NASHVILLE, TENN. — Liver and spleen injuries account for most sports-related solid organ injuries, William Dexter, M.D., said at the annual meeting of the American College of Sports Medicine.
Liver injuries, which occur in about 5% of athletic abdominal traumas, can be occult, which makes them especially concerning, said Dr. Dexter of the Maine Medical Center, Portland. “While these aren't terribly common injuries, they can cause serious problems.”
“We have to have a game plan in mind for dealing with these folks, both on the field and after treatment,” he said.
Liver injuries are usually caused by blunt force to the abdomen. Symptoms include vomiting, pain in the abdomen or referred to the right shoulder or right side of the neck, and a rapid pulse.
Diagnosis must be made by both clinical assessment and diagnostic imaging. Ultrasound is becoming more popular, but remains second to computed axial tomography. “It's fairly clear that a CT scan is leading the way,” Dr. Dexter said.
“Ultrasound has become more popular, but a 2005 Cochrane review found insufficient evidence to promote an ultrasound-based treatment algorithm,” he said.
Oral contrast is unnecessary when CT scans are used, he said. “Oral contrast doesn't increase the sensitivity or predict outcome, but it does delay time of diagnosis by at least 30 minutes.”
Diagnostic peritoneal lavage has fallen out of favor because, while it is sensitive for intraperitoneal bleeding, it is invasive and does not predict outcome or the need for laparotomy.
Minor injuries (contusion or small laceration), in which the patient is clinically stable (no active bleeding or other peritoneal signs, no associated abdominal injury), heal without surgery with a success rate of up to 98%. These athletes can usually return to play 1 month after the injury.
Major injuries (large laceration, burst, or pedicle injury) usually require surgical intervention. “There are no consistent guidelines on return to play for these athletes, but most authors advise at least 3–6 months,” Dr. Dexter said.
The spleen is another commonly injured organ. The usual cause is a direct blow to the abdomen, though injury can be related to lower rib fracture. The diagnostic imaging method of choice is the CT scan.
Surgery is usually unnecessary if the patient is clinically and hemodynamically stable and if there are no other abdominal injuries. In these cases, rest with close monitoring is advised because late rupture can occur.
Most athletes with minor spleen injuries can return to play about 1 month after the injury. Surgery is advised if the patient is unstable or there is a pedicle injury. Athletes can return to play 6 weeks after a splenectomy.
There has been some speculation that splenomegaly associated with infectious mononucleosis increases the risk of splenic rupture in sports, especially among college-aged males.
“Splenic fragility is greatest on days 4–21 of the infection, when there is a profuse lymphocytic proliferation,” he said.
“Most ruptures occur on days 4–21 from symptom onset and most are spontaneous. They are rarely lethal.”
There is no consensus in the literature about return to play for athletes with mononucleosis, Dr. Dexter said. “In general, if there are no signs or symptoms, and the labs and ultrasound are normal, the athlete can return to contact sports within 3 weeks.”
A damaged solid organ, such as the lacerated spleen in this MRI, usually results from a direct blow to the abdomen. Courtesy Dr. William Dexter