Initial Workup and Management of Splenic Infarction
The initial workup for a patient with suspected splenic infarction should include contrast-enhanced CT scan as the gold standard diagnostic test, followed by appropriate etiological investigation to determine the underlying cause, which is most commonly thromboembolic or hematologic in nature. 1, 2
Diagnostic Approach
Initial Assessment
- Evaluate for left upper quadrant abdominal pain, fever, tachycardia, and signs of systemic inflammation, which are the most common presenting symptoms of splenic infarction 2
- Consider splenic infarction in patients with known hematologic disorders or thromboembolic conditions who develop left upper quadrant pain 2
- Assess hemodynamic stability (systolic blood pressure ≥90 mmHg without signs of skin vasoconstriction, altered consciousness, or shortness of breath) 3
Imaging Studies
- Contrast-enhanced CT scan is the gold standard for diagnosis of splenic infarction 3, 1
- Doppler ultrasound (DUS) and contrast-enhanced ultrasound (CEUS) can be useful adjuncts to evaluate splenic vascularization and for follow-up 3
- CT findings typically show wedge-shaped hypodense lesions in the spleen 1
Laboratory Evaluation
- Complete blood count to assess for anemia, leukocytosis, and thrombocytosis, which are common findings in splenic infarction 4
- Coagulation profile to evaluate for hypercoagulable states 5
- Blood cultures if infectious etiology is suspected, particularly in cases of suspected infective endocarditis 6
Etiological Investigation
Evaluate for hematologic disorders (particularly in patients under 40 years old) 4
- Leukemia, lymphoma, myeloproliferative disorders
- Sickle cell disease
- Hypercoagulable states
Assess for thromboembolic sources (more common in patients over 40 years old) 4
- Atrial fibrillation
- Valvular heart disease
- Infective endocarditis
- Atherosclerotic disease
- Recent myocardial infarction
Consider other potential causes 2
- Collagen vascular diseases
- Pancreatic disorders
- Splenic vascular abnormalities
Management Protocol
Initial Management
- Admit to an institution with 24/7 capacity to perform emergency interventions 3
- Provide continuous monitoring for at least the first 24 hours in an intensive care unit 3
- Implement clinical and laboratory observation for a minimum of 3-5 days 3
- Administer intravenous fluids for hydration 4
- Provide appropriate analgesia for pain control 4
- Monitor for intra-abdominal pressure elevation to detect abdominal compartment syndrome early 3
Conservative Management
- Most uncomplicated splenic infarctions can be managed conservatively with resolution of symptoms typically occurring within 7-14 days 4
- Maintain bed rest for the first 48-72 hours 3
- Perform serial clinical examinations and laboratory monitoring 3
Anticoagulation Considerations
- Consider anticoagulation in cases with cardioembolic etiology, particularly atrial fibrillation 5
- Balance anticoagulation decisions carefully in patients with concurrent hematologic disorders that may increase bleeding risk 5
Follow-up Imaging
- Consider repeat CT scan before hospital discharge and/or when complications are suspected 3
- Particularly important in patients with moderate to severe lesions, decreasing hematocrit, vascular anomalies, underlying splenic pathology, coagulopathy, or neurological impairment 7
Indications for Surgical Intervention
- Persistent symptoms despite conservative management 4
- Development of complications such as 4:
- Splenic abscess
- Splenic rupture or hemorrhage
- Pseudocyst formation
- Hemodynamic instability or signs of persistent hemorrhage 7
Complications to Monitor For
- Splenic abscess formation, particularly in patients with infective endocarditis 6
- Splenic rupture, which can be life-threatening 2
- Pseudocyst formation 4
- Abdominal compartment syndrome 3
By following this structured approach to the diagnosis and management of splenic infarction, clinicians can ensure appropriate care while minimizing the risk of complications and optimizing patient outcomes.