What is the management of splenic infarcts?

Management of Splenic Infarcts

Most splenic infarcts should be managed conservatively with supportive care (hydration, analgesia, monitoring), reserving splenectomy only for life-threatening complications such as splenic rupture, abscess formation, or persistent hemorrhage. 1, 2, 3

Initial Management Approach

Conservative Management (First-Line)

The cornerstone of management for uncomplicated splenic infarction is medical treatment with close monitoring. 3

• Provide intravenous hydration and analgesics for symptom control, with resolution typically occurring within 7-14 days 3
• Monitor hemodynamic stability with frequent vital signs and serial hematocrit measurements 1
• Implement clinical and laboratory observation with bed rest for the first 48-72 hours, particularly in moderate to severe lesions 1
• Watch for signs of complications including persistent or recurrent fever, ongoing abdominal pain, and bacteremia, which suggest progression to splenic abscess or rupture 1, 2

Diagnostic Confirmation

• CT scan with intravenous contrast is the gold standard for diagnosis, with 90-95% sensitivity and specificity, showing peripheral wedge-shaped low-density areas 2, 4
• Repeat CT scanning during admission should be considered in patients with moderate/severe lesions, decreasing hematocrit, vascular anomalies, underlying splenic pathology, coagulopathy, or neurologic impairment 1

Indications for Surgical Intervention (Splenectomy)

Early surgical intervention is necessary to lower mortality when complications develop. 3

Absolute Indications

• Splenic rupture with hemorrhage and hemodynamic instability 1, 2, 5
• Splenic abscess formation that responds poorly to antibiotics alone 1, 2
• Failed non-operative management with continued hemodynamic instability or significant drop in hematocrit requiring continuous transfusions 1, 2

Relative Indications

• Large abscesses that respond poorly to antibiotics alone 1
• Persistent symptoms despite appropriate medical management 3, 6
• Splenic pseudocyst formation causing ongoing symptoms 1, 2

Alternative to Splenectomy

• Percutaneous drainage may be considered for splenic abscesses in high-risk surgical candidates 1

Context-Specific Management

In Hematologic Malignancies (CML)

• Cytoreductive therapy for the underlying CML can lead to successful regression of splenic infarction without surgical intervention 1
• Limit splenectomy to patients with persistent symptoms and complications such as hemorrhage, splenic abscesses, pseudocyst formation, or emergency organ-threatening conditions like splenic rupture 1

In Infective Endocarditis

• Splenic emboli are common but splenic abscesses are rare in this setting 1
• Splenectomy should be performed before valvular surgery unless cardiac surgery is urgent, or rarely both procedures can be performed simultaneously 1
• Treatment consists primarily of appropriate antibiotic regimens for the underlying endocarditis 1

In Trauma Settings

• Management follows trauma protocols based on hemodynamic stability and injury grade 1, 2
• Non-operative management is preferred in hemodynamically stable patients 2

Monitoring for Complications

Clinical Indicators of Progression

• Persistent fever, recurrent bacteremia, or ongoing sepsis suggest abscess formation 1, 2
• Persistence or enlargement of splenic defects on imaging with ongoing clinical deterioration indicates failed conservative management 2
• Differentiation between uncomplicated infarction and abscess is based on clinical and radiographic improvement with appropriate therapy 2

Common Pitfalls

• Clinical splenomegaly is present in only 30% of cases and is not a reliable sign 2
• Splenic infarction is often underdiagnosed clinically - in one autopsy series, only 10% were suspected clinically despite contributing substantially to morbidity and mortality in 44% of cases 7
• Concomitant infarcts in other organ systems occur in 62% of thromboembolic cases, so evaluate for multi-organ involvement 7