Patient Presentation
A 6-year-old male came to clinic after hospitalization for a bike-automobile accident. He was wearing a bicycle helmet and had an initial Glascow Coma Score of 11 (i.e. responded to speech, moved to pain and used inappropriate words), and was hemodynamically stable. He had 9th and 10th left rib fractures, a left mid-shaft radial fracture, splenic hematoma, and left renal contusion. He had undergone exploratory laparotomy because of inconclusive initial radiological imaging regarding the extent of his abdominal injuries. His intensive care unit course showed him treated with heavy sedation, casting of radial fracture and monitoring. He remained hemodynamically stable and did not require intubation or transfusion. His mentation returned to normal as sedation was decreased. He was discharged after 9 days including 6 in the intensive care unit. Since discharge a visiting nurse had been seeing him and reported normal vital signs, increasing activity and decreasing fatigue, along with decreasing need for pain medications.

The pertinent physical exam showed a tired appearing male with normal vital signs. He had healing bruises and “road rash” mainly on the left side of his body, along with a cast on his left forearm. He had a healing abdominal scar. His left lower ribs were more bruised and sore with palpation. His abdomen had no tenderness except for the area around the incision. The rest of his examination was normal.

The diagnosis of a patient with post-traumatic injuries that were improving was confirmed. The patient’s clinical course showed that he returned to limited activities at 5 weeks post-injury. By 8 weeks he was out of his cast and only complained of intermittent rib pain that required no treatment. Repeated imaging showed resolution of the splenic hematoma and renal contusion, and he also had normal laboratory testing.

Figure 146 – Axial CT with contrast of the abdomen (above) shows multiple areas of low density in the spleen, a perisplenic fluid collection, and (below) a large amount of free fluid in the pelvis.

Discussion
The spleen is an intraperitoneal organ tucked up under the 9-11th ribs by the diaphragm, and is lateral to the left kidney and stomach which it is connected to by parts of the greater omentum. It is a highly vascular organ where the splenic artery arises from the celiac trunk and branches into 5 splenic segmental arteries. The splenic vein combines with the superior mesenteric vein to form the hepatic portal vein. It has an important role in filtering blood, removing old blood cells, assisting regulation of the amount of blood circulating, and in immunoregulation. People can live without a spleen if it is structurally or functionally damaged (e.g. trauma or sickle cell disease). Patients have an increased risk of infections especially encapsulated organisms and need to be expectantly managed with prophylactic antibiotics and vaccination (especially for pneumococcus, meningococcus and influenza).

Splenic injuries are more common in children than adults due to location, relative size and higher transmission rate of forces through the abdominal wall.

Potential splenic problems include:

• Capsular hematoma
  • At risk for capsular rupture
  • Can be “bruised” to severe capsular distension
• Capsular rupture or laceration
• Arterial thrombosis
• Venous thrombosis

Because the spleen is a highly vascular organ, intra-abdominal bleeding can quickly cause shock even with 5-10% of blood volume loss. Signs of splenic rupture include left sided abdominal pain, left shoulder tip pain, abdominal distension and hemodynamic instability such as syncope and hypotension. Non-operative management of splenic injury is preferred. If operative management is needed then more minimal treatment such as embolization is preferred to splenectomy.

Acutely enlarged spleens are more often caused by infections such as Epstein Barr virus and can cause early satiety, left upper quadrant/shoulder pain, and there could be problems with anemia, or platelets. It can be hard to discern an enlarged spleen on physical examination, but palpable fullness or blottable mass (sometimes described as feeling like a water balloon) in the lateral abdomen indicate potential enlargement.

Learning Point
Causes of splenic rupture include:

• Trauma (very common)
• Atraumatic rupture (uncommon)
  • Infection
    • Epstein Barr virus (up to ~70% in some studies as the cause)
    • Cytomegalovirus
    • HIV
    • COVID-19
  • Malignancy
  • Inflammatory disease/non-infection
    • Pancreatitis
    • Cirrhosis
  • Congenital anomalies

Questions for Further Discussion
1. With Epstein Barr virus and splenic enlargement, when can a patient return to sports?
2. What are presentations of Epstein Barr virus? A review can be found here
3. At what age are patients with sickle cell disease considered functionally asplenic?
Related Cases

Disease: Spleen Diseases | Abdominal Pain

Symptom/Presentation: Trauma

Specialty: Critical Care | Surgery | Radiology / Nuclear Medicine / Radiation Oncology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Spleen Diseases

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Dixon S, Horgan LF. The elusive spleen. Ann R Coll Surg Engl. 2019;101(3):176-179. doi:10.1308/rcsann.2018.0215

Grootenhaar M, Lamers D, Ulzen KK van, de Blaauw I, Tan EC. The management and outcome of paediatric splenic injuries in the Netherlands. World Journal of Emergency Surgery. 2021;16(1):8. doi:10.1186/s13017-021-00353-4

Bakalli I, Biqiku M, Cela D, et al., Atraumatic splenic rupture in a child with COVID 19. BMC Pediatrics 2022;22:300. Accessed June 9, 2025. https://pubmed-ncbi-nlm-nih-gov.proxy.lib.uiowa.edu/35597923/

Schwartz K, Krishnasarma R, Snyder E, et al. Spontaneous splenic rupture in a neonate: a case report and literature review. Emerg Radiol. 2024;31(1):117-122. doi:10.1007/s10140-024-02199-0

Spleen problems and spleen removal. NHS.uk. October 18, 2017. Accessed June 9, 2025. https://www.nhs.uk/tests-and-treatments/spleen-problems-and-spleen-removal/

The Spleen – Position – Structure – Neurovasculature – TeachMeAnatomy. Accessed July 15, 2025. https://teachmeanatomy.info/abdomen/viscera/spleen/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa