splenic infarct

Question 1

what is a splenic infarct?

Answer 1

infarction caused by occlusion of the splenic artery or one of its branches, resulting in tissue necrosis

rare events

Question 2

why is a splenic infarct usually not complete?

Answer 2

spleen is supplied by the splenic artery (from the coeliac axis) and the short gastric arteries (from the left gastroepiploic artery) infarction is often not complete due to collateral circulation

Question 3

what are the most common causes of a splenic infarct?

Answer 3

• haematological disease, through congestion of splenic circulation by abnormal cells , made worse in conditions by anaemia and splenomegaly. Such disease includes lymphoma, polycythaemia rubra vera, hyper coagulable states.
• embolic disorders e.g endocarditis, AF, fibrillation, infected aneurysm grafts, or post MI mural thrombus
• thromboembolism
• vasculitis
• trauma e.g blunt or torsion
• collagen tissue disease
• surgery e.g pancreatectomy or liver transplant

Question 4

what are the clinical features of a splenic infarct?

Answer 4

• LUQ abdo pain that may radiate to left shoulder
• fever
• nausea and vomiting
• pleurites chest pain

can be asymptomatic and diagnosed purely by imaging or explorative surgery

on examination

• LUQ tenderness

Question 5

what are the differentials for LUQ pain?

Answer 5

• peptic ulcer disease
• pyelonephritis
• ureteric colic
• left sided basal pneumonia

Question 6

what investigations are done into splenic infarcts?

Answer 6

• CT abdo scan with IV contrast. Necrotic area won’t be visible on CT scan
• routine bloods including FBC, U&E, LFTs and coagulation screen
• high WCC usually seen and raised d dimer levels may help diagnosis

Question 7

what is the long term management for a splenic infarct?

Answer 7

may need IV hydration and analgesia on presentation if acute

identify underlying cause and manage

avoid splenectomy to avoid risk of overwhelming post splenectomy infection (OPSI)

if symptoms persist may be unavoidable

due to spleens role in protection against encapsulated bacteria, vaccinate against s pneumoniae, N mengitidis, H influenza in extensive splenic infarcts.

also give low dose antibiotic cover, ideally penicillin V due to inability to clear encapsulated bacteria without spleen

Question 8

how can the cause of an infarction be identified?

Answer 8

investigations

haematologist help and an ECHO

consider long term anticoagulation

Question 9

what is a splenic abscess?

Answer 9

a complication of splenic infarction when underlying cause was a non sterile embolus e.g infective endocarditis

embolus seeds infection into necrotic splenic tissue. Can be hard to differentiate from a uncomplicated infarction. Can base diagnosis on ct scan viewed by experienced radiologist, especially when combined with raised inflammatory markers

most cases only confirmed with explorative surgery

Question 10

what is an auto splenectomy?

Answer 10

a rare condition that results in asplenism

repeated splenic infarctions results in progressive fibrosis and atrophy of spleen

this can lead to complete atrophy of the spleen, called autosplenectomy

most common cause is sickle cell anaemia, with recurrent sickle cell crisis leading to recurrent occlusion of the splenic atrophy. if this keeps happening through childhood, can get asplenism but adulthood