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A - MSRA Gastrointestinal [7] > [4] Splenic Infarct > Flashcards

[4] Splenic Infarct Flashcards

1
Q

What causes a splenic infarct?

A

Occlusion of the splenic artery, or one of its branches, resulting in tissue necrosis

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2
Q

What is the cause of a splenic infarct?

A

It is caused by many separate pathophysiological processes

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3
Q

What provides the blood supply to the spleen?

A

The splenic artery and the short gastric arteries

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4
Q

Where does the splenic artery come from?

A

Coeliac axis

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5
Q

Where do the short gastric arteries come from?

A

The left gastroepiploic artery

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6
Q

What is the result of the spleen being supplied with blood from multiple arteries?

A

Infarction is often not complete due to collateral circulation

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7
Q

Are splenic infarctions common?

A

No, they are rare events

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8
Q

Give an example of a condition that has a high incidence of splenic infarcts?

A

Chronic myelogenous leukaemia (72%)

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9
Q

Are splenic infarcts always symptomatic?

A

No

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10
Q

What are the most common causes of splenic infarcts?

A

Haemotological disease or thromboembolism

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11
Q

What is a more common cause of splenic embolism, haemotological disorders or embolic disorders?

A

Haemotological disorders

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12
Q

What haemotoloical disorders can cause splenic infarction?

A 
Leukaemia or lymphoma
Myelofibrosis
Sickle Cell Disease
Chronic Myeloid Leukaemia
Polycythaemia Rubra Vera
Hypercoaguable states
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13
Q

What embolic disorders can lead to splenic infarction?

A

Endocarditis
AF
Infected aneurysm grafts
Post-MI mural thrombus

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14
Q

What are some rarer causes of splenic infarction?

A

Vasculitis
Trauma
Collagen tissue defects
Surgery

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15
Q

What kinds of trauma can cause splenic infarction?

A

Blunt trauma, or torsion of a ‘wandering’ splenic artery

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16
Q

What surgeries can cause splenic infarction?

A

Pancreatectomy

Liver transplantation

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17
Q

How does haematological disease cause splenic infarction?

A

Through congestion of the splenic circulation by abnormal cells

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18
Q

What often confounds splenic infarction caused by haematological disease in conditions such as CML or myelofibrosis?

A

Anaemia and splenomegaly

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19
Q

How will symptomatic splenic infarct patients classically present?

A

Left upper quadrant abdominal pain, radiating to the left shoulder (Kehr’s sign)

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20
Q

What are the less common symptoms of splenic infarcts?

A

Fever

Nausea and vomiting

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21
Q

How can splenic infarcts be diagnosed if they are asymptomatic?

A

Purely by imaging or laparotomy/laparoscopy

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22
Q

What is commonly found on examination with splenic infarcts?

A

LUQ tenderness

Other signs may be present depending on any complications that may have developed

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23
Q

What are the differential diagnoses of splenic infarcts?

A

The most important differentials to consider for LUQ pain include;
Peptic ulcer disease
Pyelonephritis or ureteric colid
Left sided basal pneumonia

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24
Q

What is the gold standard investigation for suspected splenic infarction?

A

CT abdominal scan with IV contrast

25
Q

What routine bloods should be performed in suspected splenic infarction?

A

FBC
U&E
LFTs
Coagulation screen

26
Q

When are bloods particularly useful for the diagnosis of splenic infarction?

A

If a haemotological or thromboembnolic cause is suspected

27
Q

What may be found on bloods with splenic infarction?

A

WCC is high in around half of cases

Raised d-dimer levels may aid diagnosis

28
Q

How does a splenic infarction appear on CT scanning with contrast?

A

As a segmental wedge of hypoattenuated tissue, with the apex of the wedge pointing to the hilum of the spleen from the segmental branching of the splenic artery

29
Q

Why does CT scanning with contrast produce a hypoattenuated wedge on CT?

A

Because the IV contrast cannot reach the infarcted area

30
Q

What will be shown on CT with contrast if the splenic artery, rather than one of its segmental branches, is affected?

A

The entire spleen will be hypoattenuated

31
Q

How are most cases of splenic infarction followed up after treatment?

A

With repeat CT scanning

32
Q

What may be shown on repeat CT scanning with contrast following treatment for splenic infarction?

A

Either full resolution, fibrosis of the original infarct, or liquefaction of the affected region

33
Q

Are there any specific treatments for splenic infarcts?

A

No

34
Q

What is involved in the management of splenic infarct?

A

Regular monitoring, ensuring haemodynamic stability, with appropriate analgesia and IV hydration prescribed

35
Q

What do most cases of splenic infarct warrant in terms of management?

A

Suitable management of the underlying condition, in order to minimise future risk

36
Q

Why is it important to identify the cause of splenic infarction?

A

As it may require the involvement of a haematologist and an ECHO scan, as well as consideration for long-term anticoagulation

37
Q

Why should splenectomy be avoided following splenic infarction?

A

Due to risks of overwhelming post-splenectomy infection (OPSI) syndrome

38
Q

When might splenectomy be unavoidable in splenic infarction?

A

If complications develop, or symptoms persist

39
Q

How long should a splenectomy be delayed in young patients?

A

Most cases should be delayed until the patient >2 years old, ideally >10 years

40
Q

Why should most cases of splenic infarction be delayed until the patient is >2 years of age?

A

To ensure appropriate immune response can be developed post-splenectomy

41
Q

What is recommended following extensive splenic infarctions?

A

Vaccinations against Pneumococcus, N. Mengitidis, and H. Influenza
Life-long antibiotic cover

42
Q

Why should patients with extensive splenic infarction receive vaccinations and life-long low dose antibiotics?

A

Due to the spleens role in protection against encapsulated bacteria, which cannot be performed as effectively in those with extensive infarctions

43
Q

What is the prognosis of splenic infarctions?

A

The prognosis of splenic infarctions varies enormously

44
Q

What does the prognosis of splenic infarction depend on?

A

The cause and severity of the disease

45
Q

Which patients have an extremely good prognosis following splenic infarction?

A

Patients with benign underlying disease, and asymptomatic infarcts

46
Q

Which patients have a poor outcome following splenic infarction?

A

Patients with splenic infaction secondary to haematological malignancy

47
Q

What are the most common complications of splenic infarction?

A

Splenic rupture
Splenic abscess
Pseudocyst formation

48
Q

What will most complications of splenic infarction warrant?

A

Splenectomy

49
Q

When will a splenic abscess be seen post-splenic infarct?

A

When the underlying cause was from a non-sterile embolus, such as infective endocarditis, or in rarer cases where the patient is immunocompromised

50
Q

How does a non-sterile embolus cause a splenic abscess?

A

The embolus seeds infection to the necrotic splenic tissue

51
Q

What is the problem with the diagnosis of a splenic abscess?

A

It can be difficult to differentiate from an uncomplicated infection

52
Q

How can a splenic abscess be diagnosed?

A

Based on CT scanning viewed by an experienced radiographer, especially when combined with raised inflammatory markers

53
Q

How will most cases of splenic abscess be confirmed?

A

Explorative surgery

54
Q

What is auto-splenectomy?

A

A rare condition that results in asplenism

55
Q

What causes auto-splenectomy?

A

Repeated splenic infarctions, resulting in the progressive fibrosis and atrophy of the spleen. When this continues over a prolonged period of time, it can lead to complete atrophy of the spleen

56
Q

When is repeated infarction particularly likely to cause auto-splenectomy?

A

During childhood

57
Q

What is the most common cause of auto-splenectomy?

A

Sickle-cell anaemia

58
Q

How does sickle-cell anaemia cause auto-splenectomy?

A

Repeated sickle-cell crises lead to recurrent occlusion of the splenic artery.

A - MSRA Gastrointestinal [7] (44 decks)

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