Splenic abscess: Difference between revisions

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{{CMG}}; {{AE}}{{VSKP}}
{{CMG}}; {{AE}}{{VSKP}}


{{SK}}Abscess of spleen
{{SK}}Abscess of spleen<br>
 
'''To return to abscess main page click [[Abscess|here]]'''
==Overview==
==Overview==
Splenic abscess is an uncommon and lifethreatening condition. Clinical presentation, etiological factors, natural history, treatment and prognosis depends on whether the abscess was solitary or multiple.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref> It is always fatal if left untreated. Most commonly associated with [[Immunodeficiency|immunodeficient]] patients especially, [[Hematological|hematological disorders]] such as [[leukemia]], [[sickle cell disease]] etc.
[[Splenic]] [[abscess]] is an uncommon and life-threatening condition. Clinical presentation, etiological factors, natural history, treatment and prognosis depends on whether the abscess was solitary or multiple.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref> It is always fatal if left untreated. Most commonly associated with [[Immunodeficiency|immunodeficient]] patients especially and [[Hematological|hematological disorders]] such as [[leukemia]] and [[sickle cell disease]]. Diagnostic [[needle]] [[aspiration]] is very important in the management with [[antibiotics]] as [[blood]] culture may not be the best correlate as [[abscess]] culture. [[Antibiotic]] of choice depends on the [[organism]] but aggressive and early surgical intervention of [[splenic]] [[abscess]] should be encouraged especially when the risk factors are present. High suspicion of [[splenic]] [[abscess]] with history of risk factors, broad-spectrum empirical antibiotic therapy should be initiated.<ref name="pmid14139921">{{cite journal| author=ZATZKIN HR, DRAZAN AD, IRWIN GA| title=ROENTGENOGRAPHIC DIAGNOSIS OF SPLENIC ABSCESS. | journal=Am J Roentgenol Radium Ther Nucl Med | year= 1964 | volume= 91 | issue=  | pages= 896-9 | pmid=14139921 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14139921  }} </ref>


==Definition==
==Definition==
Splenic abscess is defined as any infectious [[suppurative]] process involving identifiable macroscopic filling defects either in the [[Parenchyma|parenchym]]<nowiki/>a of the [[spleen]] or in the subcapsular space.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref>
[[Splenic]] abscess is defined as any [[infectious]] [[suppurative]] process involving identifiable [[macroscopic]] filling defects either in the [[Parenchyma|parenchym]]<nowiki/>a of the [[spleen]] or in the sub-capsular space.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref>
==Historical Perspective==
==Historical Perspective==
* Since the times of Hippocrates, splenic abscess has been reported several times and he described the natural history and prognosis of splenic abscess.<ref name="pmid17865957">{{cite journal| author=Billings AE| title=ABSCESS OF THE SPLEEN. | journal=Ann Surg | year= 1928 | volume= 88 | issue= 3 | pages= 416-28 | pmid=17865957 | doi= | pmc=1398901 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17865957  }} </ref>
* Since the times of Hippocrates, [[splenic]] [[abscess]] has been reported several times and he described the natural history and prognosis of splenic abscess.<ref name="pmid17865957">{{cite journal| author=Billings AE| title=ABSCESS OF THE SPLEEN. | journal=Ann Surg | year= 1928 | volume= 88 | issue= 3 | pages= 416-28 | pmid=17865957 | doi= | pmc=1398901 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17865957  }} </ref>
* In the early days of 20th century, splenic abscess most commonly caused by typhoid and then followed by malaria.<ref name="pmid17863403">{{cite journal| author=Elting AW| title=ABSCESS OF THE SPLEEN. | journal=Ann Surg | year= 1915 | volume= 62 | issue= 2 | pages= 182-92 | pmid=17863403 | doi= | pmc=1406707 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17863403  }} </ref>
* In the early days of 20th century, splenic abscess most commonly caused by [[typhoid]] and then followed by [[malaria]].<ref name="pmid17863403">{{cite journal| author=Elting AW| title=ABSCESS OF THE SPLEEN. | journal=Ann Surg | year= 1915 | volume= 62 | issue= 2 | pages= 182-92 | pmid=17863403 | doi= | pmc=1406707 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17863403  }} </ref>
* Ooi et al. described significant etiological differences such increase in the percentage of [[abscess]] cases due to [[Anaerobic|anaerobics]] as compared to [[aerobics]] (7 vs 18-28%), [[fungi]] (1 vs 18-41%) as well as [[Mycobacterium tuberculosis|Mycobacterium tuberculosi]]<nowiki/>s (0.8 vs. 14%) in the second half of 20th century.<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
* Ooi et al described significant etiological differences such increase in the percentage of [[abscess]] cases due to [[Anaerobic|anaerobics]] as compared to [[aerobics]] (7 vs 18-28%), [[fungi]] (1 vs 18-41%) as well as [[Mycobacterium tuberculosis|mycobacterium tuberculosi]]<nowiki/>s (0.8 vs. 14%) in the second half of 20th century.<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>


==Classification==
==Classification==
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Splenic abscess is classified traditionally by ''Chun and colleagues'' based on the predisposing causes as follows:<ref name="pmid6986009">{{cite journal| author=Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R et al.| title=Splenic abscess. | journal=Medicine (Baltimore) | year= 1980 | volume= 59 | issue= 1 | pages= 50-65 | pmid=6986009 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6986009  }} </ref><ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref><ref name="pmid9403539">{{cite journal| author=Phillips GS, Radosevich MD, Lipsett PA| title=Splenic abscess: another look at an old disease. | journal=Arch Surg | year= 1997 | volume= 132 | issue= 12 | pages= 1331-5; discussion 1335-6 | pmid=9403539 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9403539  }} </ref>
[[Splenic]] [[Abscesses|abscess]] is classified traditionally by ''Chun and colleagues'' based on the predisposing causes as follows:<ref name="pmid6986009">{{cite journal| author=Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R et al.| title=Splenic abscess. | journal=Medicine (Baltimore) | year= 1980 | volume= 59 | issue= 1 | pages= 50-65 | pmid=6986009 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6986009  }} </ref><ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref><ref name="pmid9403539">{{cite journal| author=Phillips GS, Radosevich MD, Lipsett PA| title=Splenic abscess: another look at an old disease. | journal=Arch Surg | year= 1997 | volume= 132 | issue= 12 | pages= 1331-5; discussion 1335-6 | pmid=9403539 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9403539  }} </ref>
* '''Hematogenous or Metastatic infection:''' Seen in [[endocarditis]]
* '''Hematogenous or Metastatic infection:''' Seen in [[endocarditis]]
* '''Embolic phenomenon:''' splenic abscess developed as consequence of cellular [[embolism]] in [[hemoglobinopathies]] such as [[Sickle-cell disease|sickle cell disease]]
* '''Embolic phenomenon:''' splenic abscess developed as consequence of cellular [[embolism]] in [[hemoglobinopathies]] such as [[Sickle-cell disease|sickle cell disease]]
* '''Contagious infection:''' Splenic abscesses can develop through continuity of infection from primary sources which are anatomically close (e.g. [[Subphrenic abscess|subphrenic abscesses]])
* '''Contagious infection:''' Splenic abscesses can develop through continuity of [[infection]] from primary sources which are [[Anatomical|anatomically]] close (e.g. [[Subphrenic abscess|subphrenic abscesses]])
* '''Splenic trauma:''' secondary infections may developed due to splenic trauma
* '''Splenic trauma:''' secondary [[infections]] may developed due to [[splenic]] [[trauma]].
* '''Depressed immune defenses:''' [[chemotherapy]]-induced abscesses developed particularily in [[Leukemia|leukemias]]
* '''Depressed immune defenses:''' [[chemotherapy]]-induced [[abscesses]] developed particularly in [[Leukemia|leukemias]]
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Classification of splenic abscesses based on the etiological factors is as follows:<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
Classification of [[splenic]] [[abscesses]] based on the etiological factors is as follows:<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
* Mono-microbial [[abscess]]
* Mono-microbial [[abscess]]
* Poly-microbial [[abscess]] (~10-15%)
* Poly-microbial [[abscess]] (~10-15%)
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Lawhorne and Zuidema classified splenic abscees based on pathological findings as follows:<ref name="pmid1273753">{{cite journal| author=Lawhorne TW, Zuidema GD| title=Splenic abscess. | journal=Surgery | year= 1976 | volume= 79 | issue= 6 | pages= 686-9 | pmid=1273753 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1273753  }} </ref>
Lawhorne and Zuidema classified splenic abscees based on pathological findings as follows:<ref name="pmid1273753">{{cite journal| author=Lawhorne TW, Zuidema GD| title=Splenic abscess. | journal=Surgery | year= 1976 | volume= 79 | issue= 6 | pages= 686-9 | pmid=1273753 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1273753  }} </ref>
* Unilocular abscess
* Unilocular abscess
* Bilocular abscess
* Bilocular [[abscess]]
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!Hematogenous Dissemination
!Hematogenous Dissemination
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* Hematogenous Dissemination or arterial dissemination is the most common mode of infection that results in splenic abscess.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* Hematogenous dissemination or arterial dissemination is the most common mode of [[infection]] that results in [[splenic]] [[abscess]].<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* It is a metastatic infection through hematologic seeding from distant infections such as [[infective endocarditis]], purulent teeth-related infections and [[urinary tract infections]]
* It is a [[metastatic]] [[infection]] through [[hematologic]] seeding from distant infections such as [[infective endocarditis]], purulent teeth-related infections and [[urinary tract infections]]
* Most common organism involved is [[Staphylococcus aureus|Staphylococcs aureus]]
* Most common [[organism]] involved is [[Staphylococcus aureus|staphylococcs aureus]]
* Often results in multiple [[abscesses]]
* Often results in multiple [[abscesses]]
'''Sources of pathogen'''<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
* Intra-abdominal sepsis especially after bowel surgery
* Chest infection
* [[Osteomyelitis]]
* Infected vascular access sites
* Infected [[Ventriculoperitoneal shunt|ventriculoperitoneal shunts]]
* Skin lesions
* Tooth extraction
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!Secondary infection of splenic infarction
!Secondary infection of splenic infarction
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* [[Embolic]] or [[thrombotic]] non-infectious events due to red cell abnormalities such as [[hemolytic]] and [[Sickle-cell disease|sickle cell anemia]] causes [[ischemia]] followed by [[superinfection]] of [[emboli]] which tend to obstruct free blood flow and oxygen delivery to the spleen on the microscopic level.
* [[Embolic]] or [[thrombotic]] non-infectious events due to [[Red blood cell|red cell]] abnormalities such as [[hemolytic]] and [[Sickle-cell disease|sickle cell anemia]] causes [[ischemia]] followed by [[superinfection]] of [[emboli]] which tend to obstruct free [[blood]] flow and oxygen delivery to the [[spleen]] on the [[microscopic]] level.
'''Sources of emboli:'''<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
* [[Cardiac arrhythmia]]
* [[Bacterial endocarditis]]
* [[Embolization|Lipid embolization]] with [[Weber-Christian disease]]
* Iatrogenic splenic artery [[embolization]] for the treatment of [[autoimmune hemolytic anemia]]
'''Source of thrombus formation in splenic artery'''
* [[Sickle cell disease]]
* [[Hemoglobinopathies]] such as [[thalassemia]]
* Unexplained [[thrombocytosis]]
* After [[pancreatitis]]
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!Contiguous spread of bacteria
!Contiguous spread of bacteria
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* It is a mode of infection spread to the spleen from anatomically neighboring structures such as stomach or large bowel [[perforation]], infected [[pancreatic cyst]], perisplenic or [[Subphrenic abscess|subpleuric abscess]].
* It is a mode of [[Infection (disambiguation)|infection]] spread to the spleen from anatomically neighboring structures such as [[stomach]] or large bowel [[perforation]], infected [[pancreatic cyst]], perisplenic or [[Subphrenic abscess|subpleuric abscess]].
* Can cause either solitory or multiple [[abscesses]]<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref>
* Can cause either solitory or multiple [[abscesses]]<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref>
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! Trauma
! Trauma or Surgery
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* secondary infections may developed due to splenic trauma during any intra-abdominal procedures.<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
* [[Secondary]] [[infections]] may developed due to [[splenic]] [[trauma]] during any intra-abdominal procedures.<ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
'''Iatrogenic causes of splenic truma'''
*[[Trauma]] leads to [[hematoma]] formation.
* [[Bariatric surgery|Gastric surgery]]
*In case of penetrating trauma to the [[spleen]] or intraabdominal surgery, direct inoculation of the spleen with pathogens may form a septic focus which, left untreated, may lead to formation of an abscess.
* [[Pancreatectomy|Distal pancreatectomy]]
* [[Endoscopic retrograde cholangiopancreatography|Endoscopic retrograde cholangio pancreatography]]
* [[Nephrostomy|Percutaneous nephrostomy]]
* Therapeutic splenic arterial [[embolization]] for [[autoimmune hemolytic anemia]] and [[hypersplenism]]
* During splenic conservative techniques such as exploration only, mesh splenorraphy
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! Immunodeficiency
! Immunodeficiency
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* It is major factor involved in the course of splenic abscess especially if the causative organism is [[fungi]] or any other atypical organism.
* It is major factor involved in the course of [[splenic]] [[abscess]] especially if the causative organism is [[fungi]] or any other atypical organism.
'''Common immunodeficient states associate with splenic absecess'''
* [[Systemic lupus erythematosus]]
* [[Felty's syndrome|Felty’s syndrome]]
* [[End-stage renal disease]]
* [[Infectious mononucleosis]]
* Cancers like [[multiple myeloma]] and [[leukemia]]
* [[chemotherapy]]-induced abscesses developed particularily in [[leukemias]]
* [[Immunosuppressive therapy]] with [[renal transplantation]]
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{{Family tree/start}}
 
{{Family tree | | | | | A01 | | | | A02 | | | | A03 | | | | A04 | | | | | | A05 | | | | |A01='''Hematogenous'''|A02='''Splenic infarction'''|A03='''Immunodeficiency'''|A04='''Splenic Trauma'''|A05='''Contiguous'''}}
=== Gross Findings ===
{{Family tree | | | | | |!| | | | | |`|-|-|v|-|-|'| |,|-|-|-|^|-|-|-|.| | | |!| | | | | |}}
'''Solitary splenic abscess'''
{{Family tree | | | | | B01 | | | | | | | B02 | | | B03 | | | | | | B04 | | B05 | | | | |B01='''Septic focus'''|B02='''Superinfection'''|B03='''Hematoma'''|B04='''Bacteremia'''|B05='''Direct extension'''}}
* Enlarged [[spleen]] with due to large [[solitary]] [[abscesses]] with thick wall around the abscess to prevent dissemination is seen
{{Family tree | | | | | |!| | | | | | | | |!| | | | |`|-|-|-|v|-|-|-|'| | | |!| | | | | |}}
'''Multiple splenic abscess'''
{{Family tree | | | | | C01 | | | | | | | |!| | | | | | | | |!| | | | | | | |!| | | | | |C01='''Bacteremia'''}}
* At the time of [[autopsy]], [[spleen]] present as large and soft, and [[pus]] extruded organ from the cut surface.
{{Family tree | | | | | |`|-|-|-|-|-|-|-|-|^|-|-|-|-|v|-|-|-|^|-|-|-|-|-|-|-|'| | | | | |}}
 
{{Family tree | | | | | | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | |D01='''Splenic abscess'''}}
=== Microscopic Findings ===
{{Family tree/end}}
'''Solitary splenic abscess'''
* Microscopically the [[abscess]] consist of [[necrotic tissue]] with a [[fibrous]] wall surrounded by [[inflammatory]] [[cell]] [[Infiltration (medical)|infiltration]].
'''Multiple splenic abscess'''
* Multiple microscopically visible foci of [[infection]] riddled homogeneously throughout the [[spleen]]
* [[Abscesses]] are filled with [[polymorphonuclear leukocytes]] which were scattered throughout the [[parenchyma]], intermixed with other foci of microinfarction and [[coagulation necrosis]]
 
===Association===
[[Splenic]] [[abscess]] is commonly associate with:<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
* [[Liver disease|Paranchymal liver disease]]
* [[Pancreatitis]]
* [[Pleural effusion]]
* [[Renal cysts]]
* [[Ovarian cysts]]
* [[Lymphadenopathy|Abdominal lymphadenopathy]]


==Causes==
==Causes==
Spleenic abscess is caused mostly by monomicrobial but some times it can be caused by polymicrobial agents. [[Bacteria]] is more common than other microbial agents such as [[fungi]], [[protozoa]] which can cause splenic abscess in [[Immunocompromised|immunocompromised patients]].
Splenic abscess is caused mostly by monomicrobial but some times it can be caused by polymicrobial agents. [[Bacteria]] is more common than other microbial agents such as [[fungi]], [[protozoa]] which can cause [[splenic]] [[abscess]] in [[Immunocompromised|immunocompromised patients]].
=== Common causes ===
=== Common causes ===
Common causes of splenic abscess includes:<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref><br> Aerobes are the most predominant organisms causing splenic abscess in 50% of cases.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398 }} </ref><ref name="pmid8343056">{{cite journal| author=Ho HS, Wisner DH| title=Splenic abscess in the intensive care unit. | journal=Arch Surg | year= 1993 | volume= 128 | issue= 8 | pages= 842-6; discussion 846-8 | pmid=8343056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8343056 }} </ref>
The most common causative bacteria of the splenic abscess in 50% of the cases is the aerobic bacteria.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref><ref name="pmid8343056">{{cite journal| author=Ho HS, Wisner DH| title=Splenic abscess in the intensive care unit. | journal=Arch Surg | year= 1993 | volume= 128 | issue= 8 | pages= 842-6; discussion 846-8 | pmid=8343056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8343056 }} </ref>
 
Other common causes of splenic abscess includes:<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398 }} </ref>
 
{| border="1"
{| border="1"
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Aerobes}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Aerobes}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Anaerobes}}  
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Anaerobes}}  
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Fungal}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Fungal}}
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Parasite}}
|-
|-
|valign=top|
| valign="top" |
* [[Staphylococcus|Staphylococcus species]]
* [[Staphylococcus|Staphylococcus species]]
* [[Streptococcus|Streptococcal species]]
* [[Streptococcus|Streptococcal species]]
Line 130: Line 116:
* [[Enterococcus|Enterococcus species]]
* [[Enterococcus|Enterococcus species]]
* [[Mycobacterium]]
* [[Mycobacterium]]
|valign=top|
| valign="top" |
* [[Bacteroides]]
* [[Bacteroides]]
* [[Actinomyces]]  
* [[Actinomyces]]  
Line 136: Line 122:
* [[Clostridium]]
* [[Clostridium]]
* [[Fusobacterium]]
* [[Fusobacterium]]
|valign=top|
| valign="top" |
* [[Candida albicans]]
* [[Candida albicans]]
* [[Candida tropicalis]]  
* [[Candida tropicalis]]  
* [[Aspergillus]]
* [[Aspergillus]]
| valign="top" |
* [[Entamoeba histolytica]]
|}
|}


=== '''Less common causes''' ===
=== '''Less common causes''' ===
{{columns-list|3|  
{{columns-list|  
*[[Aureobasidium pullulans]]
*[[Aureobasidium pullulans]]
*[[Bacillus cereus]]
*[[Bacillus cereus]]
Line 164: Line 152:


==Differentiating {{PAGENAME}} from Other Diseases==
==Differentiating {{PAGENAME}} from Other Diseases==
Splenic abscess should be differented from other causes of left upper quadrent pain:<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
Splenic [[abscess]] should be differented from other causes of left upper quadrent pain:<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
* [[Splenic cyst|Splenic cysts]]
* [[Splenic cyst|Splenic cysts]]
* [[Splenic infarct]]
* [[Splenic infarct]]
* [[Splenic hemangioma|Splenic hematomas]]
* [[Splenic hemangioma|Splenic hematomas]]
* Peri splenic abscess
* [[Subphrenic abscess]]
{| border="1"
|+
'''Difference between Solitary abscess and Multiple splenic abscesses'''
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Characteristic}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Solitary splenic abscess}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Multiple splenic abscesses}}
|-
!Presentation
|Delayed onset of presentation with history of trauma, [[sepsis]], or adjacent organ disease.
Common presentation is [[Fever|feve]]<nowiki/>r, abdominal pain, nausea and vomiting with signs of left
upper abdominal quadrant tenderness, [[splenomegaly]], [[left pleural effusion]], and [[leukocytosis]]
|Most commonly present with generalized [[sepsis]] because of an ineradicable septic focus remote from the [[spleen]]. Commonly associate with abscess in other organs such as lung and liver.
|-
!Caueses
|valign=top|
* [[Bacterial endocarditis]]
* [[Intravenous drug use|Intravenous drug abuse]]
* Iatrogenic operative trauma to the spleen
* Direct extension from an extrasplenic focus
* [[Mastoiditis]]
|
* [[Bacteroides]]
* [[Pseudomonas]]
* [[Serratia]]
* [[Enterobacter]]
* [[Klebsiella]]
* [[Escherichia coli]]
* [[Staphylococcus aureus]]
* [[Streptococcus viridans]]
* [[Candida|Candida infection]]
|-
!Pathological findings
|'''Gross findings:'''
* Enlarged spleen with due to large solitary abscesses with thick wall around the abscess to prevent dissemination is seen
'''Microscopic findings:'''
* Microscopically the abscess consist of [[necrotic tissue]] with a fibrous wall surrounded by [[inflammatory]] cell infiltration.
|'''Gross findings:'''
* At the time of [[autopsy]], spleen present as large and soft, and pus extruded organ from the cut surface.
'''Microscopic findings:'''
* Multiple microscopically visible foci of infection riddled homogeneously throughout the spleen
* Abscesses are filled with [[polymorphonuclear leukocytes]] which were scattered throughout the [[parenchyma]], intermixed with other foci of microinfarction and [[coagulation necrosis]]
|-
!Diagnosis
|
* Generally diagnosed clinically
|
* Usually appears small and diagnose at the time of autopsy.
|-
!Complications
|valign=top|
* [[Splenic rupture]]
* [[Peritonitis]]
* [[bacteraemia|Recurrent bacteraemia]]
* [[Intestinal obstruction]] due to local adhesisons
|
* [[Pneumonia]] and [[pulmonary abscess]]
* Uncontrolled nonsplenic abdominal [[suppuration]]
* [[Bacterial endocarditis]]
* [[Septicemia]]
* [[Immunosuppression]] with [[septicemia]]
* [[Meningoencephalitis]]
|-
!Treatment of choice
|Best initial treatment is '''percutaneous drainage'''. If recurrent or not responding to combination of anti microbial therapy and drainage, then most appropriate treatment is '''[[splenectomy]]'''.
|'''[[Splenectomy]]'''
|-
!Outcome
|Prognosis is good if early dignonsis and prompt treatment occurs.
|Most of the patient died of sepsis even though splenic infection had been eliminated
|}
 
{| border="1"
|+
'''Difference between Bacterial abscess and Fungal abscess of spleen'''
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Characteristic}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Bacterial Cause }} 
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Fungal Cause}}
|-
!Presentation
|Common presentation is [[fever]], abdominal pain, nausea and vomiting. Signs of [[sepsis]] is common bacterial cause.
|Similar presentation but signs of sepsis are rare
|-
!Risk factors
!
|Common risk factors for splenic abscess due to [[fungal]] infection:<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref>
* [[Chemotherapy]]
* Long term [[corticosteroid]] treatment
* [[Neutropenia]]
* Antibiotic therapy for over 3 weeks
* Colonization of digestive tract by [[fungi]]
|-
! Common causes
|
| Most common etiological include:
*[[Candida albicans]]
* [[Candida tropicalis]]
* [[Aspergillus fumigatus]]
|-
! Lab findings
|
|
* Elevated [[leukocytes]]
* ± Elevated [[Erythrocyte sedimentation rate|ESR]]
* Elevated [[alkaline phosphatase]] to 200-500 IU/L<ref name="pmid3518659">{{cite journal| author=Helton WS, Carrico CJ, Zaveruha PA, Schaller R| title=Diagnosis and treatment of splenic fungal abscesses in the immune-suppressed patient. | journal=Arch Surg | year= 1986 | volume= 121 | issue= 5 | pages= 580-6 | pmid=3518659 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3518659  }} </ref>
|-
!Treatment
|'''Splenectomy''' is the most appropriate treatment of choice despite high complication rate.
|
'''Medical therapy'''
* [[Amphotericin B]] for 6-24 weeks
'''Surgery'''
* No surgery is usually required as treatment with [[Amphotericin B]] is more efficacious than surgery<ref name="pmid3518659">{{cite journal| author=Helton WS, Carrico CJ, Zaveruha PA, Schaller R| title=Diagnosis and treatment of splenic fungal abscesses in the immune-suppressed patient. | journal=Arch Surg | year= 1986 | volume= 121 | issue= 5 | pages= 580-6 | pmid=3518659 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3518659  }} </ref>
* During percutaneous drainage [[amphotericin B]] is administered directly into the abscess cavity<ref name="pmid6385895">{{cite journal| author=Johnson JD, Raff MJ| title=Fungal splenic abscess. | journal=Arch Intern Med | year= 1984 | volume= 144 | issue= 10 | pages= 1987-93 | pmid=6385895 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6385895  }} </ref>
|}


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Incidence===
===Incidence===
Indceidence of spelenic abscess varies between 0.1% to 0.7% based on population based autopsy studies.<ref name="pmid6986009">{{cite journal| author=Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R et al.| title=Splenic abscess. | journal=Medicine (Baltimore) | year= 1980 | volume= 59 | issue= 1 | pages= 50-65 | pmid=6986009 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6986009  }} </ref><ref name="pmid3892934">{{cite journal| author=Gadacz TR| title=Splenic abscess. | journal=World J Surg | year= 1985 | volume= 9 | issue= 3 | pages= 410-5 | pmid=3892934 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3892934  }} </ref> Incidence of splenic abscess due to hematogenous spread is gradually declining due to increased antibiotic use, but incidence due to fungal infection is increasing due to aggressive chemotherapeutic methods.<ref name="pmid3518659">{{cite journal| author=Helton WS, Carrico CJ, Zaveruha PA, Schaller R| title=Diagnosis and treatment of splenic fungal abscesses in the immune-suppressed patient. | journal=Arch Surg | year= 1986 | volume= 121 | issue= 5 | pages= 580-6 | pmid=3518659 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3518659  }} </ref><ref name="pmid6503858">{{cite journal| author=Linker CA, DeGregorio MW, Ries CA| title=Computerized tomography in the diagnosis of systemic candidiasis in patients with acute leukemia. | journal=Med Pediatr Oncol | year= 1984 | volume= 12 | issue= 6 | pages= 380-5 | pmid=6503858 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6503858  }} </ref>
Incidence of [[splenic]] [[abscess]] varies between 0.1% to 0.7% based on population based [[autopsy]] studies.<ref name="pmid6986009">{{cite journal| author=Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R et al.| title=Splenic abscess. | journal=Medicine (Baltimore) | year= 1980 | volume= 59 | issue= 1 | pages= 50-65 | pmid=6986009 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6986009  }} </ref><ref name="pmid3892934">{{cite journal| author=Gadacz TR| title=Splenic abscess. | journal=World J Surg | year= 1985 | volume= 9 | issue= 3 | pages= 410-5 | pmid=3892934 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3892934  }} </ref> Incidence of splenic abscess due to hematogenous spread is gradually declining due to increased [[antibiotic]] use, but incidence due to [[fungal]] [[infection]] is increasing due to aggressive [[chemotherapeutic]] methods.<ref name="pmid3518659">{{cite journal| author=Helton WS, Carrico CJ, Zaveruha PA, Schaller R| title=Diagnosis and treatment of splenic fungal abscesses in the immune-suppressed patient. | journal=Arch Surg | year= 1986 | volume= 121 | issue= 5 | pages= 580-6 | pmid=3518659 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3518659  }} </ref><ref name="pmid6503858">{{cite journal| author=Linker CA, DeGregorio MW, Ries CA| title=Computerized tomography in the diagnosis of systemic candidiasis in patients with acute leukemia. | journal=Med Pediatr Oncol | year= 1984 | volume= 12 | issue= 6 | pages= 380-5 | pmid=6503858 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6503858  }} </ref>
===Prevalence===
===Prevalence===
Prevalence of splenic abscess is increasing gradually due to increased risk factors and increased imaging modalities that can diagnose more accurately.<ref name="pmid15287600">{{cite journal| author=Farres H, Felsher J, Banbury M, Brody F| title=Management of splenic abscess in a critically ill patient. | journal=Surg Laparosc Endosc Percutan Tech | year= 2004 | volume= 14 | issue= 2 | pages= 49-52 | pmid=15287600 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15287600  }} </ref>  
Prevalence of [[splenic]] [[abscess]] is increasing gradually due to increased risk factors and increased imaging modalities that can diagnose more accurately.<ref name="pmid15287600">{{cite journal| author=Farres H, Felsher J, Banbury M, Brody F| title=Management of splenic abscess in a critically ill patient. | journal=Surg Laparosc Endosc Percutan Tech | year= 2004 | volume= 14 | issue= 2 | pages= 49-52 | pmid=15287600 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15287600  }} </ref>  
===Case Fatality Rate===
===Case Fatality Rate===
Splenic abscesses are associate with increased morbidity and mortality. If left untreated, mortality is definite (100%).<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref> Mortality rate also varies with treatment of choice such as splenectomy, percutaneous drainage, anti microbial therapy carries 8%, 29%, 20% of mortality rate respectively.<ref name="pmid16489650">{{cite journal| author=Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC et al.| title=Clinical characteristics and prognostic factors of splenic abscess: a review of 67 cases in a single medical center of Taiwan. | journal=World J Gastroenterol | year= 2006 | volume= 12 | issue= 3 | pages= 460-4 | pmid=16489650 | doi= | pmc=4066069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16489650  }} </ref>
[[Splenic]] [[abscesses]] are associate with increased morbidity and mortality. If left untreated, mortality is definite (100%).<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref> Mortality rate also varies with treatment of choice such as [[splenectomy]], [[percutaneous]] drainage, [[Antimicrobial|anti microbial]] therapy carries 8%, 29%, 20% of mortality rate respectively.<ref name="pmid16489650">{{cite journal| author=Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC et al.| title=Clinical characteristics and prognostic factors of splenic abscess: a review of 67 cases in a single medical center of Taiwan. | journal=World J Gastroenterol | year= 2006 | volume= 12 | issue= 3 | pages= 460-4 | pmid=16489650 | doi= | pmc=4066069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16489650  }} </ref>


===Age===
===Age===
''Nelken and coworkers'' described that splenic abscess shows bimodal distribution in age of the patients, with peak incidence seen in thirties and sixties.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref> First peak of age group is people < 40 years of age who are immunosuppressed or intravenous drug abusers, who commonly present multilocular abscesses. Second peak of age group patients > 70 years with diabetes or nonendocardic septic focus and commonly develop a unilocular abscess.
Splenic abscess shows bimodal distribution in age of the patients, with peak incidence seen in thirties and sixties.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref> First peak of age group is people < 40 years of age who are [[immunosuppressed]] or [[intravenous]] [[drug]] abusers, who commonly present multilocular abscesses. Second peak of age group patients > 70 years with [[diabetes]] or nonendocardic septic focus and commonly develop a unilocular abscess.


===Gender===
===Gender===
Splenic abscess is more predominant in male compared to female (~2 folds).<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref><ref name="pmid6986009">{{cite journal| author=Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R et al.| title=Splenic abscess. | journal=Medicine (Baltimore) | year= 1980 | volume= 59 | issue= 1 | pages= 50-65 | pmid=6986009 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6986009  }} </ref><ref name="pmid6834894">{{cite journal| author=Linos DA, Nagorney DM, McIlrath DC| title=Splenic abscess--the importance of early diagnosis. | journal=Mayo Clin Proc | year= 1983 | volume= 58 | issue= 4 | pages= 261-4 | pmid=6834894 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6834894  }} </ref>
[[Splenic]] [[abscess]] is more predominant in male compared to female (~2 folds).<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref><ref name="pmid6986009">{{cite journal| author=Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N, Daffner R et al.| title=Splenic abscess. | journal=Medicine (Baltimore) | year= 1980 | volume= 59 | issue= 1 | pages= 50-65 | pmid=6986009 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6986009  }} </ref><ref name="pmid6834894">{{cite journal| author=Linos DA, Nagorney DM, McIlrath DC| title=Splenic abscess--the importance of early diagnosis. | journal=Mayo Clin Proc | year= 1983 | volume= 58 | issue= 4 | pages= 261-4 | pmid=6834894 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6834894  }} </ref>


===Developing Countries===
===Developing Countries===
In Africa, splenic abscess is more common in hemoglobinopathies such as sickle cell disease [heterozygous (SA or SC) > homogygous(SS)].<ref name="pmid4744723">{{cite journal| author=Kolawole TM, Bohrer SP| title=Splenic abscess and the gene for hemoglobin S. | journal=Am J Roentgenol Radium Ther Nucl Med | year= 1973 | volume= 119 | issue= 1 | pages= 175-89 | pmid=4744723 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4744723  }} </ref>
In Africa, [[splenic]] abscess is common due to prevalence of [[hemoglobinopathies]] such as [[sickle cell disease]], which is a common risk factor for this disease.<ref name="pmid4744723">{{cite journal| author=Kolawole TM, Bohrer SP| title=Splenic abscess and the gene for hemoglobin S. | journal=Am J Roentgenol Radium Ther Nucl Med | year= 1973 | volume= 119 | issue= 1 | pages= 175-89 | pmid=4744723 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4744723  }} </ref>


==Risk Factors==
==Risk Factors==
Spleen abscess often co-exists with several risk factors, but the major one is the patient’s immunodeficiency. Common risk factors of splenic abscess include:<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
Spleen abscess often co-exists with several risk factors, but the major one is the patient’s [[immunodeficiency]]. Common risk factors of [[splenic]] abscess include:<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
{| border="1"
{| border="1"
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Infectious risk factors}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Infectious risk factors}}
Line 335: Line 209:
==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
===Natural History===
===Natural History===
Splenic abscess is a rare cause of abdominal abscesss, but life-threatening. Because of it's rarity, splenic abscess usually diagnosed at the late stages or after the onset of complications.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref> Early diagnosis, prompt treatment can prevent complications.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref> Mortality rate is very high if left untreated.
Splenic abscess is a rare cause of [[abdominal]] [[abscesses]], but life-threatening. Because of it's rarity, splenic abscess usually diagnosed at the late stages or after the onset of complications.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref> Solitory abscess present with delayed onset of presentation with history of [[trauma]], [[sepsis]], or adjacent organ disease with [[Fever|feve]]<nowiki/>r, [[abdominal pain]], [[nausea and vomiting]] where as multiple [[splenic]] [[abscess]] most commonly present with generalized [[sepsis]] because of an ineradicable [[septic]] focus remote from the [[spleen]]. Early diagnosis, prompt treatment can prevent complications.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref> Mortality rate is very high if left untreated.
 
===Complications===
===Complications===
{| border="1"
{| border="1"
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* [[Splenic rupture]] and [[peritonitis]]<ref name="pmid12107789">{{cite journal| author=Balasubramanian SP, Mojjada PR, Bose SM| title=Ruptured staphylococcal splenic abscess resulting in peritonitis: report of a case. | journal=Surg Today | year= 2002 | volume= 32 | issue= 6 | pages= 566-7 | pmid=12107789 | doi=10.1007/s005950200100 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12107789  }} </ref>
* [[Splenic rupture]] and [[peritonitis]]<ref name="pmid12107789">{{cite journal| author=Balasubramanian SP, Mojjada PR, Bose SM| title=Ruptured staphylococcal splenic abscess resulting in peritonitis: report of a case. | journal=Surg Today | year= 2002 | volume= 32 | issue= 6 | pages= 566-7 | pmid=12107789 | doi=10.1007/s005950200100 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12107789  }} </ref>
|valign=top|
|valign=top|
* Bacterial sepsis or [[septicemia]]
* [[Bacterial]] [[sepsis]] or [[septicemia]]
* Respiratory complications such as [[Pneumonia|post operative pneumonia]]<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
* [[Respiratory]] complications such as [[Pneumonia|post operative pneumonia]]<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
* [[Fistula]] formation with [[abscess]]<ref name="pmid15855993">{{cite journal| author=Nikolaidis N, Giouleme O, Gkisakis D, Grammatikos N| title=Posttraumatic splenic abscess with gastrosplenic fistula. | journal=Gastrointest Endosc | year= 2005 | volume= 61 | issue= 6 | pages= 771-2 | pmid=15855993 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15855993  }} </ref>
* [[Fistula]] formation with [[abscess]]<ref name="pmid15855993">{{cite journal| author=Nikolaidis N, Giouleme O, Gkisakis D, Grammatikos N| title=Posttraumatic splenic abscess with gastrosplenic fistula. | journal=Gastrointest Endosc | year= 2005 | volume= 61 | issue= 6 | pages= 771-2 | pmid=15855993 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15855993  }} </ref>
|valign=top|
|valign=top|
* Wound infection
* [[Wound]] [[infection]]
* [[Paralytic ileus]]
* [[Paralytic ileus]]
* [[Deep vein thrombosis]]
* [[Deep vein thrombosis]]
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===Prognosis===
===Prognosis===
Prognosis of splenic abscess depends on the time of diagnosis and treatment. Delay in the management can lead to [[splenic rupture]] followed by spilling into [[peritoneal cavity]] or an adjacent organ which can lead to [[septicemia]] and death in severe cases.
Prognosis of splenic abscess depends on the time of diagnosis and treatment. Delay in the management can lead to [[splenic rupture]] followed by spilling into [[peritoneal cavity]] or an adjacent organ which can lead to [[septicemia]] and death in severe cases.


==Association==
Splenic abscess is commonly associate with:<ref name="pmid23204694">{{cite journal| author=Sreekar H, Saraf V, Pangi AC, Sreeharsha H, Reddy R, Kamat G| title=A retrospective study of 75 cases of splenic abscess. | journal=Indian J Surg | year= 2011 | volume= 73 | issue= 6 | pages= 398-402 | pmid=23204694 | doi=10.1007/s12262-011-0370-y | pmc=3236272 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23204694  }} </ref>
* [[Liver disease|Paranchymal liver disease]]
* [[Pancreatitis]]
* [[Pleural effusion]]
* [[Renal cysts]]
* [[Ovarian cysts]]
* [[Lymphadenopathy|Abdominal lymphadenopathy]]
==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
Splenic abscess commonly present with a triad of symptoms include [[fever]], [[Nausea and vomiting|nausea, vomiting]] and [[abdominal pain]] along with palpable [[spleen]] on examination. Early diagnosis with imaging studies and prompt drainage is required to reduce morbidity and mortality. Presence of [[fever]], left upper abdominal pain, [[leukocytosis]] and radiologic evidence shows pathology in the left [[chest X-ray]] especially in [[immunocompromised]] patients are the indications for high suspicion of [[splenic]] [[abscess]].


Splenic abscess commonly present with a triad of symptoms include [[fever]], [[Nausea and vomiting|nausea, vomiting]] and [[abdominal pain]] along with palpable spleen on examination. Early diagnosis with imaging studies and prompt drainage is required to reduce morbidity and mortality. Presence of [[fever]], left upper abdominal pain, [[leukocytosis]] and radiologic evidence shows pathology in the left [[chest X-ray]] especially in [[immunocompromised]] patients are the indications for high suspicion of splenic abscess.
===History and Symptoms===
===History and Symptoms===
Common symptoms of splenic abscess include:<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref><ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
Common symptoms of splenic abscess include:<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref><ref name="pmid9240961">{{cite journal| author=Ooi LL, Leong SS| title=Splenic abscesses from 1987 to 1995. | journal=Am J Surg | year= 1997 | volume= 174 | issue= 1 | pages= 87-93 | pmid=9240961 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9240961  }} </ref>
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* [[Left upper quadrant abdominal pain|Abdominal pain localized in the left upper quadrant]] or mesogastrium
* [[Left upper quadrant abdominal pain|Abdominal pain localized in the left upper quadrant]] or mesogastrium
* [[Nausea and vomiting]]
* [[Nausea and vomiting]]
* Constitutional symptoms such as [[fatigue]], loss of body weight, sweat and chills
* Constitutional symptoms such as [[fatigue]], loss of body weight, [[Sweat|sweating]] and chills
Other symptoms include:<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
Other symptoms include:<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* [[Referred pain]] in the left shoulder
* [[Referred pain]] in the left shoulder
* [[Confusion]]
* [[Confusion]]
* Pain in the lower half of the chest
* [[Pain]] in the left lower hemithorax
* [[Cough]]
* [[Cough]]


===Physical Examination Findings===
===Physical Examination Findings===
===Appearance===
===Appearance===
Patient with splenic abscess appear ill appearing and [[diaphoretic]]
Patient with [[splenic]] [[abscess]] appear ill appearing and [[diaphoretic]]
===Vital signs===
===Vital signs===
* [[Fever|High-grade fever]]
* [[Fever|High-grade fever]]
* [[Hyperthermia]]
* [[Tachycardia]]
* [[Tachycardia]]
If patient present with sepsis:  
If patient present with [[sepsis]]:  
* [[Hypotension]]
* [[Hypotension]]
* [[Tachycardia]]
* [[Tachycardia]]
* Increased [[capillary refill time]]
* Increased [[capillary refill time]]
Signs of sepsis indicate that splenic abscess is most likely due to bacterial cause than fungal source.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref>
Signs of sepsis indicate that splenic abscess is most likely due to [[bacterial]] cause than [[fungal]] source.<ref name="pmid3300398">{{cite journal| author=Nelken N, Ignatius J, Skinner M, Christensen N| title=Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. | journal=Am J Surg | year= 1987 | volume= 154 | issue= 1 | pages= 27-34 | pmid=3300398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3300398  }} </ref>


===Heart===
===Heart===
* New onset [[Heart murmur|murmur]] may be present
* New onset [[Heart murmur|murmur]] may be present
===Lungs===
===Lungs===
* Left sided pleural effusion may be present with signs of:
* Left sided [[pleural effusion]] may be present with signs of:
** Decreased [[breath sounds]] on left side
** Decreased [[breath sounds]] on left side
** Dullness to percussion on left side
** Dullness to [[percussion]] on left side
** Absent [[tactile fremitus]] on left side
** Absent [[tactile fremitus]] on left side
** [[Friction rub]] over the left chest
** [[Friction rub]] over the left chest
Line 408: Line 273:
'''Palpation'''
'''Palpation'''
* Tender [[splenomegaly]]
* Tender [[splenomegaly]]
* Palpable spleen or abdominal mass
* Palpable [[spleen]] or [[abdominal mass]]
'''Auscultation'''
'''Auscultation'''
* [[Friction rub]] over the spleen<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* [[Friction rub]] over the spleen<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
Line 414: Line 279:
===Laboratory Tests===
===Laboratory Tests===
===Blood Tests===
===Blood Tests===
Blood tests such [[leukocytosis]] are increased but not significant in the diagnosis of splenic abscess because these tests may not be appropriate in immunocompromised patients.
Blood tests such [[leukocytosis]] are increased but not significant in the diagnosis of [[splenic]] [[abscess]] because these tests may not be appropriate in immunocompromised patients.
* CBC with differential
* CBC with differential
* [[Erythrocyte Sedimentation Rate|Erythrocyte sedimentation rate]] ([[Erythrocyte sedimentation rate|ESR]])
* [[Erythrocyte Sedimentation Rate|Erythrocyte sedimentation rate]] ([[Erythrocyte sedimentation rate|ESR]])
* '''Microbiological tests:''' In solitary abscesses blood culture is not sensitive in the initial stages when as in multiple abscesses it is helpful in prompt diagnosis and early treatment.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>  
* '''Microbiological tests:''' In solitary abscesses blood culture is not sensitive in the initial stages when as in multiple abscesses it is helpful in prompt diagnosis and early treatment.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>  
** [[Gram staining|Gram stain]]
** [[Gram staining|Gram stain]]
** Bacterial culture
** [[Bacterial]] culture
** [[Abscess]] culture
* '''Mycological tests'''
* '''Mycological tests'''
** [[KOH test]]
** Fungal culture
===Diagnostic Evaluation of Splenic abscess===
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | |A01= '''Suspicion of splenic abscess'''<br>(Patients with [[immunodeficiency|immunodeficiency disorders]], [[fever]], changes in [[chest X-ray]], [[abdominal pain]]) }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | |B01= '''Blood culture'''}}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | |C01='''Patient with [[immunodeficiency|immunodeficiency disorders]]?'''}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | |D01='''If immunodeficent patient'''<br> Initiate wide spectrum antibiotics + antifungal medication|D02='''If [[immunocompetent]] patient'''<br> Initiate wide spectrum antibiotics}}
{{Family tree | | | | | | | |`|-|-|-|-|-|-|-|-|v|-|-|-|-|-|-|-|-|'| | | | |}}
{{Family tree | | | | | | | | | | | | | | | | E01 |-|-| E02 | | | | | | | |E01=[[Ultrasound]] of abdominal cavity, [[CT scan]] with contrast|E02=If imaging shows negative or equivocal with high clinical '''suspicion of splenic abscess''' }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | E03 | | | | | | | |E03='''Arteriography'''}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|^|-|-|-|.| | | | |}}
{{Family tree | | | | | | | G01 | | | | | | | | | | | | | | | | G02 | | | |G01='''Presence of indications for minimally invasive procedures''' |G02='''Absence of indications for minimally invasive procedures'''}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | |}}
{{Family tree | | | | | | | G03 | | | | | | | | | | | | | | | | |!| | | | |G03=Aspiration or abscess drainage under US or CT guidance}}
{{Family tree | | |,|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | |!| | | | |}}
{{Family tree | | H01 | | | | | | | | | | | H02 | | | | | | | | |!| | | | |H01=Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy|H02=If ineffective drainage or recurrent abscess}}
{{Family tree | | | | | | | | | | | | | | | |`|-|-|-|-|v|-|-|-|-|'| | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | |I01='''[[Spleenectomy]] or Open abscess drainage'''}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | J01 | | | | | | | | |J01=Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy}}
{{Family tree/end}}


===Imaging===
===Imaging Findings===
As the clinical features of splenic absecess are non specific and vague such as abdominal pain, fever and vomiting, that makes diagnosis is challenging and relied on imaging modalities. Imaging studies such as [[ultrasound]], [[computerized tomography]] made the diagnosis early and more accurate that reduces morbidity and mortality.<ref name="pmid12185032">{{cite journal| author=Thanos L, Dailiana T, Papaioannou G, Nikita A, Koutrouvelis H, Kelekis DA| title=Percutaneous CT-guided drainage of splenic abscess. | journal=AJR Am J Roentgenol | year= 2002 | volume= 179 | issue= 3 | pages= 629-32 | pmid=12185032 | doi=10.2214/ajr.179.3.1790629 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12185032  }} </ref>
As the clinical features of [[splenic]] [[abscess]] are non specific and vague such as [[abdominal pain]], [[fever]] and [[vomiting]], that makes diagnosis is challenging and relied on imaging modalities. Imaging studies such as [[ultrasound]], [[computerized tomography]] made the diagnosis early and more accurate that reduces morbidity and mortality.<ref name="pmid12185032">{{cite journal| author=Thanos L, Dailiana T, Papaioannou G, Nikita A, Koutrouvelis H, Kelekis DA| title=Percutaneous CT-guided drainage of splenic abscess. | journal=AJR Am J Roentgenol | year= 2002 | volume= 179 | issue= 3 | pages= 629-32 | pmid=12185032 | doi=10.2214/ajr.179.3.1790629 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12185032  }} </ref>


{| class="wikitable"
====X-ray====
|-
! rowspan="2" |'''X- ray'''
! rowspan="2" |'''Ultrasound'''
! rowspan="2" |'''Computerized tomography'''
! colspan="2" |'''Other diagnostic studies'''
|-
! style="width: 20%;" | '''Scintigraphic studies'''
! style="width: 20%;" | '''Arteriography'''
|-
|valign=top|
'''Advantages'''
'''Advantages'''
* High [[sensitivity]]
* High [[sensitivity]]
* Directly points to pathological changes
* Directly points to pathological changes
* It is the first line of examination for patients suspected of an ongoing infection
* It is the first line of examination for patients suspected of an ongoing [[infection]]
* Can determine [[phrenic]]/ [[Diaphragmatic Elevation|diaphragmatic dome]] positioning and air-fluid level in the left [[hypochondrium]]
* Can determine [[phrenic]]/ [[Diaphragmatic Elevation|diaphragmatic dome]] positioning and air-fluid level in the left [[hypochondrium]]
Common '''chest x- ray''' findings includes:
Common '''chest x- ray''' findings includes:
* Elevated and immobile left [[diaphragm]]
* Elevated and immobile left [[diaphragm]]
* Ipsilateral [[pleural effusion]]
* Ipsilateral [[pleural effusion]]
* [[Atelectasis|Atelectalic]] and inflammatory changes in interior lung lobe
* [[Atelectasis|Atelectalic]] and [[inflammatory]] changes in interior lung lobe
Common '''abdominal x- ray''' findings includes:
Common '''abdominal x- ray''' findings includes:
* Shift of the stomach and colon by a soft tissue mass( splenic abscess) which is more rectangular than in other causes of splenomegaly
* Shift of the [[stomach]] and [[colon]] by a [[soft tissue]] mass (splenic abscess) which is more rectangular than in other causes of [[splenomegaly]]
* Increased air-fluid levels with extra alimentary gas collection in the left upper quadrant<ref name="pmid14139921">{{cite journal| author=ZATZKIN HR, DRAZAN AD, IRWIN GA| title=ROENTGENOGRAPHIC DIAGNOSIS OF SPLENIC ABSCESS. | journal=Am J Roentgenol Radium Ther Nucl Med | year= 1964 | volume= 91 | issue=  | pages= 896-9 | pmid=14139921 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14139921  }} </ref>
* Increased air-fluid levels with extra [[Alimentary|alimentary gas]] collection in the left upper quadrant<ref name="pmid14139921">{{cite journal| author=ZATZKIN HR, DRAZAN AD, IRWIN GA| title=ROENTGENOGRAPHIC DIAGNOSIS OF SPLENIC ABSCESS. | journal=Am J Roentgenol Radium Ther Nucl Med | year= 1964 | volume= 91 | issue=  | pages= 896-9 | pmid=14139921 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14139921  }} </ref>
|valign=top|
[[File:Splenic abscess chest x-ray.jpg|500px|center|thumb|Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 19149]]
Ultrasound shows lesions of mixed echogenicity i.e anechoic central zone with a surrounding hyperechoic area.<ref name="pmid7039270">{{cite journal| author=Ralls PW, Quinn MF, Colletti P, Lapin SA, Halls J| title=Sonography of pyogenic splenic abscess. | journal=AJR Am J Roentgenol | year= 1982 | volume= 138 | issue= 3 | pages= 523-5 | pmid=7039270 | doi=10.2214/ajr.138.3.523 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7039270  }} </ref><ref name="pmid6976726">{{cite journal| author=Pawar S, Kay CJ, Gonzalez R, Taylor KJ, Rosenfield AT| title=Sonography of splenic abscess. | journal=AJR Am J Roentgenol | year= 1982 | volume= 138 | issue= 2 | pages= 259-62 | pmid=6976726 | doi=10.2214/ajr.138.2.259 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6976726  }} </ref>
 
====Ultrasound====
Ultrasound shows lesions of mixed [[echogenicity]] i.e anechoic central zone with a surrounding hyperechoic area.<ref name="pmid7039270">{{cite journal| author=Ralls PW, Quinn MF, Colletti P, Lapin SA, Halls J| title=Sonography of pyogenic splenic abscess. | journal=AJR Am J Roentgenol | year= 1982 | volume= 138 | issue= 3 | pages= 523-5 | pmid=7039270 | doi=10.2214/ajr.138.3.523 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7039270  }} </ref><ref name="pmid6976726">{{cite journal| author=Pawar S, Kay CJ, Gonzalez R, Taylor KJ, Rosenfield AT| title=Sonography of splenic abscess. | journal=AJR Am J Roentgenol | year= 1982 | volume= 138 | issue= 2 | pages= 259-62 | pmid=6976726 | doi=10.2214/ajr.138.2.259 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6976726  }} </ref>
 
'''Advantages'''<br>
'''Advantages'''<br>
* Emergency radiography with high sensitivity (75-100%)<ref name="pmid9403539">{{cite journal| author=Phillips GS, Radosevich MD, Lipsett PA| title=Splenic abscess: another look at an old disease. | journal=Arch Surg | year= 1997 | volume= 132 | issue= 12 | pages= 1331-5; discussion 1335-6 | pmid=9403539 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9403539  }} </ref><ref name="pmid8161087">{{cite journal| author=Paris S, Weiss SM, Ayers WH, Clarke LE| title=Splenic abscess. | journal=Am Surg | year= 1994 | volume= 60 | issue= 5 | pages= 358-61 | pmid=8161087 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8161087  }} </ref>
* Emergency [[radiography]] with high sensitivity (75-100%)<ref name="pmid9403539">{{cite journal| author=Phillips GS, Radosevich MD, Lipsett PA| title=Splenic abscess: another look at an old disease. | journal=Arch Surg | year= 1997 | volume= 132 | issue= 12 | pages= 1331-5; discussion 1335-6 | pmid=9403539 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9403539  }} </ref><ref name="pmid8161087">{{cite journal| author=Paris S, Weiss SM, Ayers WH, Clarke LE| title=Splenic abscess. | journal=Am Surg | year= 1994 | volume= 60 | issue= 5 | pages= 358-61 | pmid=8161087 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8161087  }} </ref>
* Non invasive
* Non invasive
* Cost effective
* Cost effective
* Determine the size of the spleen, size of the abscess, its location and [[echogenicity]]
* Determine the size of the [[spleen]], size of the [[abscess]], its location and [[echogenicity]]
|valign=top|
 
Computerised tomography with contrast is both diagnostic and therapeutic test of choice for splenic abscess.<ref name="pmid2589597">{{cite journal| author=Faught WE, Gilbertson JJ, Nelson EW| title=Splenic abscess: presentation, treatment options, and results. | journal=Am J Surg | year= 1989 | volume= 158 | issue= 6 | pages= 612-4 | pmid=2589597 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2589597  }} </ref><ref name="pmid11206904">{{cite journal| author=Green BT| title=Splenic abscess: report of six cases and review of the literature. | journal=Am Surg | year= 2001 | volume= 67 | issue= 1 | pages= 80-5 | pmid=11206904 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11206904  }} </ref>
====CT images====
Computerised [[tomography]] with contrast is both diagnostic and therapeutic test of choice for [[splenic]] [[abscess]].<ref name="pmid2589597">{{cite journal| author=Faught WE, Gilbertson JJ, Nelson EW| title=Splenic abscess: presentation, treatment options, and results. | journal=Am J Surg | year= 1989 | volume= 158 | issue= 6 | pages= 612-4 | pmid=2589597 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2589597  }} </ref><ref name="pmid11206904">{{cite journal| author=Green BT| title=Splenic abscess: report of six cases and review of the literature. | journal=Am Surg | year= 2001 | volume= 67 | issue= 1 | pages= 80-5 | pmid=11206904 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11206904  }} </ref>
<br>'''Advantages'''
<br>'''Advantages'''
* High [[sensitivity]] (88-100%)
* High [[sensitivity]] (88-100%)
* Can differentiate unolocular and multilocular abscesses
* Can differentiate unolocular and multilocular [[abscesses]]
* Can identify the contents of abscess
* Can identify the contents of abscess
* Can determine the density index of abscess.
* Can determine the density index of abscess.
* Can differentiate splenic abscess from [[Splenic cyst|splenic cysts]] and [[Splenic hemangioma|splenic hematomas]]
* Can differentiate splenic abscess from [[Splenic cyst|splenic cysts]] and [[Splenic hemangioma|splenic hematomas]]
* More precise and accurate than ultrasonography, in identifying the location of abscess in relation to other internal organs during per-cutaneous drainage.
* More precise and accurate than [[ultrasonography]], in identifying the location of abscess in relation to other internal organs during [[percutaneous]] drainage.
* It is superior to all other diagnostic tests for splenic abscess.
* It is superior to all other diagnostic tests for splenic abscess.
|valign=top|
|valign=top|
Scintigraphic studies include [[technetium-99m]] liver and spleen scans, [[gallium]] scans, and [[indium]] scans. Splenic scan is diagnostic modality to identify abscesses which relies upon splenic uptake of the [[Technetium-99m|radionuclide 99m technetium]] which shows abscess as a negative or filling defect.
Scintigraphic studies include [[technetium-99m]] [[liver]] and spleen scans, [[gallium]] scans, and [[indium]] scans. [[Splenic]] scan is diagnostic modality to identify [[abscesses]] which relies upon splenic uptake of the [[Technetium-99m|radionuclide 99m technetium]] which shows [[abscess]] as a negative or filling defect.


'''Advantages'''
'''Advantages'''
Line 472: Line 359:
'''Disadvantages:'''
'''Disadvantages:'''
* Scan can not identifie or visualize incurable small abscesses.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* Scan can not identifie or visualize incurable small abscesses.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* Less sensitive: If the scan shows negative or equivocal results for splenci abscess but clinical suspicion remains, an arteriogram should be ordered.
* Less sensitive: If the scan shows negative or equivocal results for splenci abscess but clinical suspicion remains, an [[arteriogram]] should be ordered.
|valign=top|
 
Arteriography is the technique that involves injection of contrast material through a catheter passed retrograde into the [[splenic artery]] followed by rapid exposure of sequential x-ray films which shows abscesses as filling defects in the spleen.
===Other Imaging Studies===
====Scintigraphic studies====
Scintigraphic studies include [[technetium-99m]] [[liver]] and [[spleen]] scans, [[gallium]] scans, and [[indium]] scans. Splenic scan is diagnostic modality to identify [[abscesses]] which relies upon splenic uptake of the [[Technetium-99m|radionuclide 99m technetium]] which shows abscess as a negative or filling defect.
 
'''Advantages'''
* High [[specificity]]: If patient showing high suspicion of splenic abscess and scan supports the diagnosis, then [[splenectomy]] can be performed.
'''Disadvantages:'''
* Scan can not identifie or visualize incurable small [[abscesses]].<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* Less sensitive: If the scan shows negative or equivocal results for [[splenic]] abscess but clinical suspicion remains, an arteriogram should be ordered.
====Arteriography====
[[Arteriography]] is the technique that involves injection of contrast material through a [[catheter]] passed retrograde into the [[splenic artery]] followed by rapid exposure of sequential [[x-ray]] films which shows [[abscesses]] as filling defects in the [[spleen]].


'''Advantages:'''
'''Advantages:'''
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'''Disadvantages:'''
'''Disadvantages:'''
* Invasive technique
* Invasive technique
|}
===Diagnostic Evaluation of Splenic abscess===
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | |A01= '''Suspicion of splenic abscess'''<br>(Patients with [[immunodeficiency|immunodeficiency disorders]], [[fever]], changes in [[chest X-ray]], [[abdominal pain]]) }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | |B01= '''Blood culture'''}}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | |C01='''Patient with [[immunodeficiency|immunodeficiency disorders]]?'''}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | |D01='''If immunodeficent patient'''<br> Initiate wide spectrum antibiotics + antifungal medication|D02='''If [[immunocompetent]] patient'''<br> Initiate wide spectrum antibiotics}}
{{Family tree | | | | | | | |`|-|-|-|-|-|-|-|-|v|-|-|-|-|-|-|-|-|'| | | | |}}
{{Family tree | | | | | | | | | | | | | | | | E01 |-|-| E02 | | | | | | | |E01=[[Ultrasound]] of abdominal cavity, [[CT scan]] with contrast|E02=If imaging shows negative or equivocal with high clinical '''suspicion of splenic abscess''' }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |)|-|-|-| E03 | | | | | | | |E03='''Arteriography'''}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | | | | | | | G01 | | | | | | | | | | | | | | | | G02 | | | |G01='''Presence of indications for minimally invasive procedures''' |G02='''Absence of indications for minimally invasive procedures'''}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | |}}
{{Family tree | | | | | | | G03 | | | | | | | | | | | | | | | | |!| | | | |G03=Aspiration or abscess drainage under US or CT guidance}}
{{Family tree | | |,|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | |!| | | | |}}
{{Family tree | | H01 | | | | | | | | | | | H02 | | | | | | | | |!| | | | |H01=Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy|H02=If ineffective drainage or recurrent abscess}}
{{Family tree | | | | | | | | | | | | | | | |`|-|-|-|-|v|-|-|-|-|'| | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | |I01='''[[Spleenectomy]] or Open abscess drainage'''}}
{{Family tree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | J01 | | | | | | | | |J01=Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy}}
{{Family tree/end}}


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
Antibiotic regimen should start before the procedure and continue until 7days after the procedure.<ref name="pmid14139921">{{cite journal| author=ZATZKIN HR, DRAZAN AD, IRWIN GA| title=ROENTGENOGRAPHIC DIAGNOSIS OF SPLENIC ABSCESS. | journal=Am J Roentgenol Radium Ther Nucl Med | year= 1964 | volume= 91 | issue=  | pages= 896-9 | pmid=14139921 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14139921  }} </ref>
[[Antibiotic]] regimen should start before the procedure and continue until 7 days after the procedure. Diagnostic [[needle]] [[aspiration]] is very important in the management with antibiotics as [[blood culture]] may not be the best correlate as abscess culture. [[Antibiotic]] of choice depends on the [[organism]], but aggressive and early surgical [[Intervention (counseling)|intervention]] of [[splenic]] [[abscess]] should be encouraged especially when the risk factors are present. High suspicion of splenic abscess with history of risk factors, [[Broad-spectrum antibiotics|broad-spectrum]] [[empirical]] [[antibiotic therapy]] should be initiated. <ref name="pmid14139921">{{cite journal| author=ZATZKIN HR, DRAZAN AD, IRWIN GA| title=ROENTGENOGRAPHIC DIAGNOSIS OF SPLENIC ABSCESS. | journal=Am J Roentgenol Radium Ther Nucl Med | year= 1964 | volume= 91 | issue=  | pages= 896-9 | pmid=14139921 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14139921 }} </ref> Empiric antibiotic should cover [[Streptococcus|streptococci]], [[Staphylococcus aureus|staphylococci]], and [[Gram-negative bacteria|aerobic gram-negative rods]] such as [[vancomycin]] or [[oxacillin]] plus an [[aminoglycoside]], a third- or fourth-generation [[cephalosporin]], [[fluoroquinolone]] or [[carbapenem]]. If culture shows [[fungi]] as causative organism, start [[Amphotericin B]] immediately and continue for 6-24 weeks and during the procedure [[amphotericin B]] should be administered directly into the [[abscess]].<ref name="pmid6385895">{{cite journal| author=Johnson JD, Raff MJ| title=Fungal splenic abscess. | journal=Arch Intern Med | year= 1984 | volume= 144 | issue= 10 | pages= 1987-93 | pmid=6385895 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6385895 }} </ref>


===Surgery===
===Surgery===
Treatment of splenic abscess depends on etiology. In bacterial abscesses, [[splenectomy]] combined with post-operative antibiotic therapy is the most appropriate treatment of choice with least mortality rate when compared to percutaneous drainage or antimicrobial therapy.<ref name="pmid16489650">{{cite journal| author=Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC et al.| title=Clinical characteristics and prognostic factors of splenic abscess: a review of 67 cases in a single medical center of Taiwan. | journal=World J Gastroenterol | year= 2006 | volume= 12 | issue= 3 | pages= 460-4 | pmid=16489650 | doi= | pmc=4066069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16489650  }} </ref>
Treatment of [[splenic]] [[abscess]] depends on etiology. In [[bacterial]] abscesses, [[splenectomy]] combined with post-operative [[antibiotic therapy]] is the most appropriate treatment of choice with least mortality rate when compared to [[percutaneous]] drainage or [[antimicrobial]] therapy.<ref name="pmid16489650">{{cite journal| author=Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC et al.| title=Clinical characteristics and prognostic factors of splenic abscess: a review of 67 cases in a single medical center of Taiwan. | journal=World J Gastroenterol | year= 2006 | volume= 12 | issue= 3 | pages= 460-4 | pmid=16489650 | doi= | pmc=4066069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16489650  }} </ref>
{| class="wikitable"
====Percutaneous Drainage====
|-
Percutaneous drainage is the initial tretament of choice for splenic abscess even though [[Splenectomy|splenectom]]<nowiki/>y is the definitive treatment because of increased risk of infections in splenectomised patient.<ref name="pmid17143953">{{cite journal| author=Zerem E, Bergsland J| title=Ultrasound guided percutaneous treatment for splenic abscesses: the significance in treatment of critically ill patients. | journal=World J Gastroenterol | year= 2006 | volume= 12 | issue= 45 | pages= 7341-5 | pmid=17143953 | doi= | pmc=4087495 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17143953  }} </ref><ref name="pmid16410091">{{cite journal| author=Choudhury S R, Rajiv C, Pitamber S, Akshay S, Dharmendra S| title=Management of splenic abscess in children by percutaneous drainage. | journal=J Pediatr Surg | year= 2006 | volume= 41 | issue= 1 | pages= e53-6 | pmid=16410091 | doi=10.1016/j.jpedsurg.2005.10.085 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16410091  }} </ref> It is genereally done under the guidance of imaging studies such as [[ultrasound]] or [[computerised tomography]] and under the guidence of imaging efficy of percuteneous drainage is equivalent to [[splenectomy]].<ref name="pmid3521422">{{cite journal| author=Teich S, Oliver GC, Canter JW| title=The early diagnosis of splenic abscess. | journal=Am Surg | year= 1986 | volume= 52 | issue= 6 | pages= 303-7 | pmid=3521422 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3521422  }} </ref><ref name="pmid1450832">{{cite journal| author=Hadas-Halpren I, Hiller N, Dolberg M| title=Percutaneous drainage of splenic abscesses: an effective and safe procedure. | journal=Br J Radiol | year= 1992 | volume= 65 | issue= 779 | pages= 968-70 | pmid=1450832 | doi=10.1259/0007-1285-65-779-968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1450832  }} </ref>
! style="width: 50%;" | '''Percutaneous Drainage'''
* First line of treatment for [[splenic]] [[abscess]]
! style="width: 50%;" | '''Splenectomy'''
* Safe and effective than [[surgery]] in both unilocular and bilocular [[abscesses]], especially in peripherally located abscesses.
|-
* Preferred in critically ill patient and patients unfit for general [[anesthesia]]
| valign = top |
Percutaneous drainage is the initial tretament of choice for splenic abscess, even though [[Splenectomy|splenectom]]<nowiki/>y is the definitive treatment because of increased risk of infections in splenectomised patient.<ref name="pmid17143953">{{cite journal| author=Zerem E, Bergsland J| title=Ultrasound guided percutaneous treatment for splenic abscesses: the significance in treatment of critically ill patients. | journal=World J Gastroenterol | year= 2006 | volume= 12 | issue= 45 | pages= 7341-5 | pmid=17143953 | doi= | pmc=4087495 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17143953  }} </ref><ref name="pmid16410091">{{cite journal| author=Choudhury S R, Rajiv C, Pitamber S, Akshay S, Dharmendra S| title=Management of splenic abscess in children by percutaneous drainage. | journal=J Pediatr Surg | year= 2006 | volume= 41 | issue= 1 | pages= e53-6 | pmid=16410091 | doi=10.1016/j.jpedsurg.2005.10.085 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16410091  }} </ref> It is genereally done under the guidance of imaging studies such as [[ultrasound]] or [[computerised tomography]] and under the guidence of imaging efficy of percuteneous drainage is equivalent to [[splenectomy]].<ref name="pmid3521422">{{cite journal| author=Teich S, Oliver GC, Canter JW| title=The early diagnosis of splenic abscess. | journal=Am Surg | year= 1986 | volume= 52 | issue= 6 | pages= 303-7 | pmid=3521422 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3521422  }} </ref><ref name="pmid1450832">{{cite journal| author=Hadas-Halpren I, Hiller N, Dolberg M| title=Percutaneous drainage of splenic abscesses: an effective and safe procedure. | journal=Br J Radiol | year= 1992 | volume= 65 | issue= 779 | pages= 968-70 | pmid=1450832 | doi=10.1259/0007-1285-65-779-968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1450832  }} </ref>
* First line of treatment for splenic abscess
* Safe and effective than surgery in both unilocular and bilocular abscesses, especially in peripherally located abscesses.
* Preferred in critically ill patient and patients unfit for general anesthesia
'''Advantages'''
'''Advantages'''
* Preserves spleen. So, it become the the treatment of choice in children to prevent post-splenectomy [[septicemia]]<ref name="pmid14530888">{{cite journal| author=Kang M, Saxena AK, Gulati M, Suri S| title=Ultrasound-guided percutaneous catheter drainage of splenic abscess. | journal=Pediatr Radiol | year= 2004 | volume= 34 | issue= 3 | pages= 271-3 | pmid=14530888 | doi=10.1007/s00247-003-1068-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14530888  }} </ref>
* Preserves [[spleen]] so, it became the treatment of choice in children to prevent post-splenectomy [[septicemia]]<ref name="pmid14530888">{{cite journal| author=Kang M, Saxena AK, Gulati M, Suri S| title=Ultrasound-guided percutaneous catheter drainage of splenic abscess. | journal=Pediatr Radiol | year= 2004 | volume= 34 | issue= 3 | pages= 271-3 | pmid=14530888 | doi=10.1007/s00247-003-1068-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14530888  }} </ref>
* No abdominal spillage of abscess contents
* No [[abdominal]] spillage of [[abscess]] contents
* Less expensive, high acceptance rate and less operative risk
* Less expensive, high acceptance rate and less operative risk
'''Complications'''  
'''Complications'''  
* Splenic [[haemorrhage]]  
* Splenic [[haemorrhage]]  
* Injury to other abdominal organs
* Injury to other [[abdominal]] organs
* [[Septicemia]]  
* [[Septicemia]]  
* [[Empyema]]
* [[Empyema]]
Line 538: Line 404:
* [[Deep vein thrombosis]]
* [[Deep vein thrombosis]]
'''Contraindications or limitations'''
'''Contraindications or limitations'''
* Multiple or septated abscesses<ref name="pmid3977590">{{cite journal| author=Gerzof SG, Johnson WC, Robbins AH, Nabseth DC| title=Expanded criteria for percutaneous abscess drainage. | journal=Arch Surg | year= 1985 | volume= 120 | issue= 2 | pages= 227-32 | pmid=3977590 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3977590  }} </ref><ref name="pmid9403539">{{cite journal| author=Phillips GS, Radosevich MD, Lipsett PA| title=Splenic abscess: another look at an old disease. | journal=Arch Surg | year= 1997 | volume= 132 | issue= 12 | pages= 1331-5; discussion 1335-6 | pmid=9403539 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9403539  }} </ref><ref name="pmid8343056">{{cite journal| author=Ho HS, Wisner DH| title=Splenic abscess in the intensive care unit. | journal=Arch Surg | year= 1993 | volume= 128 | issue= 8 | pages= 842-6; discussion 846-8 | pmid=8343056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8343056  }} </ref>
* Multiple or septated [[abscesses]]<ref name="pmid3977590">{{cite journal| author=Gerzof SG, Johnson WC, Robbins AH, Nabseth DC| title=Expanded criteria for percutaneous abscess drainage. | journal=Arch Surg | year= 1985 | volume= 120 | issue= 2 | pages= 227-32 | pmid=3977590 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3977590  }} </ref><ref name="pmid9403539">{{cite journal| author=Phillips GS, Radosevich MD, Lipsett PA| title=Splenic abscess: another look at an old disease. | journal=Arch Surg | year= 1997 | volume= 132 | issue= 12 | pages= 1331-5; discussion 1335-6 | pmid=9403539 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9403539  }} </ref><ref name="pmid8343056">{{cite journal| author=Ho HS, Wisner DH| title=Splenic abscess in the intensive care unit. | journal=Arch Surg | year= 1993 | volume= 128 | issue= 8 | pages= 842-6; discussion 846-8 | pmid=8343056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8343056  }} </ref>
* Anatomically inaccessible for drainage such as upper pole or hilar of the spleen,
* Anatomically inaccessible for drainage such as upper pole or hilar of the spleen,
* Uncontrolled [[coagulopathies]]
* Uncontrolled [[coagulopathies]]
* [[Ascites]]
* [[Ascites]]
* Simultaneous surgical procedure required of other indications such as [[subphrenic abscess]]
* Simultaneous [[surgical procedure]] required of other indications such as [[subphrenic abscess]]
* Abscess [[perforation]] or bleeding  
* [[Abscesses|Abscess]] [[perforation]] or [[bleeding]]
* Refractoriness to abscess-content drainage
* Refractoriness to abscess-content drainage
* Secondary infected [[Splenic hemangioma|spleen hematoma]]
* Secondary infected [[Splenic hemangioma|spleen hematoma]]
|valign=top|
====Splenectomy====
Splenectomy is the most effective and definitive treatment of choice for splenic abscess. splenectomy can be performed either from left subcostal incision or from midline epigastric entry.
[[Splenectomy]] is the most effective and definitive treatment of choice for [[splenic]] [[abscess]]. Splenectomy can be performed either from left [[subcostal]] [[incision]] or from midline [[epigastric]] entry.
<br>'''Advantages'''
<br>'''Advantages'''
* Definitive treatment for splenic abscess
* Definitive treatment for [[splenic]] [[abscess]]
* Treatment of choice if more than 2 abscesses are present
* Treatment of choice if more than 2 [[abscesses]] are present
* Patients with failed percutaneous drainage  
* Patients with failed [[percutaneous]] drainage  
* Patient with recurrent abscesses
* Patient with recurrent abscesses
'''Disadvantages'''
'''Disadvantages'''
* Splenecetomisesd patients are more prone to infections especially catalase positive bacteria such as [[Staphylococcus aureus]].
* Splenecetomisesd patients are more prone to [[infections]] especially [[catalase]] positive [[bacteria]] such as [[Streptococcus pneumoniae]].
* Mortality rate varies between 0-20% <ref name="pmid11206904">{{cite journal| author=Green BT| title=Splenic abscess: report of six cases and review of the literature. | journal=Am Surg | year= 2001 | volume= 67 | issue= 1 | pages= 80-5 | pmid=11206904 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11206904  }} </ref>
* Mortality rate varies between 0-20% <ref name="pmid11206904">{{cite journal| author=Green BT| title=Splenic abscess: report of six cases and review of the literature. | journal=Am Surg | year= 2001 | volume= 67 | issue= 1 | pages= 80-5 | pmid=11206904 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11206904  }} </ref>
* Extended duration operation time, larger volume of intra-operative blood loss
* Extended duration operation time, larger volume of intra-operative [[blood]] loss
* Longer duration of hospital stay than percutaneous drainage procedure
* Longer duration of hospital stay than [[percutaneous]] drainage procedure
'''Complications'''  
'''Complications'''  
* [[Lung infection]]
* [[Lung infection]]
* Wound infection   
* [[Wound]] [[infection]]  
* [[Septicemia]]  
* [[Septicemia]]  
* [[Paralytic ileus]]  
* [[Paralytic ileus]]  
* [[Deep vein thrombosis]]
* [[Deep vein thrombosis]]
|}


==Prevention==
==Prevention==
===Primary Prevention===
===Primary Prevention===
Primary prevention for splenic abscess can prevent in specific cases especially patients who are at high risk such as [[Immunocompromised|immunocompromised patients]] (e.g. recipients of [[Renal transplantation|renal transplants]] or patients on [[immunosuppressive drugs]] for other reasons).  
[[Primary prevention]] for splenic abscess can prevent in specific cases especially patients who are at high risk such as [[Immunocompromised|immunocompromised patients]] (e.g. recipients of [[Renal transplantation|renal transplants]] or patients on [[immunosuppressive drugs]] for other reasons).  
* In transplant patients best way to prevent splenic abscess is by [[splenectomy]], where as in patients with other immunocompromised states it can be achieved by proper care, early detection and aggressive treatment of minor infections.<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* In transplant patients best way to prevent splenic abscess is by [[splenectomy]], where as in patients with other [[immunocompromised]] states it can be achieved by proper care, early detection and aggressive treatment of minor [[infections]].<ref name="pmid4550054">{{cite journal| author=Gadacz T, Way LW, Dunphy JE| title=Changing clinical spectrum of splenic abscess. | journal=Am J Surg | year= 1974 | volume= 128 | issue= 2 | pages= 182-7 | pmid=4550054 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4550054  }} </ref>
* Avoid [[Intravenous drug use|intravenous drug abuse]]
* Avoid [[Intravenous drug use|intravenous drug abuse]]


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WS}}
{{WH}}


[[Category:Hematology]]
[[Category:Hematology]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Infectious disease]]
[[Category:Emergency medicine]]
 
[[Category:Disease]]
{{WS}}
[[Category:Up-To-Date]]
{{WH}}
[[Category:Surgery]]

Latest revision as of 00:14, 30 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Synonyms and keywords:Abscess of spleen
To return to abscess main page click here

Overview

Splenic abscess is an uncommon and life-threatening condition. Clinical presentation, etiological factors, natural history, treatment and prognosis depends on whether the abscess was solitary or multiple.[1] It is always fatal if left untreated. Most commonly associated with immunodeficient patients especially and hematological disorders such as leukemia and sickle cell disease. Diagnostic needle aspiration is very important in the management with antibiotics as blood culture may not be the best correlate as abscess culture. Antibiotic of choice depends on the organism but aggressive and early surgical intervention of splenic abscess should be encouraged especially when the risk factors are present. High suspicion of splenic abscess with history of risk factors, broad-spectrum empirical antibiotic therapy should be initiated.[2]

Definition

Splenic abscess is defined as any infectious suppurative process involving identifiable macroscopic filling defects either in the parenchyma of the spleen or in the sub-capsular space.[3]

Historical Perspective

  • Since the times of Hippocrates, splenic abscess has been reported several times and he described the natural history and prognosis of splenic abscess.[4]
  • In the early days of 20th century, splenic abscess most commonly caused by typhoid and then followed by malaria.[5]
  • Ooi et al described significant etiological differences such increase in the percentage of abscess cases due to anaerobics as compared to aerobics (7 vs 18-28%), fungi (1 vs 18-41%) as well as mycobacterium tuberculosis (0.8 vs. 14%) in the second half of 20th century.[6]

Classification

Classification by Mechanism of pathogenesis Classification by Etiology Classification by Pathological Findings

Splenic abscess is classified traditionally by Chun and colleagues based on the predisposing causes as follows:[7][1][8]

Classification of splenic abscesses based on the etiological factors is as follows:[6]

Lawhorne and Zuidema classified splenic abscees based on pathological findings as follows:[9]

  • Unilocular abscess
  • Bilocular abscess

Pathophysiology

Splenic abscess can result from various sources such as:[10]

Pathogenic Mechanism Description
Hematogenous Dissemination
Secondary infection of splenic infarction
Contiguous spread of bacteria
Trauma or Surgery
  • Secondary infections may developed due to splenic trauma during any intra-abdominal procedures.[6]
  • Trauma leads to hematoma formation.
  • In case of penetrating trauma to the spleen or intraabdominal surgery, direct inoculation of the spleen with pathogens may form a septic focus which, left untreated, may lead to formation of an abscess.
Immunodeficiency
  • It is major factor involved in the course of splenic abscess especially if the causative organism is fungi or any other atypical organism.

Gross Findings

Solitary splenic abscess

  • Enlarged spleen with due to large solitary abscesses with thick wall around the abscess to prevent dissemination is seen

Multiple splenic abscess

  • At the time of autopsy, spleen present as large and soft, and pus extruded organ from the cut surface.

Microscopic Findings

Solitary splenic abscess

Multiple splenic abscess

Association

Splenic abscess is commonly associate with:[11]

Causes

Splenic abscess is caused mostly by monomicrobial but some times it can be caused by polymicrobial agents. Bacteria is more common than other microbial agents such as fungi, protozoa which can cause splenic abscess in immunocompromised patients.

Common causes

The most common causative bacteria of the splenic abscess in 50% of the cases is the aerobic bacteria.[3][12]

Other common causes of splenic abscess includes:[3]

Aerobes Anaerobes Fungal Parasite

Less common causes

Differentiating Splenic abscess from Other Diseases

Splenic abscess should be differented from other causes of left upper quadrent pain:[11]

Epidemiology and Demographics

Incidence

Incidence of splenic abscess varies between 0.1% to 0.7% based on population based autopsy studies.[7][13] Incidence of splenic abscess due to hematogenous spread is gradually declining due to increased antibiotic use, but incidence due to fungal infection is increasing due to aggressive chemotherapeutic methods.[14][15]

Prevalence

Prevalence of splenic abscess is increasing gradually due to increased risk factors and increased imaging modalities that can diagnose more accurately.[16]

Case Fatality Rate

Splenic abscesses are associate with increased morbidity and mortality. If left untreated, mortality is definite (100%).[3] Mortality rate also varies with treatment of choice such as splenectomy, percutaneous drainage, anti microbial therapy carries 8%, 29%, 20% of mortality rate respectively.[17]

Age

Splenic abscess shows bimodal distribution in age of the patients, with peak incidence seen in thirties and sixties.[3] First peak of age group is people < 40 years of age who are immunosuppressed or intravenous drug abusers, who commonly present multilocular abscesses. Second peak of age group patients > 70 years with diabetes or nonendocardic septic focus and commonly develop a unilocular abscess.

Gender

Splenic abscess is more predominant in male compared to female (~2 folds).[3][7][18]

Developing Countries

In Africa, splenic abscess is common due to prevalence of hemoglobinopathies such as sickle cell disease, which is a common risk factor for this disease.[19]

Risk Factors

Spleen abscess often co-exists with several risk factors, but the major one is the patient’s immunodeficiency. Common risk factors of splenic abscess include:[11]

Infectious risk factors Non infectious risk factors

Screening

No specific screening test for splenic abscess.

Natural History, Complications and Prognosis

Natural History

Splenic abscess is a rare cause of abdominal abscesses, but life-threatening. Because of it's rarity, splenic abscess usually diagnosed at the late stages or after the onset of complications.[1] Solitory abscess present with delayed onset of presentation with history of trauma, sepsis, or adjacent organ disease with fever, abdominal pain, nausea and vomiting where as multiple splenic abscess most commonly present with generalized sepsis because of an ineradicable septic focus remote from the spleen. Early diagnosis, prompt treatment can prevent complications.[1] Mortality rate is very high if left untreated.

Complications

Life threatening complications Common complications Less common complications

Prognosis

Prognosis of splenic abscess depends on the time of diagnosis and treatment. Delay in the management can lead to splenic rupture followed by spilling into peritoneal cavity or an adjacent organ which can lead to septicemia and death in severe cases.

Diagnosis

Splenic abscess commonly present with a triad of symptoms include fever, nausea, vomiting and abdominal pain along with palpable spleen on examination. Early diagnosis with imaging studies and prompt drainage is required to reduce morbidity and mortality. Presence of fever, left upper abdominal pain, leukocytosis and radiologic evidence shows pathology in the left chest X-ray especially in immunocompromised patients are the indications for high suspicion of splenic abscess.

History and Symptoms

Common symptoms of splenic abscess include:[3][6]

Other symptoms include:[1]

Physical Examination Findings

Appearance

Patient with splenic abscess appear ill appearing and diaphoretic

Vital signs

If patient present with sepsis:

Signs of sepsis indicate that splenic abscess is most likely due to bacterial cause than fungal source.[3]

Heart

  • New onset murmur may be present

Lungs

Abdomen

Palpation

Auscultation

Laboratory Tests

Blood Tests

Blood tests such leukocytosis are increased but not significant in the diagnosis of splenic abscess because these tests may not be appropriate in immunocompromised patients.

Diagnostic Evaluation of Splenic abscess

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspicion of splenic abscess
(Patients with immunodeficiency disorders, fever, changes in chest X-ray, abdominal pain)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood culture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with immunodeficiency disorders?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If immunodeficent patient
Initiate wide spectrum antibiotics + antifungal medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If immunocompetent patient
Initiate wide spectrum antibiotics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrasound of abdominal cavity, CT scan with contrast
 
 
If imaging shows negative or equivocal with high clinical suspicion of splenic abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Arteriography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of indications for minimally invasive procedures
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Absence of indications for minimally invasive procedures
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aspiration or abscess drainage under US or CT guidance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy
 
 
 
 
 
 
 
 
 
 
If ineffective drainage or recurrent abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spleenectomy or Open abscess drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy
 
 
 
 
 
 
 
 

Imaging Findings

As the clinical features of splenic abscess are non specific and vague such as abdominal pain, fever and vomiting, that makes diagnosis is challenging and relied on imaging modalities. Imaging studies such as ultrasound, computerized tomography made the diagnosis early and more accurate that reduces morbidity and mortality.[23]

X-ray

Advantages

Common chest x- ray findings includes:

Common abdominal x- ray findings includes:

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 19149

Ultrasound

Ultrasound shows lesions of mixed echogenicity i.e anechoic central zone with a surrounding hyperechoic area.[24][25]

Advantages

CT images

Computerised tomography with contrast is both diagnostic and therapeutic test of choice for splenic abscess.[27][28]
Advantages

  • High sensitivity (88-100%)
  • Can differentiate unolocular and multilocular abscesses
  • Can identify the contents of abscess
  • Can determine the density index of abscess.
  • Can differentiate splenic abscess from splenic cysts and splenic hematomas
  • More precise and accurate than ultrasonography, in identifying the location of abscess in relation to other internal organs during percutaneous drainage.
  • It is superior to all other diagnostic tests for splenic abscess.

|valign=top| Scintigraphic studies include technetium-99m liver and spleen scans, gallium scans, and indium scans. Splenic scan is diagnostic modality to identify abscesses which relies upon splenic uptake of the radionuclide 99m technetium which shows abscess as a negative or filling defect.

Advantages

  • High specificity: If patient showing high suspicion of splenic abscess and scan supports the diagnosis, then splenectomy can be performed.

Disadvantages:

  • Scan can not identifie or visualize incurable small abscesses.[1]
  • Less sensitive: If the scan shows negative or equivocal results for splenci abscess but clinical suspicion remains, an arteriogram should be ordered.

Other Imaging Studies

Scintigraphic studies

Scintigraphic studies include technetium-99m liver and spleen scans, gallium scans, and indium scans. Splenic scan is diagnostic modality to identify abscesses which relies upon splenic uptake of the radionuclide 99m technetium which shows abscess as a negative or filling defect.

Advantages

  • High specificity: If patient showing high suspicion of splenic abscess and scan supports the diagnosis, then splenectomy can be performed.

Disadvantages:

  • Scan can not identifie or visualize incurable small abscesses.[1]
  • Less sensitive: If the scan shows negative or equivocal results for splenic abscess but clinical suspicion remains, an arteriogram should be ordered.

Arteriography

Arteriography is the technique that involves injection of contrast material through a catheter passed retrograde into the splenic artery followed by rapid exposure of sequential x-ray films which shows abscesses as filling defects in the spleen.

Advantages:

More reliable and precise than splenic scan in diagnosing small abscesses.

Disadvantages:

  • Invasive technique

Treatment

Medical Therapy

Antibiotic regimen should start before the procedure and continue until 7 days after the procedure. Diagnostic needle aspiration is very important in the management with antibiotics as blood culture may not be the best correlate as abscess culture. Antibiotic of choice depends on the organism, but aggressive and early surgical intervention of splenic abscess should be encouraged especially when the risk factors are present. High suspicion of splenic abscess with history of risk factors, broad-spectrum empirical antibiotic therapy should be initiated. [2] Empiric antibiotic should cover streptococci, staphylococci, and aerobic gram-negative rods such as vancomycin or oxacillin plus an aminoglycoside, a third- or fourth-generation cephalosporin, fluoroquinolone or carbapenem. If culture shows fungi as causative organism, start Amphotericin B immediately and continue for 6-24 weeks and during the procedure amphotericin B should be administered directly into the abscess.[29]

Surgery

Treatment of splenic abscess depends on etiology. In bacterial abscesses, splenectomy combined with post-operative antibiotic therapy is the most appropriate treatment of choice with least mortality rate when compared to percutaneous drainage or antimicrobial therapy.[17]

Percutaneous Drainage

Percutaneous drainage is the initial tretament of choice for splenic abscess even though splenectomy is the definitive treatment because of increased risk of infections in splenectomised patient.[10][30] It is genereally done under the guidance of imaging studies such as ultrasound or computerised tomography and under the guidence of imaging efficy of percuteneous drainage is equivalent to splenectomy.[31][32]

  • First line of treatment for splenic abscess
  • Safe and effective than surgery in both unilocular and bilocular abscesses, especially in peripherally located abscesses.
  • Preferred in critically ill patient and patients unfit for general anesthesia

Advantages

  • Preserves spleen so, it became the treatment of choice in children to prevent post-splenectomy septicemia[33]
  • No abdominal spillage of abscess contents
  • Less expensive, high acceptance rate and less operative risk

Complications

Contraindications or limitations

Splenectomy

Splenectomy is the most effective and definitive treatment of choice for splenic abscess. Splenectomy can be performed either from left subcostal incision or from midline epigastric entry.
Advantages

Disadvantages

Complications

Prevention

Primary Prevention

Primary prevention for splenic abscess can prevent in specific cases especially patients who are at high risk such as immunocompromised patients (e.g. recipients of renal transplants or patients on immunosuppressive drugs for other reasons).

References

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