A 24-year-old man is brought in after a fall from a mountain bike onto his left side. Primary survey: airway patent, respiratory rate 18/min with saturations 98%, heart rate 96/min, BP 124/78 mmHg, GCS 15. He has left upper quadrant and left shoulder-tip pain. FAST shows free fluid in the left upper quadrant. CT with contrast demonstrates a grade III splenic laceration with a moderate haemoperitoneum and a small focus of active contrast extravasation (blush) within the spleen; no other injuries. After two units of blood his observations are unchanged and he remains stable in a centre with interventional radiology and immediate theatre access. What is the most appropriate management?
- AImmediate laparotomy and splenectomy
- BLaparotomy and splenorrhaphy with mesh wrap
- CDischarge with outpatient review once the pain settles
- DNon-operative management with angioembolisation of the bleeding focus and close monitoring in a high-dependency setting
- EDiagnostic laparoscopy with washout of the haemoperitoneum and inspection of the spleen
Show answer and explanation
Correct answer: D
Blunt splenic injury in a haemodynamically stable patient is managed non-operatively, and this has become the standard for most grades in adults — preserving the spleen's immunological function and avoiding laparotomy. The refinement this vignette tests is the role of angioembolisation: a contrast blush signifies active bleeding and predicts failure of purely expectant management, and splenic artery embolisation (proximal or selective) controls it in the great majority, raising splenic salvage rates substantially. The mandatory conditions for non-operative management are all present: haemodynamic stability, a monitored high-dependency environment, immediate access to theatre and interventional radiology, and serial clinical and haemoglobin review. Deterioration at any point converts the plan to splenectomy without hesitation.
Why the others are wrong: A — splenectomy for a stable patient with an embolisable blush sacrifices the spleen unnecessarily and commits a young man to lifelong overwhelming post-splenectomy infection precautions. B — operative splenic repair is largely historical; if the abdomen is opened for haemorrhage, splenectomy is the reliable operation. C — a grade III injury with active extravasation can decompensate suddenly; discharge is dangerous. E — laparoscopy neither controls a bleeding spleen reliably nor betters embolisation, and washout alone treats nothing.
Key point: Stable blunt splenic injury is managed non-operatively; a contrast blush is the trigger for angioembolisation rather than surgery, provided monitoring, radiology and theatre are immediately available — instability at any stage means splenectomy.
Guidelines: WSES spleen trauma guidelines 2017: haemodynamically stable patients with contrast blush on CT are suitable for non-operative management with splenic angioembolisation in a monitored setting with surgery immediately available.