The most commonly injured abdominal organ is the spleen with many of these injuries being self-limiting and showing no evidence of bleeding. Splenic injuries account for 25% of all abdominal organ injuries globally. In low income developing countries including Uganda, due to an increase in motorization, urbanization and civil violence, splenic injury and injuries in general are increasing [1]. The commonest cause in civilian practice of blunt splenic injuries are road traffic accidents (RTAs) and account for 80-90% of cases [2]. These splenic injuries are more common in young adults and teenagers [3]. In civil society in Sub-Saharan Africa there has been an increase in the use of firearms and hence an increase in the rate of penetrating injury to the spleen [4].

The mortality after blunt splenic injury is 9.3% which is likely to be caused by a delay in attending the hospital and associated injuries [5]. Generally, the mortality rate following splenic trauma has been reported to range between 7-18% in the literature [6].  At the time of presentation, the haemorrhage from splenic injury may be ongoing or it may have stopped resulting in no further blood loss.

Penetrating splenic injury is less common it accounts for 8.5% of all abdominal penetrating injuries [7]. Haemodynamically unstable patients with free fluid intra-abdominally on FAST scan require an emergency laparotomy. If the patient is haemodynamically stable then an intravenous contrast-enhanced abdominal CT scan is necessary to evaluate the grade of splenic injury. The American Association for the Surgery of Trauma (AAST) scale have characterized splenic injuries and grades injuries on the basis of vascular involvement and subcapsular or parenchymal abnormality [5].

Splenic injuries may be fatal on admission to the Accident and Emergency Department however it may be delayed due to pseudoaneurysm rupture or delayed subcapsular haematoma rupture. Following splenectomy, due to lack of immunological function, complications may develop due to overwhelming post-splenectomy sepsis. The appreciation of immunologic function of the spleen due to the risk of postoperative infectious complications has resulted in attempts to preserve the spleen following trauma [8]. In Europe and the USA there have been advances in diagnostic imaging, resuscitation, prehospital care, splenorrhaphy techniques and the use of haemostatic agents and therefore non-operative management is more commonly performed [9]. Over the past decades, splenic injury management has evolved from being entirely splenectomy to selective non-operative management [10-13].

In developing low-income countries in Sub-Saharan Africa, however, splenic injuries are still managed operatively in the majority of blunt abdominal trauma cases [1,9,14]. Nonoperative management is a challenge in Uganda and most of Sub-Saharan Africa due to a lack of effective ambulance systems for transportation and a lack of pre-hospital care. There is also an inability to afford or a lack of diagnostic imaging for diagnosing splenic injury due to trauma [15].

Therefore in developing low-income countries in Sub-Saharan Africa there is a need to develop protocols to manage splenic trauma by categorizing patients following clinical assessment, rather than using expensive imaging studies if conservative management is to be adopted in this part of the world.

In this paper, the author would like to report on a case of splenic trauma that presented in a Regional Referral hospital in Uganda and discuss the management of this condition.

A 43 year old gentleman was admitted to Masaka Regional Referral Hospital after having been involved in a road traffic accident (RTA). On examination his Glasgow coma score was 15, airway was intact, chest clear and his pulse was 120 bpmin-1 and blood pressure (BP) 90/60 mmHg. He complained of generalized abdominal pain and nausea on admission. Abdominal examination revealed generalized abdominal tenderness particularly in the upper abdomen. His haemoglobin (Hb) on admission was 9g/dl and a FAST ultrasound scan from the A&E Department showed fluid in the splenorenal angle. The patient was transfused 2 units of blood and was transferred to the emergency operating theatre for an exploratory laparotomy. At laparotomy there was 5 litres of blood intraperitoneally and a grade 4 splenic injury (figure 1 and figure 2) involving laceration of segmental and hilar vessels. A splenectomy was carried out and there were no other associated injuries of the liver or bowel and other intraabdominal organs were intact.

Postoperatively he remained haemodynamically stable and experienced an uneventful postoperative recovery. He was discharged on the fourth postoperative day from the surgical ward.

In keeping with observations from authors in other studies, splenic injuries affect males more commonly than females and are present in life in the third decade [2,16,9,10,14]. The high incidence of splenic injuries in this age group may be due to high-risk activities at an economically active age. In order to prevent these injuries the risk behavior among trauma patients needs to be identified [17]. Similar to findings from other studies our case study is reporting that most patients admitted to our Referral hospital sustain blunt injury to the spleen [2,9,10]. This finding is in contrast with that found in other studies where the most common mechanism of injury is penetrating splenic injury [4,18]. In keeping with increased motorization in our urban environment, blunt splenic injuries are commonly caused by road traffic accidents.

Many studies have found that road traffic accidents are the most common aetiology of blunt splenic injury [2, 9,10,11,15]. A study has reported a fall from a height as the commonest cause of blunt splenic injury [19]. Driving under the influence of drugs and alcohol and disregard for any traffic laws may result in a high incidence of road traffic accidents. Therefore these injuries will be decreased by enforcement of traffic laws, avoidance of overloading commuter vehicles and an improvement in the infrastructure of roads. It is the opinion of the author and findings from other studies that the high mortality and morbidity of these patients is affected by the injury arrival time [2,10,11]. A reduction in the morbidity and mortality has been reported with definitive treatment and early presentation with the injury to hospital [2,10,11].

Figure 1: Grade 4 splenic injury found at laparotomy.

Figure 2: Postsplenectomy specimen retried from the exploratory laparotomy.

In this case study, the patient was brought to the hospital by relatives and police who have no training experience in trauma management and this patient, therefore, did not receive any pre-hospital care at the trauma site.

An important outcome determinant for patients with splenic injury is the presence of associated injuries [20]. Associated injuries to the bowel, diaphragm or liver injuries are significantly associated with morbidity resulting from the length of hospital stay and mortality. In order to reduce the morbidity and mortality from splenic injuries, early treatment and early recognition of associated injuries is important. In developing low-income countries, more than 75% of patients tend to have a grade III or above splenic injury [9-11, 16]. Studies have found that a higher grade of splenic injury is significantly associated with the need for splenectomy [20,17]. Due to the important role in humoral and cellular immunity and the risk of overwhelming sepsis in asplenic individuals, a policy of splenic conservation has been adopted in recent years [8,10-13]. With the introduction of abdominal CT scanning, non-operative management of splenic injuries has become more common, leading surgeons to consider methods to preserve the spleen [21]. In the West, 60-70% of blunt adult splenic injuries and 90% of pediatric blunt splenic injuries are managed conservatively [9, 20, 15].

Selection of patients for non-operative conservative management of the splenic injury include: grade of splenic injury, haemodynamic stability on admission, age <55 years, extent of haemoperitoneum on abdominal CT scan, eliciting physical signs on abdominal examination, a limited amount of blood transfusion required and the exclusion of other injuries that need laparotomy [22]. In East Africa, conservative management of splenic injuries remains a challenge. This treatment modality cannot be offered to most Africans, as conservative management is dependent on the availability of abdominal CT scanning which many cannot afford. A better alternative is splenorrhaphy however many surgeons in East Africa do not have the technical material at their disposal such as dexon mesh or fibrin glue and success using these materials is also operator dependent [23,24]. The higher grades of splenic injury and low splenorrhaphy rates account for the higher incidence of splenectomy in our patient population. This finding may be explained from the lack of technical materials in particular dexon mesh or fibrin glue which are used for splenorrhaphy. Non-operative management of splenic injury in adults may be challenging as 10-20% are haemodynamically unstable, 15-20% have associated intra-abdominal injuries and up to 60% are alcohol intoxicated. Cogbill’s multicentric study confirmed that only 15% of splenic injury patients satisfy the criterion for non-operative management [25].

In the case study presented the patient underwent a splenectomy following blunt abdominal trauma and many studies from East Africa have shown similar treatment patterns with 80% of patients being treated by splenectomy [10,15,16,26]. In East Africa, most of the patients presenting to the A&E Department are in poor clinical condition, haemodynamically unstable requiring an emergency exploratory laparotomy unlike patients from Western countries who present after a few hours of injury and are in a relatively stable haemodynamic state [20,22]. Studies in East Africa have shown that many splenectomies are performed during the night time and most emergency surgery is performed by junior surgeons at night [17]. These junior surgeons are unfamiliar with techniques of splenic salvage resulting in an increased rate of splenectomy. Another reason for the high splenectomy rates with low grades of splenic injury is due to concomitant visceral injury in particular bowel injury. When non-operative management is adopted, proper clinical assessment, resuscitation and co-operation between doctors, nursing staff and patients is required [15].

If the conservative non-operative approach to management is adopted then the surgeon will follow up the patient in a high-dependency unit HDU setting. The haemoglobin, haematocrit and white cell count are repeated at frequent intervals. Failure of non-operative conservative management occurs if:

• In 24 hours there is transfusion of more than two units of packed red cells.
• After 12 hours, a repeated abdominal/pelvic CT scan shows an increase in free intra-peritoneal fluid.

Within 72 hours failure of non-operative management occurs. Patients may be fed normally after this 72-hour observation period [27].

The lack of intensive care units (ICU) and dedicated trauma centres in East Africa results in a large number of trauma patients being admitted and managed on the general surgery wards which tend not to be well equipped for managing trauma patients. ICU admission has been shown to be influenced by the presence of co-morbidity, the transfusion requirements, and extent of haemoperitoneum, grade of injury, associated injuries and the presence of coagulopathy. The outcome of splenic injury patients is dependent on the presence of complications from other injuries. Since other injuries such as bowel injury are associated with splenic injuries then the outcome of management may be affected by these other injuries [10,15]. The morbidity and mortality from splenic injury may be reduced through the early management of these associated injuries. Among trauma patients the length of hospital stay is an important determinant of morbidity. The disability of these trauma patients through prolonged hospitalization results in an excessive burden on health reasons and reduces the capacity of a young population [28].

The operative mortality with splenic injury has ranged from 10.9% to 19.5% in countries in Sub-Saharan Africa [10,26,17]. An older age, trauma scores, a systolic blood pressure on admission ≤90 mmHg, grade of splenic injury, concomitant injuriesm CD4 ≤200cells/µl in HIV infection, blood loss of >200mls and postoperative complications are factors responsible for mortality following splenic injury. The mortality from splenic injury may be reduced by addressing these factors [10]. Prior to discharge from the hospital, all splenectomy patients should receive vaccination against encapsulated organisms in particular Streptococcus pneumonia, Haemophilus influenza and Neisseria meningitides. Re-vaccination every 5-10 years and antibiotic prophylaxis is necessary to counteract any failure in vaccination [29,30]. In East Africa, the majority of post-splenectomy patients do not attend follow-up surgical outpatient clinics, making it problematic to manage these patients in the long term. Therefore surgeon’s particularly junior surgeons should be trained to salvage the spleen at operation using techniques such as splenorrhaphy. In our setting prevention of post-splenectomy sepsis is problematic and therefore health education should be given to those patients regarding the risk of this condition. Patients should be admitted and comply with anti-malarial prophylaxis and they should be educated to come to the hospital early with signs and symptoms of infection for early diagnosis and treatment of postsplenectomy sepsis.

In our setting, amongst trauma patients, a recognized problem is self-discharge against medical advice [31].This results from long distances from hospitals and poverty. After discharge from the hospital poor follow-up visits is also a concern. Health education programmes in our setting is therefore necessary to prevent post-splenectomy complications in particular post-splenectomy sepsis.

In East Africa, splenectomy is performed for the majority of cases and the mose common cause of splenic injury in our setting are road traffic accidents (RTAs). In blunt abdominal trauma with low grade splenic injury (grade I and II), non-operative management should be adopted, to avoid the potential complications post-splenectomy in particular post-splenectomy sepsis. However non-operative management requires a trauma radiologist and an experienced surgeon capable of treating and recognizing failed conservative management. An HDU setting would also be required which can make management of these injuries challenging particularly in many rural hospitals in East Africa.

The author declares there are no competing interests. No external funding was received to conduct this study.

Consent

The author declares that written and informed consent was obtained from the patient for publication of this case report and the accompanying images.

Ethical Approval

As per international standards and university standards, ethical approval has been collected and preserved by the author.

Acknowledgments

The author wishes to thank clinical staff in the Department of Surgery of Masaka Regional Referral Hospital for their contribution in data collection and their contribution towards the clinical management of the patient. The author also wishes to extend his warm thanks to the nursing staff, medical officers, and anesthesiologists who worked with him in the surgery theatres of Masaka Regional Referral Hospital.

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