Splenic InfarctionSplenic Infarction

Splenic infarction is a rather rare Splenic infarction is a rather rare pathology most commonly pathology most commonly

associated with hematologic associated with hematologic disorders. disorders.

• Splenic infarction typically presents on Splenic infarction typically presents on CT as a wedge-shaped region of low CT as a wedge-shaped region of low attenuation with the apex directed attenuation with the apex directed toward the splenic hilum toward the splenic hilum

• The infarct may be segmental or involve The infarct may be segmental or involve the entire organ the entire organ

• Hematologic Disorders LeukemiaHematologic Disorders LeukemiaLymphomaLymphomaMyelofibrosis Hypercoagulable statesMyelofibrosis Hypercoagulable statesErythropoietin therapyErythropoietin therapyPolycythmia VeraPolycythmia VeraSickle hemoglobinopathies Sickle hemoglobinopathies

• Embolic Disorders : Endocarditis, Atrial Embolic Disorders : Endocarditis, Atrial Fibrillation, Prosthetic mitral valve, Left Fibrillation, Prosthetic mitral valve, Left Ventricular mural thrombus following Ventricular mural thrombus following myocardial infarctmyocardial infarct

• Vascular Disorders : Wegener's Vascular Disorders : Wegener's granulomatosis, polyarteritis nodosagranulomatosis, polyarteritis nodosa

• Autoimmune/Rheumatoid :Kawasaki Autoimmune/Rheumatoid :Kawasaki Disease, Systemic Lupus ErythematosusDisease, Systemic Lupus Erythematosus

Clinical featuresClinical features

• Asymptomatic, with incidental discovery Asymptomatic, with incidental discovery from radiologic or postmortem studies from radiologic or postmortem studies

• hemorrhagic shock as a result of hemorrhagic shock as a result of subcapsular hematoma with rupture into subcapsular hematoma with rupture into the peritoneal cavity. the peritoneal cavity.

• left upper quadrant pain, fever, and left upper quadrant pain, fever, and chills. Additional symptoms include chills. Additional symptoms include nausea, vomiting, pleuritic chest pain, nausea, vomiting, pleuritic chest pain, and left shoulder pain and left shoulder pain

TreatmentTreatment• The mainstay of treatment for splenic The mainstay of treatment for splenic

infarction, in the absence of complications, infarction, in the absence of complications, is analgesia and observation. The arterial is analgesia and observation. The arterial supply to the spleen via the splenic artery supply to the spleen via the splenic artery and the short gastric arteries (from the left and the short gastric arteries (from the left gastroepiploic) allow sufficient collateral gastroepiploic) allow sufficient collateral flow to preserve much of the spleen flow to preserve much of the spleen parenchyma with minimal intervention, parenchyma with minimal intervention, even in the event of splenic artery occlusion. even in the event of splenic artery occlusion.

• complications such as splenic complications such as splenic abscess from septic emboli or abscess from septic emboli or infection of prior infarct require infection of prior infarct require immediate surgical attention immediate surgical attention

Splenic abscessSplenic abscess • Splenic abscesses occur most commonly in Splenic abscesses occur most commonly in

patients with underlying disorders such as patients with underlying disorders such as infection, embolic disease, traumatic injury, infection, embolic disease, traumatic injury, malignant hematologic conditions, or malignant hematologic conditions, or immunosuppression. Solitary abscesses immunosuppression. Solitary abscesses usually represent localized disease. Overall, usually represent localized disease. Overall, the clinician will most often (70%) the clinician will most often (70%) encounter patients with solitary abscesses encounter patients with solitary abscesses

• An abscess in the right upper pole An abscess in the right upper pole of the spleen may rupture and form of the spleen may rupture and form a left subdiaphragmatic abscess . If a left subdiaphragmatic abscess . If the abscess is in the lower pole , the abscess is in the lower pole , rupture result in diffuse peritonitisrupture result in diffuse peritonitis .

TreatmentTreatment

• As a rule , owing to dense adhesions , As a rule , owing to dense adhesions , drainage of the abscess is the only drainage of the abscess is the only course . Very rarely , splenectomy may course . Very rarely , splenectomy may be possible with the abscess in situ .The be possible with the abscess in situ .The drainage may be performed drainage may be performed percutaneously , under u/s or CT percutaneously , under u/s or CT guidance , so avoiding the need for guidance , so avoiding the need for operative intervention . operative intervention .

SplenectomySplenectomy• 1- trauma : either following an accident or 1- trauma : either following an accident or

during a surgical operation , for example when during a surgical operation , for example when mobilising the splenic flexure of the colon .mobilising the splenic flexure of the colon .

• 2- removal en bloc with the stomach as part of 2- removal en bloc with the stomach as part of a radical gastrectomy.a radical gastrectomy.

• 3- removal as part of a staging laparotomy 3- removal as part of a staging laparotomy undertaken before treatment of a Hodgkin's undertaken before treatment of a Hodgkin's lymphoma, a very rare indication with the lymphoma, a very rare indication with the advent of improved staging by imaging;advent of improved staging by imaging;

• 4- to reduce anemia or 4- to reduce anemia or thrombocytopenia in spherocytosis, thrombocytopenia in spherocytosis, ITP or hypersplenism;ITP or hypersplenism;

• 5- in association with shunt or 5- in association with shunt or variceal surgery for portal variceal surgery for portal hypertension. hypertension.

ComplicationsComplications

- Hemorrhage, if a ligature slips off the - Hemorrhage, if a ligature slips off the splenic artery.splenic artery.

- Gastric dilatation following partial - Gastric dilatation following partial mobilisation of the stomach when mobilisation of the stomach when ligating the short gastric vessels.ligating the short gastric vessels.

- Hematemesis may rarely occur - - Hematemesis may rarely occur - possibly due to mucosal damage to the possibly due to mucosal damage to the stomach when ligating the short gastric stomach when ligating the short gastric vessels.vessels.

- Left basal atelectasis, sometimes with pleural - Left basal atelectasis, sometimes with pleural effusion, is common. This may be due to damage effusion, is common. This may be due to damage or to irritation of the left hemidiaphragm or a or to irritation of the left hemidiaphragm or a subphrenic abscess, and may be accompanied by subphrenic abscess, and may be accompanied by persistent hiccough.persistent hiccough.

- Damage to the tail of the pancreas during - Damage to the tail of the pancreas during mobilisation of the splenic pedicle. This may mobilisation of the splenic pedicle. This may produce a localised abscess or, if the area has been produce a localised abscess or, if the area has been well drained, a pancreatic fistula. This may be well drained, a pancreatic fistula. This may be associated with a left pleural effusion, a peritoneal associated with a left pleural effusion, a peritoneal effusion or abdominal wall dehiscence.effusion or abdominal wall dehiscence.

- Splenectomy is frequently followed by - Splenectomy is frequently followed by a rise in the white cell and platelet count a rise in the white cell and platelet count a few days after operation. There may a few days after operation. There may be a risk of thrombosis if the platelet be a risk of thrombosis if the platelet count rises above 1000000 perlitre and it count rises above 1000000 perlitre and it is essential to anticoagulate is essential to anticoagulate prophylactically the patient should this prophylactically the patient should this level be attained.level be attained.

- Gastric fistula due to damage of - Gastric fistula due to damage of the greater curvature of the stomach the greater curvature of the stomach when ligating the short gastric when ligating the short gastric vesselsvessels.

• postsplenectomy septicemia. The spleen postsplenectomy septicemia. The spleen phagocytoses bacteria, particularly phagocytoses bacteria, particularly encapsulated bacteria.encapsulated bacteria.

• Splenectomised patients are at Splenectomised patients are at increased risk of septicemia due to increased risk of septicemia due to Streptococcus pneumoniae, Neisseria Streptococcus pneumoniae, Neisseria meningitides, Haemophylous influenzae meningitides, Haemophylous influenzae and Babesia rnicroti. and Babesia rnicroti.

• Opportunistic postsplenectomy infection Opportunistic postsplenectomy infection (OPSI)(OPSI) is now of major concern. is now of major concern. Pneumococcal vaccine (Pneumovax) Pneumococcal vaccine (Pneumovax) should be given 2 weeks preoperatively. should be given 2 weeks preoperatively. It is important to advise the patient of It is important to advise the patient of the dangers of OPSI and to prescribe the dangers of OPSI and to prescribe antibiotics with all infections. antibiotics with all infections.

• Splenectomised patients living in Splenectomised patients living in malaria endemic areas should receive malaria endemic areas should receive antimalaria prophylaxis.antimalaria prophylaxis.

• For children :long-term treatment For children :long-term treatment with antibiotic drugs to prevent post-with antibiotic drugs to prevent post-splenectomy sepsis . splenectomy sepsis . ( benzathen ( benzathen penicillin 1.2 mega units per month )penicillin 1.2 mega units per month )

• Long-term antibiotic use is usually Long-term antibiotic use is usually not necessary in adults.not necessary in adults.