Splenic Infarction Splenic infarction is a rather rare pathology most commonly associated with hematologic disorders.

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Splenic infarction typically presents on CT as a wedge-shaped region of low attenuation with the apex directed toward the splenic hilum

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The infarct may be segmental or involve the entire organ

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Hematologic Disorders Leukemia Lymphoma Myelofibrosis Hypercoagulable states Erythropoietin therapy Polycythmia Vera Sickle hemoglobinopathies Embolic Disorders : Endocarditis, Atrial Fibrillation, Prosthetic mitral valve, Left Ventricular mural thrombus following myocardial infarct Vascular Disorders : Wegener's granulomatosis, polyarteritis nodosa Autoimmune/Rheumatoid :Kawasaki Disease, Systemic Lupus Erythematosus

Clinical features

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Asymptomatic, with incidental discovery from radiologic or postmortem studies hemorrhagic shock as a result of subcapsular hematoma with rupture into the peritoneal cavity. left upper quadrant pain, fever, and chills. Additional symptoms include nausea, vomiting, pleuritic chest pain, and left shoulder pain

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Treatment

The mainstay of treatment for splenic infarction, in the absence of complications, is analgesia and observation. The arterial supply to the spleen via the splenic artery and the short gastric arteries (from the left gastroepiploic) allow sufficient collateral flow to preserve much of the spleen parenchyma with minimal intervention, even in the event of splenic artery occlusion.

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complications such as splenic abscess from septic emboli or infection of prior infarct require immediate surgical attention

Splenic abscess

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Splenic abscesses occur most commonly in patients with underlying disorders such as infection, embolic disease, traumatic injury, malignant hematologic conditions, or immunosuppression. Solitary abscesses usually represent localized disease. Overall, the clinician will most often (70%) encounter patients with solitary abscesses

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An abscess in the right upper pole of the spleen may rupture and form a left subdiaphragmatic abscess . If the abscess is in the lower pole , rupture result in diffuse peritonitis

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Treatment

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As a rule , owing to dense adhesions , drainage of the abscess is the only course . Very rarely , splenectomy may be possible with the abscess in situ .The drainage may be performed percutaneously , under u/s or CT guidance , so avoiding the need for operative intervention .

Splenectomy

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during a surgical operation , for example when mobilising the splenic flexure of the colon .

2- removal en bloc with the stomach as part of a radical gastrectomy.

3- removal as part of a staging laparotomy undertaken before treatment of a Hodgkin's lymphoma, a very rare indication with the advent of improved staging by imaging;

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4- to reduce anemia or thrombocytopenia in spherocytosis, ITP or hypersplenism;

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5- in association with shunt or variceal surgery for portal hypertension.

Complications

- Hemorrhage, if a ligature slips off the splenic artery.

- Gastric dilatation following partial mobilisation of the stomach when ligating the short gastric vessels.

- Hematemesis may rarely occur possibly due to mucosal damage to the stomach when ligating the short gastric vessels.

- Left basal atelectasis, sometimes with pleural effusion, is common. This may be due to damage or to irritation of the left hemidiaphragm or a subphrenic abscess, and may be accompanied by persistent hiccough.

- Damage to the tail of the pancreas during mobilisation of the splenic pedicle. This may produce a localised abscess or, if the area has been well drained, a pancreatic fistula. This may be associated with a left pleural effusion, a peritoneal effusion or abdominal wall dehiscence.

- Splenectomy is frequently followed by a rise in the white cell and platelet count a few days after operation. There may be a risk of thrombosis if the platelet count rises above 1000000 perlitre and it is essential to anticoagulate prophylactically the patient should this level be attained.

- Gastric fistula due to damage of the greater curvature of the stomach when ligating the short gastric vessels

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postsplenectomy septicemia. The spleen phagocytoses bacteria, particularly encapsulated bacteria.

Splenectomised patients are at increased risk of septicemia due to Streptococcus pneumoniae, Neisseria meningitides, Haemophylous influenzae and Babesia rnicroti.

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Opportunistic postsplenectomy infection (OPSI) is now of major concern. Pneumococcal vaccine (Pneumovax) should be given 2 weeks preoperatively. It is important to advise the patient of the dangers of OPSI and to prescribe antibiotics with all infections.

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Splenectomised patients living in malaria endemic areas should receive antimalaria prophylaxis.

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For children :long-term treatment with antibiotic drugs to prevent post splenectomy sepsis . nehtazneb ( 1.2

nillicinep mega units per month )

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Long-term antibiotic use is usually not necessary in adults .