From the Guidelines
Multiple splenic abscesses in a child previously operated on for biliary atresia are most commonly caused by ascending bacterial infections due to altered biliary drainage and compromised immune function. The primary causes include bacterial seeding from cholangitis, portal bacteremia, hematogenous spread from systemic infections, and direct extension from adjacent infected tissues. Children who have undergone Kasai portoenterostomy are particularly vulnerable due to bile stasis, recurrent cholangitis, and portal hypertension, as noted in the management of infected fluid collections 1. The most common pathogens involved are enteric organisms like E. coli, Klebsiella, Enterococcus, and anaerobes, reflecting the gut-biliary connection. Immunosuppression from malnutrition and chronic liver disease further increases susceptibility.
Some key points to consider in the management of multiple splenic abscesses include:
- The use of broad-spectrum antibiotics, such as piperacillin-tazobactam or meropenem, for 2-4 weeks 1
- The potential need for percutaneous or surgical drainage for larger abscesses, with splenectomy being an option for complex or multiple splenic abscesses 1
- The importance of blood cultures before starting antibiotics and imaging with ultrasound or CT for diagnosis and monitoring
- Prevention strategies, including prophylactic antibiotics after biliary surgery, prompt treatment of cholangitis, and optimizing nutritional status
Given the high mortality from untreated sepsis, intervention, either surgical or percutaneous drainage, is often required in addition to antibiotic therapy 1. The management approach should prioritize reducing morbidity, mortality, and improving quality of life, with a focus on prompt and effective treatment of the underlying infection.
From the Research
Causes of Multiple Splenic Abscesses
The causes of multiple splenic abscesses in a child previously operated on for biliary atresia (BA) can be attributed to several factors, including:
- Presence of splenic malformation, which is a known distinct subgroup of BA, as seen in Biliary Atresia Splenic Malformation (BASM) syndrome 2
- Previous splenic trauma or surgery, which can increase the risk of developing splenic abscesses 3
- Septic bacteremia due to endocarditis or diverticulitis, which can lead to the formation of splenic abscesses 3
- Immunosuppressive medication or diseases, which can predispose individuals to developing splenic abscesses 3
- Presence of other congenital anomalies, such as duodenal atresia and ductal plate malformation, which can be associated with BASM 4
Association with Biliary Atresia
Biliary atresia is a severe disease of unknown cause, affecting newborns, and can lead to jaundice, dark urines, and acholia 5. The presence of splenic malformation in BA can worsen the prognosis, as seen in the BASM syndrome 2. The Kasai operation, which is a surgical treatment for BA, may not be effective in all cases, and liver transplantation may be necessary 6, 5.
Diagnostic and Treatment Approaches
The diagnostic work-up for splenic abscesses primarily comprises sonography and computed tomography, as well as percutaneous puncture for determination of the pathogen 3. Treatment approaches include percutaneous interventional drainage, and splenectomy may be necessary in refractory cases 3.