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| {{Splenic infarction}} | | {{Splenic infarction}} |
| {{CMG}} ; '''Associate Editor-In-Chief:''' {{CZ}} | | {{CMG}} ; '''Associate Editor-In-Chief:''' {{asiri}} {{CZ}} |
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| | {{SK}} Spleen infarct, splenic artery thrombosis, splenic artery occlusion, |
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| ==Diagnosis== | | == [[Splenic infarction overview|Overview]] == |
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| ===Laboratory tests=== | | == [[Splenic infarction historical perspective|Historical Perspective]]== |
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| * Laboratory tests are not diagnostic for splenic infarction, although in a few cases there is leucocytosis, thrombocytosis, and anaemia.
| | == [[Splenic infarction classification|Classification]] == |
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| ===Imaging Studies=== | | == [[Splenic infarction pathophysiology|Pathophysiology]] == |
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| Radiological imaging tests are diagnostic. Ultrasound imaging is useful in cases where the splenic parenchyma can be visualized, but significant amount of luminal bowel gas, as well as morbid obesity, render this modality less useful.
| | == [[Splenic infarction causes|Causes]] == |
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| * [[Computerized tomography]] scan is the current diagnostic modality of choice. Prior to the CT era, diagnosis of splenic infarct was made most commonly at laparotomy for intra-abdominal catastrophe or on postmortem examination. An abdominal [[CT scan]] is the most commonly used modality to confirm the diagnosis,<ref name="pmid9486895"/> although abdominal ultrasound can also contribute.<ref name="pmid15290950">{{cite journal |author=Görg C, Seifart U, Görg K |title=Acute, complete splenic infarction in cancer patient is associated with a fatal outcome |journal=Abdom Imaging |volume=29 |issue=2 |pages=224–7 |year=2004 |pmid=15290950 |doi=10.1007/s00261-003-0108-9 |url=}}</ref><ref name="pmid3773568">{{cite journal |author=O'Keefe JH, Holmes DR, Schaff HV, Sheedy PF, Edwards WD |title=Thromboembolic splenic infarction |journal=Mayo Clin. Proc. |volume=61 |issue=12 |pages=967–72 |year=1986 |month=December |pmid=3773568 |doi= |url=}}</ref><ref name="pmid8997756">{{cite journal |author=Frippiat F, Donckier J, Vandenbossche P, Stoffel M, Boland B, Lambert M |title=Splenic infarction: report of three cases of atherosclerotic embolization originating in the aorta and retrospective study of 64 cases |journal=Acta Clin Belg |volume=51 |issue=6 |pages=395–402 |year=1996 |pmid=8997756 |doi= |url=}}</ref> In CT; focal infarcts appear as wedge-shaped areas of decreased attenuation that extend to the surface of the spleen. Global infarction can manifest as diffuse areas of decreased attenuation in the spleen and can mimic splenic abscess or tumor. In some cases of global infarction, the splenic periphery remains enhanced due to perfusion from capsular vessels.
| | == [[Splenic infarction differential diagnosis|Differentiating Splenic Infarction from other Diseases]] == |
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| '''Patient #1''' Note peripheral enhancement due to perfusion from capsular vessels
| | == [[Splenic infarction epidemiology and demographics|Epidemiology and Demographics]]== |
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| [http://www.radswiki.net Images courtesy of RadsWiki] | | == [[Splenic infarction risk factors|Risk Factors]] == |
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| <gallery>
| | == [[Splenic infarction screening|Screening]] == |
| Image:Splenic-infarct-001.jpg|CT: Splenic infarction
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| Image:Splenic-infarct-002 copy.jpg|CT: Splenic infarction
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| Image:Splenic-infarct-003 copy.jpg|CT: Splenic infarction
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| </gallery>
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| | == [[Splenic infarction natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
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| '''Patient #2''' Note peripheral enhancement due to perfusion from capsular vessels
| | == Diagnosis == |
| | [[Splenic infarction history and symptoms|History and Symptoms]] | [[Splenic infarction physical examination|Physical Examination]] | [[Splenic infarction laboratory findings|Laboratory Findings]] | [[Splenic infarction electrocardiogram|Electrocardiogram]] | [[Splenic infarction chest x ray|Chest X Ray]] | [[Splenic infarction CT|CT]] | [[Splenic infarction MRI|MRI]] | [[Splenic infarction echocardiography or ultrasound|Ultrasound]] | [[Splenic infarction other imaging findings|Other Imaging Studies]] | [[Splenic infarction other diagnostic studies|Other Diagnostic Studies]] |
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| [http://www.radswiki.net Images courtesy of RadsWiki]
| | == Treatment == |
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| <gallery>
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| Image:Splenic-infarction-101.jpg|CT: Splenic infarction
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| Image:Splenic-infarction-102.jpg|CT: Splenic infarction
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| Image:Splenic-infarction-103.jpg|CT: Splenic infarction
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| </gallery>
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| * Contrast studies clearly depict the classic segmental wedge-shaped, low-attenuation defect. Less frequently, the entire spleen may be infarcted, leaving only a rim of contrast-enhancing capsule.
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| * Other modes of diagnosis include radioisotope scans and ultrasound evaluation of the spleen.
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| * [[Angiography]] is indicated when a vascular lesion is suspected as the etiologic cause, as in cases of arterial embolization, or to manage segmental bleeding by embolization.
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| * [[Magnetic resonance imaging]] is another useful modality that clearly identifies infarcted splenic parenchyma. Magnetic resonance images may be reconstructed easily in 3 dimensions (as can spiral CT scan images) if the images are obtained using gadolinium contrast.
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| ===Histolopathological Findings===
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| * Pathologic examination of the resected spleen may provide information regarding the pathogenesis of the infarct, e.g. evidence of septic or atheromatous emboli or the presence of an infectious etiology.
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| <gallery>
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| image:Splenic infarction (left) with homogenous pinkish appearance.jpg|Splenic infarction (left) with homogenous pinkish appearance|
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| image:Inflammatory cells seated on the margin of infarct area.jpg|Inflammatory cells seated on the margin of infarct area
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| </gallery>
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| <gallery>
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| image:Inflammatory cells.jpg|Inflammatory cells
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| image:Hemosiderin laden macrophages in the more fibrous areas (junction of infarction ).jpg|Hemosiderin laden macrophages in the more fibrous areas (junction of infarction)
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| </gallery>
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| <gallery>
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| image:Spleen.jpg|Multiple infarcts in a spleen greatly enlarged by malignant lymphoma. The multiple areas of infarction are well demarcated
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| </gallery>
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| ==Treatment== | |
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| There is no specific treatment, except treating the underlying disorder and providing adequate [[analgesia|pain relief]]. Splenectomy is only required if complications ensue; surgical removal predisposes to [[overwhelming post-splenectomy infection]]s.<ref name="pmid18510036">{{cite journal |author=Salvi PF, Stagnitti F, Mongardini M, Schillaci F, Stagnitti A, Chirletti P |title=Splenic infarction, rare cause of acute abdomen, only seldom requires splenectomy. Case report and literature review |journal=Ann Ital Chir |volume=78 |issue=6 |pages=529–32 |year=2007 |pmid=18510036 |doi= |url=}}</ref>
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| ===Medical therapy===
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| Surgery is indicated only in the presence of complications. Otherwise, the infarcted spleen can be left in situ, and the patient is observed. Due to the rarity of this disorder and the largely anecdotal character of many reports, the roles of antibiotics and antiplatelet agents (for the treatment of thrombocytosis) have not been formally addressed. Similarly, no scientifically supported information exists regarding the possible increase in susceptibility to overwhelming postsplenectomy sepsis in these patients.
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| The principal mainstay of medical therapy is analgesia with either narcotics or nonsteroidal anti-inflammatory agents.
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| In one series of 59 patients, mortality amounted to 5%.<ref name="pmid9486895">{{cite journal |author=Nores M, Phillips EH, Morgenstern L, Hiatt JR |title=The clinical spectrum of splenic infarction |journal=Am Surg |volume=64 |issue=2 |pages=182–8 |year=1998 |month=February |pmid=9486895 |doi= |url=}}</ref> Complications include a [[ruptured spleen]], [[hemorrhage]], splenic abscess (for example, if the underlying cause is [[endocarditis]]) or [[pseudocyst]] formation. Splenectomy may be warranted for persistent pseudocysts due to the high risk of subsequent rupture.<ref name="pmid8371303">{{cite journal |author=Pachter HL, Hofstetter SR, Elkowitz A, Harris L, Liang HG |title=Traumatic cysts of the spleen--the role of cystectomy and splenic preservation: experience with seven consecutive patients |journal=J Trauma |volume=35 |issue=3 |pages=430–6 |year=1993 |month=September |pmid=8371303 |doi= |url=}}</ref>
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| ===Surgical therapy===
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| * For an infarcted spleen with any of the above-mentioned complications, splenectomy is required.
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| * Because of the small but real risk of fatal overwhelming post splenectomy sepsis, splenic preservation is preferable whenever possible.
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| * In cases of torsion of a wandering spleen, splenopexy with splenic salvage is the procedure of choice in the well-perfused, non infarcted spleen.
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| * Complications such as bleeding or pseudocyst formation also may be amenable to splenic salvage using techniques of partial splenectomy.
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| * While a unilocular abscess can be managed successfully in select cases with percutaneous catheter drainage, some authors advocate splenectomy in all cases of splenic infarct and abscess, questioning the utility of preserving the residual partially functioning spleen. This may be accomplished using traditional open techniques or laparoscopic techniques.
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| * Perisplenic inflammation and dense adhesions can make splenectomy difficult. Another choice is to perform preoperative splenic artery embolization, which purposely infarcts the remaining spleen and minimizes blood loss that otherwise can be quite profuse in these difficult dissections.
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| Intraoperative ligation of the splenic artery at the superior margin of the pancreas in the lesser sac is another alternative to minimize blood loss if the spleen is enlarged.
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| Contraindications:
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| * Asymptomatic infarct without complication does not require surgical intervention.
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| * Overall, most splenic infarcts do not require surgical intervention.
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| ==Complications==
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| * Hemorrhage: Hemorrhage can follow splenectomy due to the intense perisplenic inflammation.
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| * Splenic bed and/or subphrenic abscess: Abscess is not an uncommon complication. The first line of treatment is radiologic-guided percutaneous drainage.
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| * Pancreatic fistula: Because of the intimate association of the pancreatic tail and splenic hilum, pancreatic injury can occur, especially in the setting of intense inflammation and/or abscess. The majority of these resolve with nonoperative management, which includes wide drainage, use of a somatostatin analog to decrease exocrine pancreatic function, and either total parenteral nutrition (TPN) or enteral alimentation distal to the ligament of Treitz.
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| * Gastric fistula: Due to the intense inflammatory reaction that can accompany splenic abscess, the dissection of the spleen from the greater curve of the stomach can be difficult, and inadvertent unrecognized injuries to the greater curve of the stomach do occur. With adequate external drainage and with no obstruction to normal gastric emptying, these can be treated expectantly with TPN or distal luminal alimentation and nasogastric tube decompression.
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| * Overwhelming postsplenectomy sepsis: As discussed above, the incidence is unknown. The overall postoperative sepsis rate is high because splenectomy often is undertaken for treatment of splenic abscess. The rate of sepsis is due to the cause for the abscess rather than the splenectomy.
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| ==Source==
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| * Guth AA, Pachter HL, Kaplan LJ et. al., Splenic Infarct, [http://www.emedicine.com/med/topic2750.htm]
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| ==References==
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| {{Reflist|2}}
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| ==Additional Resources==
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| {{refbegin|2}}
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| * Argiris A: Splenic and renal infarctions complicating atrial fibrillation. Mt Sinai J Med 1997 Sep-Oct; 64(4-5): 342-9[Medline].
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| * Balcar I, Seltzer SE, Davis S: CT patterns of splenic infarction: a clinical and experimental study. Radiology 1984 Jun; 151(3): 723-9.
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| * Cohen BA, Mitty HA, Mendelson DS: Computed tomography of splenic infarction. J Comput Assist Tomogr 1984 Feb; 8(1): 167-8.
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| * Desai DC, Hebra A, Davidoff AM: Wandering spleen: a challenging diagnosis. South Med J 1997 Apr; 90(4): 439-43.
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| * Franklin QJ, Compeggie M: Splenic syndrome in sickle cell trait: four case presentations and a review of the literature. Mil Med 1999 Mar; 164(3): 230-3.
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| * Goerg C, Schwerk WB: Splenic infarction: sonographic patterns, diagnosis, follow-up, and complications. Radiology 1990 Mar; 174(3 Pt 1): 803-7.
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| * Jaroch MT, Broughan TA, Hermann RE: The natural history of splenic infarction. Surgery 1986 Oct; 100(4): 743-50.
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| * Kluger Y, Paul DB, Townsend RN: Enhanced rim around infarcted, traumatized spleen on computed tomographic scans: case report. J Trauma 1994 Mar; 36(3): 436-7.
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| * Lo AY, Reich H, Harvey J: Splenic infarction associated with adult respiratory distress syndrome. Mt Sinai J Med 1994 Sep; 61(4): 369-71.
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| * Nores M, Phillips EH, Morgenstern L: The clinical spectrum of splenic infarction. Am Surg 1998 Feb; 64(2): 182-8.
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| * O'Keefe JH Jr, Holmes DR Jr, Schaff HV: Thromboembolic splenic infarction. Mayo Clin Proc 1986 Dec; 61(12): 967-72.
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| * Pachter HL, Hofstetter SR, Elkowitz A: Traumatic cysts of the spleen--the role of cystectomy and splenic preservation: experience with seven consecutive patients. J Trauma 1993 Sep; 35(3): 430-6.
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| * Pachter HL, Guth AA, Hofstetter SR: Changing patterns in the management of splenic trauma: the impact of nonoperative management. Ann Surg 1998 May; 227(5): 708-17; discussion 717-9.
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| * Shackford SR, Wald SL, Ross SE: The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma 1992 Sep; 33(3): 385-94.
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| * Sheikha A: Splenic syndrome in patients at high altitude with unrecognized sickle cell trait: splenectomy is often unnecessary. Can J Surg 2005; 48: 377-381.
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| * Torda A: Postpartum toxic shock syndrome associated with multiple splenic infarcts. Med J Aust 2005; 182: 93.
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| * Walcher F, Schneider G, Marzi I: Torsion of a wandering spleen after blunt abdominal trauma. J Trauma 1997 Dec; 43(6): 983-4.
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| * Yu LK, Hsu CW, Liu NJ: Splenic infarction complicated by splenic artery occlusion after N-butyl-2-cyanoacrylate injection for gastric varices: case report. Gastrointest Endosc 2005; 61: 343-345.
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| {{refend}}
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| | [[Splenic infarction medical therapy|Medical Therapy]] | [[Splenic infarction surgery|Surgery]] | [[Splenic infarction primary prevention|Primary Prevention]] | [[Splenic infarction secondary prevention|Secondary Prevention]] | [[Splenic infarction cost-effectiveness of therapy | Cost Effectiveness of Therapy]] | [[Splenic infarction future or investigational therapies|Future or Investigational Therapies]] |
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| | ==Case Studies== |
| | :[[Splenic infarction case study one|Case #1]] |
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| [[Category:Hematology]] | | [[Category:Hematology]] |
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