Splenic Infarction Splenic Infarction Splenic infarction is a rather Splenic infarction is a rather rare pathology most rare pathology most commonly associated with commonly associated with hematologic disorders. hematologic disorders.
Transcript
Slide 1
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
hilumSplenic infarction typically presents on CT as a wedge-shaped
region of low attenuation with the apex directed toward the splenic
hilum The infarct may be segmental or involve the entire organThe
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 hemoglobinopathiesHematologic 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 infarctEmbolic
Disorders : Endocarditis, Atrial Fibrillation, Prosthetic mitral
valve, Left Ventricular mural thrombus following myocardial infarct
Vascular Disorders : Wegener's granulomatosis, polyarteritis
nodosaVascular Disorders : Wegener's granulomatosis, polyarteritis
nodosa Autoimmune/Rheumatoid :Kawasaki Disease, Systemic Lupus
ErythematosusAutoimmune/Rheumatoid :Kawasaki Disease, Systemic
Lupus Erythematosus
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Clinical features Asymptomatic, with incidental discovery from
radiologic or postmortem studiesAsymptomatic, with incidental
discovery from radiologic or postmortem studies hemorrhagic shock
as a result of subcapsular hematoma with rupture into the
peritoneal cavity.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 painleft
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.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
complications such as splenic abscess from septic emboli or
infection of prior infarct require immediate surgical
attention
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Splenic abscess 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 abscessesSplenic 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 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 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.
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Splenectomy 1- trauma : either following an accident or during
a surgical operation, for example when mobilising the splenic
flexure of the colon.1- trauma : either following an accident or
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. 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; 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;4- to reduce anemia or thrombocytopenia in
spherocytosis, ITP or hypersplenism; 5- in association with shunt
or variceal surgery for portal hypertension.5- in association with
shunt or variceal surgery for portal hypertension.
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Complications - Hemorrhage, if a ligature slips off the splenic
artery. - Gastric dilatation following partial mobilisation of the
stomach when ligating the short gastric vessels. - 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. - Hematemesis may rarely occur - possibly
due to mucosal damage to the stomach when ligating the short
gastric vessels.
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- 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. - 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. -
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.
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- 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. - 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.
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- Gastric fistula due to damage of the greater curvature of the
stomach when ligating the short gastric vessels - 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.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. 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.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.
Splenectomised patients living in malaria endemic areas should
receive antimalaria prophylaxis. 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. ( benzathen penicillin 1.2 mega
units per month )For children :long-term treatment with antibiotic
drugs to prevent post- splenectomy sepsis. ( benzathen penicillin
1.2 mega units per month ) Long-term antibiotic use is usually not
necessary in adults.Long-term antibiotic use is usually not
necessary in adults.