Splenic Infarction
Splenic infarction is a rather rare
pathology most commonly
associated with hematologic
disorders.
Splenic infarction typically presents on
CT as a wedge-shaped region of low
attenuation with the apex directed
toward the splenic hilum
The infarct may be segmental or involve
the entire organ
Hematologic Disorders Leukemia
Lymphoma
Myelofibrosis Hypercoagulable states
Erythropoietin therapy
Polycythmia Vera
Sickle hemoglobinopathies
Embolic Disorders : Endocarditis, Atrial
Fibrillation, Prosthetic mitral valve, Left
Ventricular mural thrombus following
myocardial infarct
Vascular Disorders : Wegener's
granulomatosis, polyarteritis nodosa
Autoimmune/Rheumatoid :Kawasaki
Disease, Systemic Lupus Erythematosus
Clinical features
Asymptomatic, with incidental discovery
from radiologic or postmortem studies
hemorrhagic shock as a result of
subcapsular hematoma with rupture into
the peritoneal cavity.
left upper quadrant pain, fever, and chills.
Additional symptoms include nausea,
vomiting, pleuritic chest pain, and left
shoulder pain
Treatment
The mainstay of treatment for splenic
infarction, in the absence of complications,
is analgesia and observation. The arterial
supply to the spleen via the splenic artery
and the short gastric arteries (from the left
gastroepiploic) allow sufficient collateral
flow to preserve much of the spleen
parenchyma with minimal intervention, even
in the event of splenic artery occlusion.
complications such as splenic
abscess from septic emboli or
infection of prior infarct require
immediate surgical attention
Splenic abscess
Splenic abscesses occur most commonly in
patients with underlying disorders such as
infection, embolic disease, traumatic injury,
malignant hematologic conditions, or
immunosuppression. Solitary abscesses
usually represent localized disease. Overall,
the clinician will most often (70%)
encounter patients with solitary abscesses
An abscess in the right upper pole
of the spleen may rupture and form
a left subdiaphragmatic abscess . If
the abscess is in the lower pole ,
rupture result in diffuse peritonitis .
Treatment
As a rule , owing to dense adhesions ,
drainage of the abscess is the only
course . Very rarely , splenectomy may
be possible with the abscess in situ .The
drainage may be performed
percutaneously , under u/s or CT
guidance , so avoiding the need for
operative intervention .
Splenectomy
1- trauma : either following an accident or
during a surgical operation , for example when
mobilising the splenic flexure of the colon .
2- removal en bloc with the stomach as part
of a radical gastrectomy.
3- removal as part of a staging laparotomy
undertaken before treatment of a Hodgkin's
lymphoma, a very rare indication with the
advent of improved staging by imaging;
4- to reduce anemia or
thrombocytopenia in spherocytosis,
ITP or hypersplenism;
5- in association with shunt or
variceal surgery for portal
hypertension.
Complications
- Hemorrhage, if a ligature slips off the
splenic artery.
- Gastric dilatation following partial
mobilisation of the stomach when
ligating the short gastric vessels.
- Hematemesis may rarely occur possibly due to mucosal damage to the
stomach when ligating the short gastric
vessels.
- Left basal atelectasis, sometimes with pleural
effusion, is common. This may be due to damage
or to irritation of the left hemidiaphragm or a
subphrenic abscess, and may be accompanied by
persistent hiccough.
- Damage to the tail of the pancreas during
mobilisation of the splenic pedicle. This may
produce a localised abscess or, if the area has been
well drained, a pancreatic fistula. This may be
associated with a left pleural effusion, a peritoneal
effusion or abdominal wall dehiscence.
- Splenectomy is frequently followed by
a rise in the white cell and platelet count
a few days after operation. There may be
a risk of thrombosis if the platelet count
rises above 1000000 perlitre and it is
essential to anticoagulate
prophylactically the patient should this
level be attained.
- Gastric fistula due to damage of
the greater curvature of the stomach
when ligating the short gastric
vessels.
postsplenectomy septicemia. The spleen
phagocytoses bacteria, particularly
encapsulated bacteria.
Splenectomised patients are at
increased risk of septicemia due to
Streptococcus pneumoniae, Neisseria
meningitides, Haemophylous influenzae
and Babesia rnicroti.
Opportunistic postsplenectomy infection
(OPSI) is now of major concern.
Pneumococcal vaccine (Pneumovax)
should be given 2 weeks preoperatively.
It is important to advise the patient of
the dangers of OPSI and to prescribe
antibiotics with all infections.
Splenectomised patients living in
malaria endemic areas should receive
antimalaria prophylaxis.
For children :long-term treatment
with antibiotic drugs to prevent postsplenectomy sepsis . ( benzathen
penicillin 1.2 mega units per month )
Long-term antibiotic use is usually
not necessary in adults.
