Risks and Realities of Delayed Splenic Bleeding

Abstract

Delayed splenic bleeding (DSB) is a poorly understood complication of blunt splenic injury. Treatment for splenic bleeding may involve splenectomy, but angioembolization is becoming a widely used adjuvant for management. Using the North Carolina Trauma Registry, this study aimed to evaluate the incidence, mortality, and risk factors for DSB in North Carolina. Using ICD-9 and ICD-10 codes, patients were stratified into two cohorts, those who underwent immediate splenectomy and those who were initially managed nonoperatively. DSB was then defined as splenectomy at greater than 24 hours after presentation. Of the 1688 patients included in the study, 269 patients (16%) underwent immediate splenectomy and 1419 (84%) were managed nonoperatively initially, with 32 (2%) having delayed splenectomy. Older age (≥30 years) was associated with increased odds of having delayed splenectomy (odds ratio 4.30; 95% confidence interval 1.08, 17.17; P = 0.04). Four per cent of patients managed nonoperatively and undergoing an angioembolization procedure eventually required splenectomy. Risk factors for DSB remain elusive. Splenic artery embolization may be used as an adjuvant to splenectomy for stable patients, but it is not always a definitive treatment, and patients may still require splenectomy.

Abdominal pain is a main manifestation of delayed bleeding after splenic injury in patients receiving non-operative management

“…Delayed diagnosis of bleeding episodes can be dangerous or even deadly. Peitzman et al reported 10 mortalities among 78 splenic injury patients with NOM failure 4 , 14 , 15 , 18 , and a 5–15% mortality rate have been reported by other studies 18 – 20 . Romeo et al reported two cases of delayed splenic bleeding presenting with haemorrhagic shock, who were then admitted for several months 21 .…”

“…Continuous monitoring is necessary, as the risk of bleeding remains even after discharge 2 . Therefore, identifying the signs and symptoms of bleeding after NOM is important for early detection, early haemostasis, and the prevention of unfavourable outcomes 14 , 15 . However, few studies have discussed the clinical manifestations of delayed splenic bleeding after NOM 14 – 16 .…”

Post-Discharge Rebleeding in Splenic Injury: A Predictive Model

“…It was rst described in 1902 by Baudet 33 , who noted its occurrence at 48 hours after trauma. Its incidence ranges from approximately 0.4-2% 10,34,35 and tends to occur between 4 and 8 days after injury 35 . Mortality ranges from 5-15%, compared with 1% mortality for acute injuries 36 .…”

“…Adult patients aged > 18 years with splenic injury from 2000 to 2012 were included. Splenic injury was de ned based on the following International Classi cation of Diseases-Ninth Revision (ICD-9) diagnostic codes: 865.01 (hematoma of spleen without laceration) 10 , 865.02 (laceration without major disruption), 865.03 (laceration extending into the parenchyma), 865.04 (massive splenic parenchymal disruption), and 865.09 (unspeci ed splenic injury) 20,21 . Patients who died on the rst admission and underwent total splenectomy, partial splenectomy (ICD-9-OP codes 41.5, 41.42, 41.43 10 , and 41.95 20,21 ) or transcatheter arterial embolization (TAE) (ICD-9-OP codes 39.79 and 99.29) were excluded.…”

“…Requarth et al observed that the estimated management failure rate without splenic artery embolization (SAE) increased from 4.7-83.1% in patients with splenic injury grades I-V 9 . While previous reports have indicated an Injury Severity Score (ISS) > 24, splenic injury grade > II, age > 40 years, and higher initial injury grade as risk factors for NOM failure 1,[16][17][18] , no obvious risk factors that can accurately predict delayed splenic bleeding have yet been reported 10,19 .…”