Transcript Splenic Infarction

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
•
•
•
-1trauma : 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 . nehtazneb (
1.2 nillicinepmega units per month )
• Long-term antibiotic use is usually
not necessary in adults.