What is the management plan for a patient with a splenic infarct diagnosed on computed tomography (CT) scan?

Management of Splenic Infarct on CT

Initial Management: Conservative Approach

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

Immediate Assessment and Monitoring

• Verify hemodynamic stability by checking blood pressure (>90 mmHg systolic), heart rate, capillary refill, mental status, and shock index (<1). 3
• Implement bed rest for 48-72 hours with intensive clinical observation, particularly for moderate to severe infarctions. 1, 2
• Monitor serial hematocrit measurements and vital signs frequently to detect occult bleeding. 1, 2
• Watch for complications including persistent or recurrent fever, ongoing left upper quadrant pain, and signs of bacteremia that suggest progression to splenic abscess. 1, 2

Diagnostic Confirmation

• CT scan with intravenous contrast is the gold standard (90-95% sensitivity/specificity), showing peripheral wedge-shaped low-density areas for bland infarcts. 1, 2
• Consider repeat CT imaging during admission if the patient has moderate/severe lesions, decreasing hematocrit, vascular anomalies, coagulopathy, or neurologic impairment. 2
• Add Doppler ultrasound to evaluate splenic vascularization and detect vascular complications. 1

Differentiating Bland Infarction from Abscess

This distinction is critical because it determines whether conservative management can continue or surgery is required:

• Bland infarcts improve clinically and radiographically with treatment of the underlying cause (e.g., anticoagulation for embolic disease, cytoreductive therapy for hematologic malignancy). 1, 2
• Splenic abscess is indicated by ongoing sepsis, recurrent positive blood cultures, and persistence or enlargement of splenic defects on serial imaging. 1, 2
• On imaging, abscesses appear as single or multiple contrast-enhancing cystic lesions, while infarcts remain peripheral wedge-shaped low-density areas. 1, 2

Absolute Indications for Splenectomy

Proceed immediately to surgery if any of the following develop:

• Splenic rupture with hemorrhage and hemodynamic instability (systolic BP <90 mmHg despite resuscitation, ongoing transfusion requirements). 1, 2
• Splenic abscess formation that responds poorly to antibiotics alone, confirmed by persistent fever, bacteremia, and enlarging cystic lesions on CT. 1, 2
• Failed non-operative management with continued hemodynamic instability or significant hematocrit drop requiring continuous transfusions. 1, 2

Surgical Alternatives

• Percutaneous drainage may be considered for splenic abscesses in high-risk surgical candidates who cannot tolerate splenectomy. 1, 2
• Laparoscopic splenectomy is an alternative to formal laparotomy when surgery is required in stable patients. 1, 2

Activity Restriction and Follow-Up

• Restrict activity for 4-6 weeks in minor injuries and up to 2-4 months in moderate and severe injuries. 2
• Complete healing typically occurs in 12.5 days for minor infarcts and 37.2 days for severe infarcts, with 84% showing complete resolution by 2-2.5 months. 2
• Delayed rupture can occur within the first 48 hours but more commonly between 4-10 days, requiring vigilant monitoring during this period. 2

Context-Specific Considerations

Infective Endocarditis

• Splenic infarction occurs in 40% of left-sided endocarditis cases, but only 5% progress to abscess. 2
• Perform splenectomy before valve replacement surgery (if possible) to prevent prosthetic valve infection from bacteremia, unless cardiac surgery is urgent. 1, 2

Hematologic Malignancies

• Cytoreductive therapy can lead to successful regression of splenic infarction without surgical intervention in patients with chronic myeloid leukemia or other hematologic disorders. 1

Trauma-Related Infarction

• Management follows trauma protocols based on hemodynamic stability and injury grade, with non-operative management preferred in stable patients. 3
• Angiography/angioembolization may be performed in hemodynamically stable patients with vascular injuries at CT scan (contrast blush, pseudoaneurysms). 3

Common Pitfalls to Avoid

• Do not rely on clinical splenomegaly as a reliable indicator of infarction severity—it is present in only 30% of cases. 1, 2
• Do not order obsolete nuclear medicine scans (99mTc liver-spleen scans, labeled white blood cell scans, gallium scans) as they provide no diagnostic value. 1
• Do not assume absence of contrast blush excludes active bleeding in high-grade injuries—serial monitoring and repeat imaging may be necessary. 3