Splenic Infarct Flashcards
What is a splenic infarct
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
Why is the infarction usually not complete?
Because there is collateral circulation
From splenic artery and the short gastric arteries (left gastroepiploic artery) as well.
Presdispoing condition
Chronic myelogenous leukaemia (CML) is a predisposing condition
Aetiology
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
Clinical features
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
Examination findings
LUQ tenderness
Dx
Peptic ulcer disease
Pyelonephritis
Ureteric colic
Left sided basal pneumonia
Gold standard ix
CT abdo scan with IV contrast
Lab tests
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
CT findings
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.
Following treatment CT scan should be made again, what will it show?
Either full resolution, fibrosis or liquefaction of affected region
Management
No specific management
Ensure haemodynamic stability
Analgesia + IV resus
Identify cause of infarction which may require involving haematology and ECHO scan
Long-term management
Long term anticoagulation
Splenectomy might be done but should be avoid if possible
Why should a splenectomy be avoided if possible?
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
Prognosis
Varies enormously mainly due to the ause and severity
Complications of splenic infarction
Splenic abscess
Splenic rupture
Pseudocyst formation
Auto-Splenectomy
When might splenic abscess happen?
Post-splenic infarct of a non-sterile embolus like infective endocarditis
The embolus seeds infection in the necrotic spleen.
Diagnosis of splenic abscess
Based on CT scanning in combination with raised inflammatory markers (requires experienced radiologist)
Most cases will only be confirmed with explorative surgery
Explain auto-splenectomy
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.
Most common cause of auto-splenectomy
Repeated splenic infarctions from sickle-cell anaemia.
