Rupture of the Spleen: Roentgen Diagnosis

Abstract

The diagnosis of ruptured spleen is important because of its high incidence and mortality rate. In cases treated medically or by delayed surgery (1, 2) the death rate, according to the most conservative estimates, is above 75 per cent. Failure to recognize the condition probably accounts for its apparently low incidence among hospital admission diagnoses. During the five-year period 1945–49, only 11 cases of ruptured spleen were recorded among 62,850 admissions to the Jewish Hospital of Philadelphia, which has a relatively inactive accident service. At the Chester County Hospital (West Chester, Penna.), located in a rural area with a fairly high rate of agricultural and automobile accidents, the incidence rate for the same period was three times as high, 9 cases among 21,655 admissions. The probable bearing of trauma on the incidence is further illustrated by the report of Wright and Prigot (3), who found 30 cases among 20,000 admissions to the traumatic service of Harlem Hospital (New York) in eleven years, and by that of Welch and Giddings (4) at the Massachusetts General Hospital, where among 3,154 cases of abdominal injury involvement of the spleen was encountered in 30 instances. Promptness in making the diagnosis and in carrying out surgery are essential to survival. In Wright and Prigot's series, 51 per cent of the patients died within one hour following injury. Errors in clinical diagnosis and negative or equivocal roentgenologic studies indicate the necessity of improving technics for the demonstration of an injured and bleeding spleen. Roentgen Signs of Ruptured Spleen Among the criteria for the roentgenographic recognition of ruptured spleen is dilatation of the stomach, with a ragged, serrated appearance of the greater curvature (7–9). Gastric dilatation was seen in 7 of the 15 cases here reported and is a valuable sign when it occurs. Prominent rugae in the gastric cardia and serration of the greater curvature occurred in 6 cases, but these signs are difficult to evaluate, since they may occur in the absence of trauma (10). A more widely used criterion is elevation of the left dome of the diaphragm (2, 3, 5, 9, 11–14), but in no case in this series was this observed. While the left diaphragm may be elevated by pressure of a hematoma, and tenting of the left leaf may occasionally be caused by perisplenic bleeding, profuse hemorrhage from a ruptured spleen may take place without the formation of a hematoma and without causing pressure on the diaphragm, so that reliance on this symptom may result in failure to recognize the condition. Hodges (17) has suggested that downward displacement of the gastric cardia might be due to upward and medial encroachment by the spleen, or the interposition of fluid between otherwise normally disposed upperabdominal viscera and the diaphragm. Insufficient attention to this sign seems to have been given in cases of suspected rupture of the spleen.