Trauma of the Spleen and Liver in Children

Symposium on Childhood Trauma

Trauma of the Spleen and Liver in Children W. Hardy Hendren, M.D., F.A.C.S.,* and Samuel H. Kim, M.D., F.A.C.s.**

Trauma is an important problem in childhood, accounting for about one third of all deaths under age 14 years. Most often the injuries are blunt type and of accidental origin, whereas in adults a larger proportion are penetrating, caused by knives or bullets. To put this problem in numerical perspective, accidents kill about 13,000 children annually and disable at least another 100,000.16 Wilms' tumor, also considered an important pediatric problem, occurs with a frequency of only about 500 new cases per year in the United States.9 Trauma is probably of greater statistical significance than all of the major surgically correctable congenital anomalies of the newborn added together, such as bowel atresia, omphalocele, diaphragmatic hernia, etc. In a large series of children with blunt abdominal trauma19 the order in frequency of viscera to be injured was (1) abdominal contusion, (2) ruptured spleen, (3) genitourinary tract, (4) bowel, (5) pelvic fracture, (6) liver, and (7) pancreas. In this article we shall discuss injuries of two of these organs, the spleen and the liver.

SPLENIC TRAUMA Clinical Picture Most children with rupture of the spleen in the United States have a previously normal spleen which is injured by blunt trauma. In other areas of the world where malaria is endemic, the pathologically enlarged spleen may rupture spontaneously or from minimal trauma. We have encountered two neonates, only hours after delivery, who presented with shock, pallor, and an enlarging abdomen in whom exploration revealed rupture of the spleen secondary to traumatic delivery. Others have reported this as well.15• 17 Boys present more often than girls with "Professor of Surgery. Harvard Medical School; Chief of Pediatric Surgery. Massachusetts General Hospital, Boston, Massachusetts ** Assistant Professor of Surgery, Harvard Medical School; Assistant Surgeon, Massachusetts General Hospital, Boston, Massachusetts

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rupture of the spleen, as with trauma in general, from sledding accidents, falling out of trees, contact athletic sports, etc.

Diagnosis Seldom is rupture of the spleen a precipitous surgical emergency requiring immediate operation. In most instances splenic rupture is followed by moderate intraabdominal bleeding which then stops. In even those with severe laceration of the spleen, clot may form around it and tamponade further bleeding. We have observed total avulsion of the spleen in which there was no active bleeding owing to contraction of the severed splenic vessels. If shock is present, it generally responds to a modest amount of volume replacement with blood or colloid, giving time to assess the patient. Following trauma, it is vital that the entire patient be assessed, lest clinical attention be given to one obvious injury, ignoring another which may in fact take precedence. Not infrequently several injuries may exist in the same patient, such as a head injury requiring immediate decompression, a splenic laceration as the second order of priority, and a fracture of the femur to be manipulated after the two other more life-threatening injuries have been treated. Tenderness in the left upper quadrant is usual with splenic rupture. It is often accompanied by spasm, diminished bowel sounds, and muscle guarding. The presence of referred pain from the diaphragm to the apex of the left shoulder is, in our experience, a very reliable symptom. Palpation of the left lower rib margin will sometimes disclose tenderness from fractures of the lower ribs which may be not obvious on roentgenogram. Abdominal Tap Abdominal tap can be of value in selected clinical circumstances, but we believe it has been greatly overdone. It may confuse the picture in questionable cases by causing some tenderness of the abdominal wall itself from penetration of the needle, thus making it difficult to assess minimal changes in abdominal signs. When a patient enters unconscious from head trauma, possible abdominal trauma, and often limb fracture, we generally immediately perform an abdominal tap in one or more quadrants, instilling saline through a small plastic catheter, and examining the aspirate for blood. The finding of gross blood on a tap in a patient with abdominal trauma should give laparotomy high priority if there is not an immediate response to transfusion or colloid replacement. Sometimes, however, in splenic rupture one is confronted with a youngster whose clinical signs are in doubt and whose blood pressure is stable. In this situation we much prefer frequent repetitive examination to note changing clinical signs as an aid in deciding whether laparotomy should be performed. Abdominal tap can confuse the issue in this circumstance particularly if the results are equivocal. Roentgen Diagnosis Plain film of the chest and abdomen (Fig. 1) can be of diagnostic help. The presence of rib fractures is a clue to the severity of trauma. A

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Figure 1. Plain film of abdomen in six year old boy with traumatic rupture of spleen. The stomach is displaced medially and downward by splenic hematoma (arrows). Gastric rugae in the fundus are prominent from blood dissecting in the gastrosplenic ligament and elevating the mucosa.

blow which breaks two or three ribs may well fracture the spleen which lies beneath them. Bleeding from the spleen can displace the stomach medially and the colon inferiorly. Bleeding can dissect between the leaves of the gastrosplenic ligament, elevating the mucosal folds of the stomach, "to present a scalloped appearance. IS In recent years angiography and visceral scanning with radionuclides have been of immense help to the surgeon in assessment of those children where indications for surgery were not clear-cut initially·(Figs. 2 and 3). Splenectomy Rupture of the spleen has been treated by some nonoperativelyl when bleeding has been Ininimal, abdoIninal signs have improved, and continuing observation has been possible. We have treated one youngster nonoperatively who presented with multiple trauma, including extensive orthopedic injuries. Angiography showed splenic rupture with

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Figure 2. Celiac angiogram in a four year old boy showing rupture of the upper pole of the spleen with extravasation of dye (arrow).

Figure 3. Radionuclide scan of spleen in a four year old boy (posteroanterior view). There is an obvious laceration of the lower pole of the spleen (arrow ). The adjacent liver shadow appears small because of the particular projection of film.

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local extravasation of blood. Subsequent angiography during his prolonged hospital stay showed complete healing of this splenic laceration. In most cases, however, we have preferred laparotomy and usually splenectomy. Abdominal preparation and draping should be wide to afford extending the incision appropriately should other injuries be present. Where splenic rupture is likely a left upper abdominal paramedian incision has been used, or a midline incision. The best view is afforded the surgeon by standing on the patient's right side, with two assistants to hold retractors on the patient's left, one beneath the rib cage and one for flank muscles. Ample blood should be available in the operating room, for even though the patient's blood pressure may be stable, upon entry to the abdomen considerable bleeding may ensue. Quickly passing a hand ipto the left upper quadrant will often disclose by palpation a splenic laceration tamponaded by clot. If the upper abdomen is filled with blood, making visualization of the spleen impossible, we have found it most expedient to first quickly deliver the spleen up onto the abdominal wall and to then deal with its vascular pedicle. This can be done in just a few moments by retracting the spleen medially with one hand, blindly severing its attachments to the diaphragm by scissor dissection lateral and superior to the spleen and delivering it into view (Fig. 4), while compressing the vessels between the tip of the tail of the pancreas and the hilum of the spleen between two fingers. Clamps can then be placed rapidly across the hilum without accurate identification of the vessels, and the spleen is removed (Fig. 5). Then one opens into the lesser sac by dividing the gastrocolic omentum, retracting the stomach forward to expose the splenic vessels just above the superior border of the tail of the pancreas. The splenic artery and

Figure 4. Operative view of ruptured spleen of an eight year old boy following sledding accident. The spleen (arrows) was quickly delivered up to the surface of the laparotomy wound by cutting its attachment to the diaphragm. Note the large amount of clot at the splenic hilum. There was no active ~leeding despite severe lacerations of the spleen.

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Figure 5. Typical ruptured spleen in a five year old struck by an automobile. The spleen had been completely avulsed from its pedicle and was lying free in the left upper abdomen. Initial hemorrhage had been brisk, but stopped spontaneously. After initial blood replacement, the child was explored two hours after admission.

vein are then encircled with care and individually ligated at a point about one inch medial to where the vessels were blindly clamped and ligated at the splenic hilum. An additional benefit of opening into the lesser sac is to inspect for pancreatic contusion. If the tail of the pancreas is lacerated or badly contused we do not hesitate to amputate it, to prevent formation of a pseudocyst (Fig. 6).5 In any event if there is contusion or edema surrounding the tail of the pancreas we drain the lesser sac for several days to avert accumulation of blood or pancreatic enzymes in the lesser sac. The spleen is usually badly lacerated in patients coming to operation leaving little doubt that its removal is indicated. Occasionally, we have encountered a patient with minimal laceration which was suited for suturing without splenectomy, as have others.ll A narrow strip of Gelfoam or Teflon felt is placed on each side of the tear, placing mattress sutures of chromic catgut through these strips and across the laceration, to avoid tearing the spleen when tying the sutures. To place sutures through the spleen without these re-enforcing strips will result in tears of the organ when the sutures are tied. There has been considerable attention paid in recent years to the consequence of fatal disseminated infection after splenectomy in childhood. 2 • 8 This has not proved to be a problem of significance in trauma, but after splenectomy in children with certain systemic diseases where operation was performed for palliation. In children under two years of age fatal infection with pneumococcus or meningococcus has occurred in some cases.

Delayed Splenic Rupture Any patient who has been observed for possible rupture of the spleen, and who has improved without surgical intervention, should be

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Figure 6. Large pancreatic pseudocy t in a 15 year old boy. ine weeks before ruptured spleen had been removed. The tail of the pancreas had not been inspected at the time of splenectomy. This gastrointestinal eries show marked displacement anteriorly of the stomach (arrow ) by a large p eudocyst. It was anastomosed to the back wall of the stomach with successful outcome.

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Figure 7. Post traumatic pseudocyst of the spleen in 17 year old girl two months after blunt upper abdominal trauma. A, Plain film showing mass (arrows) displacing stomach medially and downward. B, The spleen with large encapsulated pseudocyst of the upper pole. The trauma occurred when she was pushed from a swimming pier and landed on a friend in the water. Pain in her left rib cage had been treated by adhesive strapping. Two months later there was increasing left upper abdominal discomfort, with ileus, for which she was referred.

warned about the possible occurrence of splenic enlargement or rupture several weeks later. A subcapsular or intrasplenic hematoma may behave like a subdural hematoma taking up fluid by osmosis, gradually expanding and causing pain and tenderness or sudden rupture with shock. The authors recall a patient in skeletal traction whose abdominal injuries six weeks previously had seemed insignificant. He suddenly went into shock from delayed splenic rupture while still in the hospital six weeks later. Another teenage youngster (Fig. 7) presented with a large post traumatic splenic cyst two months after her original trauma. Although it is a rare occurrence, the physician is remiss in failing to alert the patient and his family to this possibility. Angiography can resolve the question.

HEPATIC TRAUMA Clinical Picture Unlike trauma to the spleen, major hepatic trauma is usually an immediate surgical emergency. Liver trauma can occur in the newborn17 in association with difficult delivery. We had one neonate with massive hepatomegaly from neuroblastoma in whom there were multiple lacerations of the liver from birth trauma. Another young infant was referred to us with liver trauma after pyloromyotomy; overly forceful retraction of the liver at surgery had produced a major laceration of the inferior

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surface of the right lobe. Most commonly, however, the child is older, and sustains blunt trauma to the right upper abdomen or chest wall from a fall, automobile accident, etc. The right lobe is most commonly involved. About one third of children with major liver lacerations die before they can be transported to a hospital. This is in distinct contrast to a comparable injury to the spleen where bleeding usually ceases. In a review of liver trauma19 mortality was 40 per cent for all types of liver injury in the age group of up to 10 years. The child usually enters in profound shock. A large bore intravenous line should be established immediately in an upper extremity, with prompt administration of colloid and blood as soon as it is available. Profound shock, a protuberant abdomen, and particularly abrasions or contusions of the right upper abdomen or rib cage, should suffice to make the diagnosis. A rapid tap of the abdomen will disclose free blood. One should proceed with dispatch to the operating room. There should be no delay for x-ray examination. It should be emphasized that in any case with major trauma there should be general surgical surveillance to assess what systems are involved and what must be given priority treatment. Except for establishing an emergency airway by passing an endotracheal tube, there is seldom an injury more urgent than rupture of the liver. That the specialist may take too narrow a view of the patient with disastrous consequences was well illustrated 20 years ago when we saw a youngster with exsanguinating hepatic injury. Because the patient was a toddler, a pediatric physician unaccustomed to major trauma was first called; this physician was concerned with calculating the patient's 24 hour fluid maintenance requirements on a basis of body surface area. In fact, this child's requirement was an immediate replacement transfusion of a full blood volume to replace what had already been lost into her protuberant abdomen! Because the child was unconscious, a neurosurgeon was summoned; he was concerned with looking into the eye grounds for evidence of increased intracranial pressure. Since there was an angulated fracture of the lower leg, an orthopedist was busy splinting the leg. No attention had been given to the presence of a skin abrasion over the right costal margin, the protuberant abdomen, and the profound shock, all pointing to a major hepatic injury. The two resident surgeons above were both from the General Surgical Service, but thinking only in terms of special organ systems pertaining to the specialty service through which they were rotating at that time! This case emphasizes that whatever the specialty of the physician or surgeon who first attends a child with trauma, horizons must be kept broad to· assess all of the potential injuries which may be present; then one should call for those with expert knowledge from other specialties to formulate a plan of treatment together. Further, only those who first see the patient with severe trauma have an accurate baseline with which to compare in making subsequent judgments over the next few hours. This responsibility should not be changed to suit the convenience of the physician whose duty hours may end during the child's period of initial assessment.

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Figure 8. Large ubcap ular hematoma of the liver in an eight year old girl. A, Hepatic angiogram outlining hematoma (arrow ). B, Thoracoabdominal exploration howing extensive subcapsular hematoma of the right lobe of the liver. While skiing, thi youngster had attempted to stop a runaway ki coming down the lope by falling upon it. She was admitted to the hospital several hours later with right upper quadrant pain and tenderne , but table vital ign . With increasing local signs, angiography was performed the next day followed by exploration. The large hematoma wa evacuated, the underlying rent in the surface of the liver wa clo ed.

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Diagnosis As described above, the diagnosis of hepatic trauma is often one at which the physician must arrive immediately if exsanguination is to be prevented. This precludes any further diagnostic measures in favor of proceeding to the operating room post haste. Fortunately there are some which are less urgent and which permit radiologic assessment. Plain film of the abdomen may show clot in the right upper abdomen with displacement of the colon. Angiography may be of help in the less acute situation where there has occurred a small laceration or a subcapsular hematoma (Fig. 8). Angiography can also be of great help in cases presenting with hematobilia, to be discussed below. Surgical Treatment We position the patient supine, with a roll under the spine, in order to prepare and drape widely the abdomen and entire thorax. Both arms are outstretched, with arterial and venous catheters in place. A large amount of blood is prepared, including warm, fresh, heparinized blood to avert the metabolic consequences of giving large volumes of ordinary bank blood which is cold and contains about 20 per cent by volume of sodium citrate solution. Clotting factors become abnormal rapidly with massive infusion of ordinary bank blood, as compared with fresh heparinized blood in which platelets and other clotting factors are normal. The anticoagulant effect of heparin is countered by appropriate adminis-· tration of protamine. A midline upper abdominal incision is made, quickly palpating the liver. If there is a laceration palpable on the upper surface of the right lobe the incision is carried across the costal margin into the right sixth or seventh interspace, converting the wound immediately to a thoracoabdominal exposure. This greatly facilitates manage. ment of the problem. Those lacerations of the left lobe, or inferior surface of the right lobe (Fig. 9) can be managed without extending the incision into the chest. For a large laceration through the dome of the liver or involving the vena cava, extension into the chest is mandatory (Fig. 10). If bleeding is massive we do not hesitate to place a soft non traumatic clamp across the portahepatis for 15 to 20 minutes at a time to occlude inflow of the hepatic artery and portal vein. If there is a major tear of the intrahepatic vena cava, or hepatic veins entering the vena cava, it may be necessary to occlude temporarily this segment of the inferior vena cava. A large plastic catheter can be inserted through the wall of the intrahepatic cava, into the right atrium, encircling the cava with occlusive tapes above and below the liver, thus allowing venous return through the catheter lumen only. A Foley catheter balloon inflated in the right atrium and pulled down against the entry of the vena cava into the atrium can substitute for a tape encircling the cava superiorly. When massive outpouring of blood has been thus controlled, the extent of injury should be assessed. In some, hepatic parenchyma can be primarily sutured with large mattress sutures on special "liver needles." Strips of Teflon felt can be used on each side of the laceration to prevent cutting through of the sutures when they are tied. When there is exten-

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Figure 9. Two small lacerations of the liver, one on each side of the falciform ligament, repaired through an abdominal inci ion with large sutures of catgut.

Figure 10. Multiple laceration of liver in a 17 year old girl following an automobile accident. Wide thoracoabdominal expo ure i shown. She died as a result of severe brain stem injury.

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sive trauma with multiple lacerations, sometimes with compromised circulation to major segments of the liver, the most conservative maneuver may be an extensive partial right hepatic lobectomy. It is imperative to place multiple large drains, preferably of the sump suction variety, after hepatic trauma to evacuate inevitable accumulations of blood and bile which can form an abscess postoperatively. We have not generally elected to drain the biliary tree through a tube in the common bile duct or gallbladder unless there is a specific injury to those structures. Injury to the gallbladder or common bile duct is infrequent,4.7 but should be looked for. Isolated injury of the gallbladder would be best treated by cholecystectomy. Treatment of the bile duct would depend on local findings. We have encountered one patient with severe trauma to the head of the pancreas, lower common bile duct, and mid duodenum, in whom a Whipple procedure was required, with resection of the head of the pancreas, end-to-end pancreaticojejunostomy, end to side choledochojejunostomy, and gastroenterostomy with vagotomy. After major hepatic trauma a stormy postoperative course should be anticipated, with requirement of large volumes of colloid, administration of antibiotics, and ventilatory support. Drainage for a time may be massive and persistent, and even despite placement of multiple drains subphrenic or subhepatic abscess may ensue. Some surgeons de-

Figure 11. Traumatic hemobilia in a five year old boy. A, Angiogram 15 days after repair of hepatic trauma. Ten days postoperatively melena had occurred, followed by hematemesis. It was thought that he had a stress ulcer. Five days later he developed pain, jaundice, and more hematemesis. . Upon referral this angiogram disclosed a 2 cm extravasation of contrast medium in the intermediate segment of the right lobe of the liver. There was a concentric defect, a "halo" of nonvascularized necrotic tissue surrounding this collection of dye (A). Despite two episodes of massive bleeding, the problem healed spontaneously. Hepatic angiogram two months later (B) was normal.

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Figure 12. Six year old boy with hematobilia. Seventeen day following repair of hepatic tra uma, there was biliary colic , hematemesis , and bleeding from his abdominal drains. A and B Hepatic angiograms showed a 3 cm vascular lake in the right lobe of the liver, with rapid arterio enou communication. After 2500 ml of blood volume replacement (estimated blood volume 1800 ml) his stools became guaiac negative for blood. C, Angiogram three week later howed healing of the lesion.

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compress the biliary tract routinely with a T tube in older children or a tube cholecystostomy in younger ones.19 Operative cholangiography has been advocated, but we do not think it is needed as a routine measure.

Traumatic Hematobilia Following liver trauma in which there is necrosis of a segment of tissue deep within the surface of the liver, hemorrhage may occur one to two weeks later. In the classic triad described by Sandblom13 there is right upper quadrant pain, and jaundice, accompanied by massive gastrointestinal bleeding. We have treated two such youngsters6 each of whom bled after repair of major liver lacerations. One had fallen from his bicycle, was explored immediately, and the laceration was sutured. He was then referred 10 days later with massive gastrointestinal bleeding, which was assumed to be from a stress ulcer. Angiography (Fig. 11) disclosed a two centimeter arterialized cavity within the center of the right hepatic lobe. The second youngster was kicked by his horse, was explored immediately, and was recovering uneventfully from repair of the laceration, when he developed the classic triad of jaundice, biliary colic, and hematemesis. Again angiography proved the diagnosis (Fig. 12) disclosing an arteriovenous fistula within the right hepatic lobe. Of the cases in the literature, most authors have advocated immediate intervention.3 • 12. 14.20 In our two cases, with precise localization of the lesion by angiography should exploration be required, we chose to observe the youngsters with a large amount of blood in readiness for immediate transfusion should uncontrollable hemorrhage occur. In each patient there was spontaneous cessation of bleeding, with complete healing of the lesion demonstrated by follow-up hepatic angiography. In each patient replacement transfusion at the time of hematemesis had required over one blood volume replacement. Since surgical intervention requires a major operative procedure such as partial lobectomy, or hepatic artery ligation with its possible consequences, we believe that nonoperative close watching should be considered when blood loss can be replaced while waiting to see if the bleeding will stop. Blood clot and microspheres have been embolized under fluoroscopic control through the angiographer's catheter to control major hemorrhage in certain locations such as the pelvis after major trauma. 10 Perhaps this could be used in selected patients with hemobilia as an alternative to surgical exploration.

CONCLUSION Rupture of the spleen should seldom be fatal when there are not multiple other injuries which jeopardize life. Rupture of the liver, in contrast, can result in death before surgical intervention can be accomplished, and mortality remains significant despite immediate surgical intervention.

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REFERENCES 1. Douglas, G. J., Simpson, J. S.: The conservative management of splenic trauma. J. Pediat. Surg., 6:565, 1971. 2. Eraklis, A. J., Kevy, S. V., Diamond, L. K., et al.: Hazard of overwhelming infection after splenectomy in childhood. New Engl. J. Med., 276:1225,1967. 3. Fowler, R, and Hiller, H. G.: Selective hepatic arteriography in the management of traumatic hemobilia. J. Pediat. Surg., 2:253, 1967. 4. Hartman, S. W., and Greaney, E. M.: Traumatic injuries to the biliary system in children. Am. J. Surg., 108:150, 1964. 5. Hendren, W. H., Greep, J. M., and Patton, A. S.: Pancreatitis in childhood: Experience with 15 cases. Arch. Dis. Child., 40:210, 1965. 6. Hendren, W. H., Warshaw, A. L., Fleischli, D. J., et al.: Traumatic hemobilia: Nonoperative management with healing documented by serial angiography. Ann. Surg., 174:991, 1971. 7. Hicks, J. H.: A case of traumatic perforation of the gallbladder in a child of three years. Brit. J. Surg., 31 :305, 1944. 8. King, H., and Schumacher, H. B., Jr.: Susceptibility to injection after splenectomy performed in infancy. Ann. Surg., 136:239, 1955. 9. Koop, C. E. Hope, J. W., and Abir, E.: Management of Wilms' tumor (nephroblastoma) and abdominal neuroblastoma. Cancer, 14: 178, 1964. 10. Margolies, M. N., Ring, E. J., Waltman, A. C., et al.: Arteriography and the management of hemorrhage from pelvic fractures. New Engl. J. Med., 287:317, 1972. 11. Mishalany, H.: Repair of the ruptured spleen. J. Pediat. Surg., 9:175,1974. 12. Poulos, E.: Traumatic hemobilia treated by massive liver resection. Arch. Surg., 88:596, 1964. 13. Sandblom, P.: Hemorrhage into the biliary tract following trauma: "Traumatic hemobilia." Surg., 24:571, 1948. 14. Shohl, T.: Hepatic artery ligation for massive hemobilia. Surgery, 56:855, 1964. 15. Sieber, W. K., and Girdany, B. R: Rupture of the spleen in newborn infants. New Engl. J. Med., 259:1074,1959. . 16. Sinclair, M. C., and Moore, T. C.: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J. Pediat. Surg., 9:155,1974. 17. Sokol, D. M., Tompkins, D., and Izant, R J., Jr.: Rupture of the spleen and liver in the newborn: A report of the first survivor and a review of the literature. J. Pediat. Surg., 9:227, 1974. 18. Wang, C. C., and Robbins, L. L.: Roentgenologic diagnosis of ruptured spleen. New Engl. J. Med., 254:445, 1956. 19. Welch, K. J.: Abdominal and thoracic injuries. In Mustard, W. T., Ravitch, M. M., Snyder, W. H., Jr., et al.: Pediatric Surgery, Vol. 1. Chicago, Year Book Medical Publishers, 1969, p. 708. 20. Wright, P. W., and Orloff, M. J.: Traumatic hemobilia. Ann. Surg., 160:42, 1964. Division of Pediatric Surgery Massachusetts General Hospital Boston, Massachusetts 02114