What is the management approach for a perisplenic collection?

Management of Perisplenic Collections

Percutaneous catheter drainage (PCD) is the first-line treatment for perisplenic collections, with splenectomy reserved for cases with no safe percutaneous approach or high bleeding risk. 1, 2

Diagnostic Approach

• Initial imaging:
  • Ultrasound: Preferred for superficial collections, providing detailed evaluation of internal structure
  • CT scan: Superior for deep collections, helps distinguish collections from adjacent vasculature
  • MRI: Reserved for complex cases requiring detailed soft tissue characterization 2

Management Algorithm

Step 1: Assessment and Classification

• Determine size, location, and characteristics of the perisplenic collection
• Evaluate for signs of infection (fever, leukocytosis)
• Assess for safe percutaneous access window

Step 2: Initial Management

• Small collections (<3cm) without signs of infection:

  • Conservative management with antibiotics alone 2
  • Regular clinical and imaging follow-up

• Larger collections (>3cm) or infected collections:

  • Image-guided percutaneous drainage as first-line treatment 1, 2
  • Success rates of 70-90% with lower morbidity compared to surgical approaches

Step 3: Percutaneous Drainage Technique

• Choose appropriate imaging guidance (ultrasound or CT)
• Ensure at least 1cm rim of normal splenic tissue for safe access 1
• Obtain cultures before or at time of drainage
• Place appropriately sized drainage catheter

Step 4: Post-Drainage Management

• Continue appropriate antibiotic therapy based on culture results
• Regular catheter care and output monitoring
• Serial imaging to assess resolution
• Criteria for drain removal: 1, 2
  • Resolution of signs of infection
  • Catheter output <10-20cc/day
  • Resolution of collection on imaging

Step 5: Management of Persistent Collections

• For inadequate drainage:

  • Catheter manipulation or upsizing
  • Additional drainage catheters for loculated collections
  • Consider intracavitary thrombolytic therapy for septated collections 2

• For collections refractory to PCD:

  • Splenectomy is indicated, especially for: 1
    • Complex or multiple splenic abscesses
    • No safe window for PCD
    • High risk of bleeding
    • Failed percutaneous drainage (reported failure rates of PCD for splenic abscess range from 14.3-75%)

Special Considerations

Hematomas

• Perisplenic hematomas may be more difficult to drain percutaneously and have higher failure rates 3
• May require surgical intervention if persistent or recurrent 4

Delayed Presentations

• Perisplenic abscesses can present months after initial splenic injury or intervention 4
• Maintain high index of suspicion in patients with prior splenic trauma or procedures who present with fever, malaise, or left upper quadrant pain

Potential Complications and Pitfalls

• Inadequate drainage leading to persistent collection
• Secondary infection during drainage procedure
• Damage to adjacent structures
• Catheter dislodgement
• Formation of fistulous tracts
• Hemorrhage from nontarget puncture 1

Follow-up Protocol

• Regular clinical assessment of symptoms
• Serial imaging to assess resolution
• Monitor drain output daily
• Adjust antibiotic therapy based on culture results and clinical response

The management of perisplenic collections requires a careful balance between conservative measures and more invasive interventions. While PCD offers a less invasive approach with good success rates, clinicians should not hesitate to proceed to splenectomy when indicated to prevent life-threatening complications from untreated sepsis.