Splenic Infarct

Question 1

What is a splenic infarct

Answer 1

Caused by occlusion of the splenic artery or one of its branches

This leads to tissue necrosis

CAn be caused by a variety of potential pathologies

Question 2

Why is the infarction usually not complete?

Answer 2

Because there is collateral circulation

From splenic artery and the short gastric arteries (left gastroepiploic artery) as well.

Question 3

Presdispoing condition

Answer 3

Chronic myelogenous leukaemia (CML) is a predisposing condition

Question 4

Aetiology

Answer 4

Haematological disease or thromboembolism

Lymphoma, myelofibrosis, sickle cell dsiease, CML, polycythaemia rubra vera, hypercoagulable states

Endocarditis, AF, infected aneurysm grafts or post-MI mural thrombus

Rarer causes include vasculitis, trauma, collagen tissue disease or surgery

Question 5

Clinical features

Answer 5

LUQ pain that may radiate to the left shoulder

Can also have fever, nausea, vomiting, pleuritic chest pain.

A lot of patients are also completely asymptomatic and diagnosed purely by imaging or explorative surgery

Question 6

Examination findings

Answer 6

LUQ tenderness

Question 7

Dx

Answer 7

Peptic ulcer disease

Pyelonephritis

Ureteric colic

Left sided basal pneumonia

Question 8

Gold standard ix

Answer 8

CT abdo scan with IV contrast

Question 9

Lab tests

Answer 9

Routine bloods with FBC, U&Es, LFTs, coag screen

WCC is high in around 50% of cases

Raised D-dimer levels may also aid diagnosis

Question 10

CT findings

Answer 10

IV contrast cannot reach the infarcted area.

This gives a segmental wedge of hypoattenuated tissue.

The apex of the wedge pointing towards the hilum of the spleen from the segmental branching of the splenic artery.

If the splenic artery instead of a segmental branch is affected the entire spleen will be hypoattenuated.

Question 11

Following treatment CT scan should be made again, what will it show?

Answer 11

Either full resolution, fibrosis or liquefaction of affected region

Question 12

Management

Answer 12

No specific management

Ensure haemodynamic stability

Analgesia + IV resus

Identify cause of infarction which may require involving haematology and ECHO scan

Question 13

Long-term management

Answer 13

Long term anticoagulation

Splenectomy might be done but should be avoid if possible

Question 14

Why should a splenectomy be avoided if possible?

Answer 14

Overwhelming post-splenectomy infection (OPSI)

This is due to the spleens role in the protection against encapsulated bacteria.

So vaccination against s.pneumonia and h.influenzae + n.meningitidis is warranted.

Low does abx cover (Penicillin V) should also be given

Question 15

Prognosis

Answer 15

Varies enormously mainly due to the ause and severity

Question 16

Complications of splenic infarction

Answer 16

Splenic abscess

Splenic rupture

Pseudocyst formation

Auto-Splenectomy

Question 17

When might splenic abscess happen?

Answer 17

Post-splenic infarct of a non-sterile embolus like infective endocarditis

The embolus seeds infection in the necrotic spleen.

Question 18

Diagnosis of splenic abscess

Answer 18

Based on CT scanning in combination with raised inflammatory markers (requires experienced radiologist)

Most cases will only be confirmed with explorative surgery

Question 19

Explain auto-splenectomy

Answer 19

Rare condition that results in asplenism.

Repeated splenic infarctions leads to progressive fibrosis and atrophy of the spleen.

Especially if this happens in childhood it can cause complete atrophy of the spleen, which is called auto-splenectomy.

Question 20

Most common cause of auto-splenectomy

Answer 20

Repeated splenic infarctions from sickle-cell anaemia.