Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis

BACKGROUND: The response of liver cirrhosis (LC) patients to abdominal trauma, including blunt splenic injury (BSI) is unfavorable. To better understand the response to BSI in LC patients, the present study reviewed a much larger group of such patients, derived from the National Trauma Data Bank. METHODS: The National Trauma Data Bank was queried for 2002 to 2010, and all adult BSI patients without severe brain trauma were identified. LC and non-LC patients were compared using nonoperative management (NOM) failure and mortality as primary outcomes. Predictors of these outcomes in LC patients were identified. RESULTS: Of the 77,753 identified BSI patients, 289 (0.37%) had LC. Overall, 90% of the patients underwent initial NOM (86% in LC and 90% in non-LC patients, p = 0.091) with a global 90% success rate. Compared with non-LC patients, LC patients had a lower NOM success rate (83% vs. 90%, p = 0.004) despite increased use of splenic artery angioembolization (13% vs. 8%, p = 0.001). LC patients also had more complications per patient, an increased hospital and intensive care unit lengths of stay, and a higher mortality (22% vs. 6%, p < 0.0001), which was independent of the treatment paradigm. In the LC group, mortality in those who underwent immediate surgery was 35% versus 46% in failed NOM (p = 0.418) and 14% (p = 0.019) in successful NOM patients. LC patients who did not require surgery were more likely to survive than those who had surgery alone (adjusted odds ratio [AOR], 0.30). Preexisting coagulopathy (AOR, 3.28) and Grade 4 to 5 BSI (AOR, 11.6) predicted NOM failure in LC patients, whereas male sex (AOR, 4.34), hypotension (AOR, 3.15), preexisting coagulopathy (AOR, 3.06), and Glasgow Coma Scale (GCS) score of less than 13 (AOR, 6.33) predicted mortality. CONCLUSION: LC patients have a higher rate of complications, mortality, and NOM failure compared with non-LC patients. Because LC patients with failed NOM have a mortality rate similar to those undergoing immediate surgery, judgment must be exerted in selecting initial management options. (J Trauma Acute Care Surg. 2014; 76: 1354-1361. Copyright (C) 2014 by Lippincott Williams & Wilkins)