The spleen is a small, fist-sized organ situated in the upper left quadrant of the abdomen, beneath the rib cage and diaphragm. It functions primarily as a blood filter, removing old or damaged red blood cells and storing platelets. The spleen also plays an important role in the immune system by producing infection-fighting white blood cells. Due to its location and highly vascular nature, the spleen is the most frequently injured solid organ following blunt abdominal trauma, such as car accidents or sports injuries. While many splenic ruptures cause immediate internal bleeding, others present with a dangerous delay, developing life-threatening symptoms hours, days, or even weeks later.
Understanding the Delayed Onset
The medical phenomenon behind delayed symptoms is often referred to as delayed splenic rupture (DSR), though it is more accurately a delayed bleeding event. This occurs when the initial traumatic force causes a laceration or tear, but the resulting hemorrhage is temporarily contained. Containment is usually accomplished by the spleen’s dense outer capsule or by surrounding tissue and blood clots, which form a subcapsular hematoma.
The contained blood mass gradually expands under pressure or dissolves over time. This process can lead to the delayed rupture of the capsule, causing a sudden and massive bleed into the abdominal cavity. The period between the initial trauma and the onset of severe symptoms can range from 48 hours to several weeks, with most cases occurring within the first four to eight days. This delayed presentation highlights why any seemingly minor injury should not be disregarded, especially following impact to the left side of the torso.
The underlying mechanism for the final rupture can be clot lysis, where the body naturally breaks down the initial clot, or a sudden increase in pressure within the hematoma. In some instances, a post-traumatic pseudoaneurysm, a weakened bulge on a blood vessel wall, may form and eventually rupture, leading to delayed hemorrhage. Even minor subsequent activities, such as straining during a bowel movement, have been documented to trigger the final tear of the contained hematoma.
Critical Warning Signs Requiring Immediate Attention
The most prominent sign of a delayed splenic injury is the sudden onset or worsening of pain in the left upper quadrant of the abdomen, directly over the spleen. This pain may be intense, sharp, or cramping, and it often does not resolve with rest or over-the-counter pain medication. Abdominal distension or rigidity, where the stomach muscles involuntarily tighten, can also be present. This suggests significant irritation from internal blood loss.
A highly specific symptom suggesting a ruptured spleen is Kehr’s sign, which is pain referred to the left shoulder. This referred pain is not musculoskeletal in origin. Instead, it is caused by blood leaking from the spleen irritating the phrenic nerve, which supplies the diaphragm and shares nerve pathways with the nerves of the shoulder. Left shoulder pain is a strong indicator of blood collecting in the abdominal cavity and requires immediate medical evaluation.
As the bleeding progresses, the patient may develop signs of hypovolemic shock, indicating massive internal blood loss and a subsequent drop in blood volume. These systemic symptoms include a rapid heart rate (tachycardia) and a sudden drop in blood pressure (hypotension). The body attempts to compensate by diverting blood flow away from the periphery. This leads to lightheadedness, pallor, cold and clammy skin, confusion, and eventually, fainting or loss of consciousness. Any combination of these symptoms following recent abdominal trauma should be treated as a life-threatening emergency.
Emergency Protocol and Treatment Options
If delayed symptoms appear, the immediate protocol is to seek emergency medical care and inform staff about any recent abdominal trauma, even if it seemed minor. Upon arrival, a rapid assessment, including monitoring of vital signs, is performed to determine the patient’s hemodynamic stability. Diagnostic tools used to confirm internal bleeding include the Focused Assessment with Sonography for Trauma (FAST) exam. This quick ultrasound identifies free fluid, or blood, in the abdomen.
For stable patients, a contrast-enhanced Computed Tomography (CT) scan is considered the gold standard. It can precisely locate the source of bleeding, grade the severity of the injury, and detect a subcapsular hematoma or pseudoaneurysm. Treatment depends entirely on the patient’s condition and the injury’s severity. Hemodynamically stable patients are often managed non-operatively (NOM), which involves close observation in a hospital setting, bed rest, and serial monitoring of blood counts.
If the patient is unstable or if non-operative management (NOM) fails due to continued bleeding, immediate operative intervention is necessary. This may involve a surgical repair of the spleen, known as splenorrhaphy. More commonly in severe cases of delayed rupture, a complete removal of the spleen, called a splenectomy, is performed. When possible, medical teams prefer to preserve the spleen due to its role in immune function. They sometimes employ splenic artery embolization, a procedure that blocks blood flow to the injured area, to stop the hemorrhage.