Management of Splenic Infarction
The management of splenic infarction primarily consists of supportive care with hydration and analgesia, while monitoring for complications such as abscess formation or rupture that would require surgical intervention. 1, 2
Diagnosis
- CT scan with intravenous contrast is the gold standard for diagnosing splenic infarction, with sensitivity and specificity of 90-95% 3
- On CT, splenic infarcts typically appear as peripheral low-density, wedge-shaped areas, while abscesses appear as single or multiple contrast-enhancing cystic lesions 3
- MRI offers similar diagnostic accuracy to CT for splenic infarction 3
- Ultrasonography may be used but is less sensitive; infarcts may not be visualized well, while abscesses appear as sonolucent lesions 3
- Older imaging techniques such as 99mTc liver-spleen scans, labeled white blood cell scans, and gallium scans are now considered obsolete for diagnosing splenic pathology 3
Clinical Presentation
- Splenic infarction may be asymptomatic (particularly in patients with hematologic disorders) or present with left upper quadrant pain, fever, and constitutional symptoms 1, 2
- Clinical splenomegaly is present in up to 30% of cases but is not a reliable sign of splenic infarction 3
- Persistent fever, recurrent bacteremia, or other signs of sepsis should raise suspicion for progression to splenic abscess 3
Initial Management
For uncomplicated splenic infarction, conservative management is recommended with: 1, 2
- Intravenous hydration
- Appropriate analgesia
- Frequent clinical monitoring
- Symptoms typically resolve within 7-14 days with this approach
Address the underlying cause of the infarction: 1, 4, 5
- Anticoagulation for cardioembolic sources (e.g., atrial fibrillation)
- Treatment of underlying hematologic disorders
- Appropriate antimicrobial therapy if associated with infective endocarditis
Monitoring and Complications
Serial clinical examinations and laboratory studies should be performed to monitor for complications 2
Complications of splenic infarction include: 1, 2
- Splenic abscess (occurs in approximately 5% of splenic infarctions)
- Splenic rupture with hemorrhage (rare)
- Pseudocyst formation
Differentiation between uncomplicated infarction and abscess: 3
- Infarcts generally show clinical and radiographic improvement with appropriate therapy
- Ongoing sepsis, recurrent positive blood cultures, and persistence or enlargement of splenic defects on imaging suggest abscess formation
Indications for Surgical Intervention
Splenectomy is indicated for: 3, 2
- Persistent symptoms despite medical management
- Development of splenic abscess
- Splenic rupture with hemorrhage
- Failed non-operative management with continued hemodynamic instability
For splenic abscess specifically: 3
- Definitive treatment is splenectomy with appropriate antibiotics
- Surgery should be performed immediately unless urgent valve surgery is also planned (in cases of infective endocarditis)
- Percutaneous drainage or aspiration may be an alternative for poor surgical candidates
- Laparoscopic splenectomy may be considered as an alternative to formal laparotomy
Special Considerations
In patients with infective endocarditis and splenic abscess: 3, 6
- If valve replacement surgery is needed, splenectomy should ideally be performed first to prevent infection of the prosthetic valve
- Some cases of splenic abscess in infective endocarditis may be cured with antibiotics alone without drainage or surgery
In trauma patients with splenic infarction: 3
- Management follows trauma protocols based on hemodynamic stability and grade of injury
- Non-operative management is preferred in hemodynamically stable patients
- Angiography with embolization may be considered in selected cases