Are splenic infarcts painful?

Splenic Infarcts Are Often Asymptomatic But Can Present with Left Upper Quadrant Pain

Splenic infarcts are very often asymptomatic, but when symptomatic, they most commonly present with abdominal or left flank pain (80% of cases) and left upper quadrant tenderness (35% of cases). 1, 2

Clinical Presentation of Splenic Infarcts

Symptoms and Signs

• Abdominal or left flank pain is the most common symptom (80% of patients) 2
• Left upper quadrant tenderness is the most common physical finding (35% of patients) 2
• Approximately 31% of patients have no signs or symptoms localized to the splenic area 3
• Other associated symptoms may include:
  • Fever and chills (especially common in embolic conditions - 70%) 4
  • Constitutional symptoms 4
  • Referred left shoulder pain (Kehr's sign) 5

Laboratory Findings

• Leukocytosis is present in 56% of cases 3
• Elevated lactate dehydrogenase (LDH) levels are found in 71% of patients 3

Etiology and Risk Factors

Splenic infarcts can occur in various conditions:

• Hematologic disorders (e.g., sickle cell anemia) 6
• Thromboembolic disorders 4
• Infective endocarditis (infected valve vegetations can embolize to the splenic artery) 1, 5
• Hypercoagulable states (protein C, protein S deficiencies, antiphospholipid syndrome) 5
• Vasculitis and mesenteric dissection 5
• Mycotic aneurysms affecting splenic arteries 5
• Traumatic injury to the spleen 5

Diagnosis

• Contrast-enhanced CT scan is the gold standard for diagnosing splenic infarction (sensitivity and specificity of 96-100%) 5
• Ultrasound has limited diagnostic value, being diagnostic in only 18% of patients 2
• Doppler ultrasound can be used to evaluate splenic vascularization 5
• Bedside E-FAST can rapidly identify intraperitoneal hemorrhage in unstable patients 5

Clinical Significance and Complications

Splenic infarction can be clinically significant for several reasons:

• It may be the presenting symptom of a previously undiagnosed underlying disease in up to 16.6% of patients 2
• In one study, 21 out of 26 cases (80.8%) of splenic infarction brought a previously undiagnosed underlying disease to attention 3
• Potential complications include:
  • Splenic abscess formation
  • Splenic rupture
  • Persistent pain requiring splenectomy 6, 4

Management Approach

1. Medical management is the first-line approach for uncomplicated splenic infarcts:

   • Intravenous hydration
   • Analgesics for pain control
   • Frequent monitoring of vital signs and symptoms 5
   • Treatment of underlying condition (e.g., appropriate antibiotic regimens for infective endocarditis) 1, 5

2. Surgical intervention may be necessary in cases of:

   • Complications (abscess, rupture)
   • Persistent symptoms
   • Large infarcts with suspicion of secondary infection 1, 6

3. Follow-up and monitoring:

   • Serial imaging (CT or MRI) to monitor resolution or development of complications
   • Close monitoring for signs of infection 5

Clinical Pearls and Pitfalls

• Splenic infarcts can be easily missed due to their often asymptomatic nature or non-specific presentation
• Consider splenic infarction in patients with unexplained left upper quadrant pain, especially those with risk factors
• The absence of localized symptoms does not rule out splenic infarction (31% have no localized signs) 3
• Splenic infarction may be the first manifestation of a serious underlying condition, warranting thorough investigation 2, 3
• Single infarcts are more likely to be associated with fever and leukocytosis than multiple infarcts 3