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AIP: Abdominal pain > Splenic infarction/ rupture > Flashcards

Splenic infarction/ rupture Flashcards

1
Q

What causes splenic infarction?

A

occlusion of the splenic artery or one of its branches

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2
Q

Why is splenic infarction often not complete?

A

the spleen is supplied by the splenic artery (from the coeliac axis) and the short gastric arteries (from the left gastroepiploic artery), so collateral circulation can also supply the spleen

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3
Q

What is an example of a predisposing condition to splenic infarction and how high are rates of it with this condition?

A

chronic mylogenous leukaemia (CML) - as high as 72% (but many are asymptomatic)

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4
Q

What are the 2 most common causes of splenic infarction?

A
  1. Haematological disease: e.g. lymphoma, myelofibrosis, sickle cell disease, chronic myeloid leukaemia, polycythaemia rubra vera, or hypercoagulable states
  2. Embolic disorders: e.g. endocarditis, AF, infected aneurysm grafts, or post-MI mural thrombus
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5
Q

What are 4 rarer causes of splenic infarction?

A
  1. Vasculitis
  2. Trauma (blunt trauma or torsion of a ‘wandering’ splenic artery)
  3. Collagen tissue diseases
  4. Surgery (pancreatectomy or liver transplantation)
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6
Q

What are 6 examples of haematological disorders predisposing to splenic infarction?

A
  1. lymphoma
  2. myelofibrosis
  3. Sickle Cell Disease
  4. Chronic Myeloid Leukaemia
  5. Polycythaemia Rubra Vera
  6. Hypercoagulable states
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7
Q

How do haematological diseases cause splenic infarction?

A

congestion of the splenic circulation by abnormal cells, often further confoudned in conditions (such as CML or myelofibrosis) by anaemia and splenomegaly

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8
Q

What are 4 examples of embolic disorders which can predispose to splenic infarction?

A
  1. Endocarditis
  2. Atrial fibrillation
  3. Infected aneurysm grafts
  4. Post-MI mural thrombus
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9
Q

What are 5 symptoms of splenic infarction?

A
  1. Left upper quadrant abdominal pain, which may radiate to the left shoulder
  2. Fever
  3. Nausea or vomiting
  4. Pleuritic chest pain
  5. Can be completely asymptomatic - in a significant number of patients
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10
Q

How can splenic infarction be diagnosed when it is asymptomatic?

A

imaging or explorative surgery

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11
Q

What may be present on examination in splenic infarction?

A

left upper quadrant tenderness is common

other signs may be present depending on complications that have developed

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12
Q

What are 3 important differentials for splenic infarction?

A
  1. Peptic ulcer disease
  2. Pyelonephritis or ureteric colic
  3. Left-sided basal pneumonia
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13
Q

What is the gold standard investigation for suspected splenic infarction?

A

CT abdominal scan with IV contrast

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14
Q

What are 5 blood tests which may aid the diagnosis of splenic infarction?

A
  1. FBC
  2. U+Es
  3. LFTs
  4. Coagulation screen
  5. D-dimer
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15
Q

What abnormality present in bloods will be positive in half of splenic infarction cases?

A

high WCC

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16
Q

What will CT abdominal scan with IV contrast show in splenic infarction?

A
  • as IV contrast can’t reach the infarcted area, a segmental wedge of hypoattenuated tissue becomes visible on CT scanning
  • apex of wedge points to hilum of the spleen from segmental branching of the splenic artery
  • if splenic artery rather than one of its segmental branches is affected, the entire spleen will be hypoattenuated
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17
Q

What are 3 things that CT scan with IV contrast may show following treatment for splenic infarction?

A
  1. full resolution
  2. firbosis of original infarct
  3. liquefaction of affected region
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18
Q

What are 4 aspects of the immediate management of splenic infarct?

A
  1. Regular monitoring to ensure haemodynamic stability
  2. Appropriate analgesia
  3. IV hydration
  4. Management of underlying condition
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19
Q

What are 3 things that should be considered when identifying and treating the underlying cause of splenic infarct?

A
  1. Involvement of haematologist
  2. ECHO scan
  3. consideration of long-term anticoagulation
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20
Q

Why should splenectomy be avoided in the long-term management of splenic infarction?

A

risks of overwhelming post-splenectomy infection (OPSI) syndrome - but may become unavoidable if complications develop or symptoms persist

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21
Q

If splenectomy must be performed for splenic infarction due to complications/ persisting symptoms, what age should it be delayed to?

A

until patient age >2 years, but ideally >10 years - to ensure appropriate immune response can be developed post-splenectomy

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22
Q

What must be done alongside splenectomy? 2 key things

A

protection against encapsulated bacteria due to spleen’s role in this usually: vaccination against S. pneumoniae, N. meningitidis, and H. influenza

long-term antibiotic cover, ideally penicillin V

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23
Q

What does the prognosis of splenic infarction vary with?

A
  • varies with cause and severity
  • if benign underlying disease and asymptomatic - extremely good prognosis
  • if secondary to haematological malignancy - more guarded outcom
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24
Q

What are the 3 most common complications of splenic infarction?

A
  1. Splenic rupture
  2. Splenic abscess
  3. Pseudocyst formation
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25
Q

When can splenic abscess develop as a complication of splenic infarct?

A

when underlying cause was from a non-sterile embolus, such as infective endocarditis (or rarer cases when patient is immunocompromised

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26
Q

How can a non-sterile embolus cause splenic abscess?

A

the embolus seeds infection into the necrotic splenic tissue - clinically difficult to differentiate from uncomplicated infarction

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27
Q

How can a diagnosis of splenic abscess be made?

A
  • CT scanning reviewed by experienced radiologist, especially when combined with raised inflammatory markers
  • most cases only confirmed with explorative surgery
28
Q

What is a rare complication resulting from repeated splenic infarctions?

A

auto-splenectomy

29
Q

What is auto-splenectomy?

A

rare condition resulting in aplenism; progressive fibrosis and atrophy due to repeated splenic infarctions

if continues over long period, especially during childhood, can lead to complete atrophy of the spleen

30
Q

What is the most common cause of auto-splenectomy?

A

sickle-cell anaemia

31
Q

How can sickle cell anaemia cause auto-splenectomy?

A

repeated sickle cell crises lead to recurrent occlusion of the splenic artery

as this can continue throughout childhood, it can cause complete asplenism by adulthood

32
Q

What can splenic rupture lead to and why?

A

large intraperitoneal haemorrhage and fatal haemorrhagic shock, because the spleen is an extremely vascular organ

33
Q

What causes the majority of cases of splenic injury?

A

abdominal trauma - particularly blunt trauma

34
Q

What are 2 examples of common situations in which the spleen is injured?

A
  1. Seat-belt injuries in road-traffic collisions
  2. Falls onto the left side e.g. patients slipping on ice, elderly patient falling in bathroom
35
Q

Overall what are 4 causes of splenic rupture?

A
  1. Trauma (usually blunt)
  2. Iatrogenic
  3. Secondary to underlying splenomegaly from haematological malignancy
  4. Splenomegaly from infective causes e.g. Epstein-Barr virus
36
Q

Why can splenomegaly from malignancy or infection lead to splenic rupture?

A

as the spleen grows, the capsule stretches and things, becoming more fragile and predisposing to rupture

37
Q

What are 5 possible clinical features of splenic rupture?

A
  1. Abdominal pain
  2. Hypovolaemic shock - some present with these features only
  3. Left upper quadrant tenderness
  4. Peritonism on examination
  5. Kehr’s sign - pain radiating to the left shoulder due to diaphragm irritation
38
Q

What is the management of patients who are haemodynamically unstable with peritonism following trauma?

A

these patients ahve abdominal bleeding (due to splenic rupture) until proven otherwise - require immediate laparotomy

39
Q

What is the key investigation needed for patients who are haemodynamically stable with suspected abdominal injury (which may include splenic rupture)?

A

urgent CT chest-abdomen-pelvis with IV contrast

40
Q

What is the benefit of CT imaging for suspected splenic injury?

A

allows identification and assessment of splenic injury, alongside any other abdominal viscera involvement

specifically allows for grading of splenic injury to guide further management

41
Q

What type of scan can sometimes be performed in the emergency department setting for suspected splenic injury, and when shouldn’t they be performed?

A

FAST scans - can reveal free peritoneal fluid or fluid in the pericardium, however whilst a potentially helpful adjunct, they should not delay CT imaging and/or surgical intervention

42
Q

What does the CT scan show?

A

traumatic splenic rupture at the rim at the lower edge showing a sign of free fluid (blood)

43
Q

What is the scale that can be used to grade splenic trauma?

A

American Association for the Surgery of Trauma (AAST) splenic injury scale

44
Q

How many grades of splenic injury are there in the American Association for the Surgery of Trauma (AAST)’s system?

A

5

45
Q

What is Grade 1 splenic injury?

A
  • capsular tear <1cm parenchymal depth
  • subcapsular haematoma <10% surface area
46
Q

What is Grade 2 splenic injury?

A
  • capsular tear 1-3 cm parenchymal depth
  • subcapsular haematoma 10-50% surface area, or intraparenchymal <5cm
47
Q

What is Grade 3 splenic injury?

A
  • capsular tear >3cm parenchymal depth, or any tear involving trabecular vessels
  • subcapsular haematoma >50% surface area, or intraparechymal >5cm or any expanding or ruptured haematoma
48
Q

What is Grade 4 splenic injury?

A
  • laceration involving segmental or hilar vessels, devascularising >25% of the spleen
49
Q

What is Grade 5 splenic injury?

A

completely shattered spleen or hilar vascular injury, devascularising the entire spleen

50
Q

What is the initial management of all patients with suspected splenic injury?

A

should be assessed, resuscitated and treated according to ATLS principles

51
Q

What are the 2 situations when, following ATLS assessment + resuscitation, a patient required urgent laparotomy (for suspected splenic rupture)?

A
  1. Haemodynamic instability
  2. Grade 5 injury (shattered spleen or major hilar vascular injury)
52
Q

What is the management of haemodynamically stable patients with splenic rupture/ those with grade 1-3 injuries without active extravasation, following ATLS resuscitation?

A
  • conservative management - should be resuscitated using permission hypotension (don’t rise BP too much - can increase bleeding)
  • bed rest
  • repeat CT at 1-week post-injury
53
Q

Where should haemodynamically stable patients with grade 1-3 injuries with splenic rupture be managed?

A

high dependency area, for observation and serial abdominal examinations to monitor for evidence of deterioration

54
Q

When should haemodynamically stable patients with grade 1-3 splenic injuries have repeat CT scans?

A

repeat CT scan at 1 week post-injury

55
Q

What should be done if there is any evidence of increasing tenderness of peritonitis in conservatively managed splenic ruptured? Why?

A

low threshold for re-imaging and / or laparotomy - associated injuries such as small bowel injuries are easily missed on initial CT imaging

56
Q

What should patients who are treated conservatively also receive?

A

prophylactic vaccinations (Strep. pneumoniae, meningococcus, H. influenzae)

57
Q

What management should a patient with splenic rupture receive if there is evidence of active extravasation of the contrast during the arterial phase of the CT scan?

A

patient should undergo embolisation (if locally available) or laparotomy with splenectomy

58
Q

What treatment will patients with vascular abnormalities or higher-grade splenic injuries benefit from?

A

embolisation of the splenic vessels

59
Q

What is the aim of embolisation of the splenic vessels in splenic injury?

A

to decrease rate of laparotomy and splenectomy

60
Q

What is the problem when performing embolisation of splenic vessels for splenic rupture?

A

not always possible to see the bleeding point

also even when vessel embolised, still a small proportion who go on to require splenectomy

61
Q

What are 4 complications of treatment of splenic rupture (conservative treatment or embolisation)?

A
  1. Ongoing bleeding
  2. Splenic necrosis
  3. Splenic abscess or cyst formation
  4. Thrombocystosis
62
Q

What are overall mortality rates of patients presenting to hospital with traumatic splenic injury?

A

around 10%

63
Q

What is the thrombotic risk in splenic rupture related to?

A

increasing platelet count

64
Q

What are 2 examples of problems associated with thrombotic risk in splenic rupture?

A

DVT and portal vein thrombosis

65
Q

When should you manage the thrombotic risk in splenic rupture and how?

A
  • once rises above 1000 x 109 /L
  • aspirin should be started
66
Q

What can result in asplenic patients when they are infected with pneumococcus/meningococcus/ H. influenzae?

A

unable to mount normal immunological response - overwhelming post-splenectomy infection (OPSI) + sepsis

67
Q

When should you conclude that a patient has splenic rupture?

A

any patient with a history of collapse or trauma with left-sided abdominal pain - should be considered to have one until proven otherwise

AIP: Abdominal pain (20 decks)

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