What is the management of a splenic infarct after hiatal hernia repair?

Management of Splenic Infarct After Hiatal Hernia Repair

The management of splenic infarct after hiatal hernia repair should begin with non-operative management (NOM) for hemodynamically stable patients, including close clinical observation, serial laboratory tests, and appropriate imaging, with surgical intervention reserved for patients with complications or persistent symptoms. 1

Diagnostic Approach

• Initial Assessment:

  • Evaluate hemodynamic stability (blood pressure, heart rate, signs of skin vasoconstriction)
  • Assess for left upper quadrant pain (the predominant symptom in splenic infarction) 2
  • Monitor for fever, which may indicate development of complications 3

• Laboratory Tests:

  • Complete blood count (anemia occurs in 53%, leukocytosis in 49%, thrombocytosis in 7% of patients) 2
  • Lactate dehydrogenase (elevated in ~25% of cases) 4
  • Serial hemoglobin/hematocrit to detect ongoing blood loss

• Imaging:

  • CT scan with IV contrast is the gold standard (diagnostic in 75% of cases) 1, 2
  • Doppler US and contrast-enhanced US are useful for evaluating splenic vascularization and follow-up 1
  • Consider repeat imaging for moderate to severe lesions or decreasing hematocrit 1

Management Algorithm

For Hemodynamically Stable Patients:

1. Initial Non-Operative Management:

   • Hydration and analgesia 2
   • Close clinical observation with hemodynamic monitoring 1
   • Serial clinical examinations and laboratory tests
   • Most uncomplicated splenic infarctions resolve with medical treatment in 7-14 days 2

2. Monitoring for Complications:

   • Persistent or recurrent fever
   • Worsening abdominal pain
   • Signs of hemodynamic instability
   • Development of abscess, pseudocyst, or hemorrhage 2

For Patients with Complications or Failed NOM:

1. Indications for Surgical Intervention:

   • Persistent symptoms beyond 2 weeks
   • Development of complications (splenic abscess, rupture, or pseudocyst)
   • Hemodynamic instability
   • Significant drop in hematocrit or requirement for continuous transfusions 3, 2

2. Surgical Options:

   • Splenectomy is the standard surgical approach for complicated splenic infarction 2
   • Consider percutaneous drainage for splenic abscess in high-risk surgical candidates 3
   • Partial splenic preservation should be attempted when possible to maintain immunological function 3

Special Considerations

• Mechanism of Injury: Splenic infarction after hiatal hernia repair typically results from inadvertent injury to peripheral splenic artery branches during division of short gastric vessels 5

• Risk Factors for Complications:

  • Larger infarct size
  • Underlying splenic pathology
  • Coagulopathy
  • Immunocompromised status

• Post-Splenectomy Care (if required):

  • Vaccination against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis) no sooner than 14 days after splenectomy 1
  • Annual influenza vaccination
  • Consider antibiotic prophylaxis for fever or signs of infection 1

Follow-up Recommendations

• Bed rest for 48-72 hours in moderate and severe lesions 1
• Activity restriction for 4-6 weeks for minor injuries and 2-4 months for moderate/severe injuries 1
• Follow-up imaging (US, DUS, or CEUS) to monitor resolution of the infarct 1

Pitfalls and Caveats

• Splenic infarction may be initially asymptomatic but can lead to serious complications if not properly monitored 3
• Delayed splenic rupture can occur days to weeks after initial injury 1
• Intense inflammation and adhesion formation should be anticipated if operating on an infarcted spleen 5
• Overwhelming post-splenectomy infection (OPSI) is a serious potential complication if splenectomy is required 1

By following this structured approach, most patients with splenic infarction after hiatal hernia repair can be successfully managed non-operatively, with surgical intervention reserved for those with persistent symptoms or complications.