, such as Streptococcus pneumoniae and Neisseria meningitidis.
The most concerning complication is Overwhelming Post-Splenectomy Infection (OPSI), a rare but rapidly progressive and potentially fatal condition with a mortality rate of up to 50 percent. The lifetime risk of OPSI is estimated to be around five percent, though incidence is highest in the first two years following the procedure. To mitigate this risk, patients must receive specific vaccinations against Pneumococcal, Meningococcal, and Haemophilus influenzae type b (Hib) bacteria. These vaccinations are administered at least two weeks after the emergency splenectomy, and periodic booster shots may be required throughout life.