What is the initial approach to managing a splenic infarct?

Initial Management of Splenic Infarct

Conservative medical management with close monitoring is the recommended initial approach for uncomplicated splenic infarction, reserving splenectomy only for life-threatening complications such as abscess, rupture, or persistent hemorrhage. 1, 2

Immediate Assessment and Stabilization

Clinical Evaluation

• Left upper quadrant pain is the predominant presenting symptom (present in approximately 69% of cases), often accompanied by fever, tachycardia, and localized tenderness 1, 3
• Approximately 31% of patients may be asymptomatic, particularly those with underlying hematologic disorders 3
• One-third of patients with splenic infarction may die, making risk stratification critical 4

Laboratory Monitoring

Key prognostic markers to assess immediately include:

• Complete blood count: Leukocytosis with neutrophilia (49%), anemia (53%), decreased lymphocytes, and thrombocytosis (7%) 1, 4
• Coagulation studies: Decreased fibrinogen and markedly elevated D-dimer 4
• Biochemical markers: Remarkably elevated LDH and CRP, hypoalbuminemia, liver dysfunction (transaminases), and elevated BUN—these parameters predict mortality 4

Diagnostic Imaging

• CT scan with IV contrast is the preferred diagnostic modality (75% sensitivity), showing peripheral wedge-shaped low-density areas 2, 1
• Liver-spleen scans demonstrate 90% diagnostic accuracy but CT/MRI are superior for differentiating infarction from abscess (90-95% sensitivity and specificity) 2, 1
• Ultrasound is less reliable but may be used for follow-up to minimize radiation exposure 5

Conservative Medical Management Protocol

Initial Treatment (First 7-14 Days)

• Hydration, analgesics, and frequent monitoring constitute the cornerstone of initial management 1
• Admission to a facility with 24/7 emergency surgical capability for at least the first 24 hours in a monitored setting 2
• Bed rest for 48-72 hours with continuous clinical and laboratory observation 2, 6
• Symptoms typically resolve within 7-14 days with conservative management 1

Monitoring for Complications

• Monitor intra-abdominal pressure in patients at risk to detect abdominal compartment syndrome early 2
• Repeat CT imaging at 48-72 hours if clinical deterioration occurs, persistent fever develops, or bacteremia recurs 2
• Watch specifically for contrast extravasation >15mm, which has 100% positive predictive value for delayed rupture when combined with hypotension 2

Identification of Underlying Etiology

Age-Based Risk Stratification

• Patients <40 years: Most commonly have hematologic disorders (sickle cell disease, leukemia, myeloproliferative disorders) 1, 3
• Patients >41 years: Most commonly have embolic events (atrial fibrillation, endocarditis, atherosclerotic disease) 1, 7
• Recent trend: Increasing cases due to infection, particularly COVID-19 4

Specific Etiologies Requiring Targeted Management

• Infective endocarditis: Only 5% of splenic infarctions progress to abscess, but persistent bacteremia mandates imaging 2
• Atrial fibrillation (22.2% of cases): Requires anticoagulation consideration 4
• Malignancy (33.3% of cases): May require oncologic management 4
• Malaria: Conservative management is preferred; outcome is generally favorable 5

Indications for Surgical Intervention

Absolute Indications for Emergency Splenectomy

Splenectomy must be performed immediately for:

• Splenic abscess (responds poorly to antibiotics alone; definitive treatment requires splenectomy) 2
• Splenic rupture with hemorrhage (rare but life-threatening complication) 2
• Persistent symptoms beyond 2 weeks despite appropriate medical management 1
• Complications including pseudocyst formation or subcapsular hemorrhage requiring intervention 2, 1

Alternative to Splenectomy

• Percutaneous drainage may be considered for splenic abscess in poor surgical candidates 2
• Laparoscopic splenectomy can be an alternative to open laparotomy in stable patients, but is contraindicated in acute trauma with active bleeding 2, 8

Critical Timing Consideration

• If valve replacement surgery is planned for endocarditis, perform splenectomy first to prevent prosthetic valve infection from abscess bacteremia 2

Post-Splenectomy Protocols (If Required)

If splenectomy becomes necessary, lifelong infection prevention is mandatory:

• Vaccination protocol: Pneumococcal, meningococcal, and Haemophilus influenzae type B vaccines 9, 8
• Lifelong antibiotic prophylaxis to prevent overwhelming post-splenectomy infection (OPSI), which carries significant mortality risk 9, 8

Common Pitfalls to Avoid

• Do not discharge patients prematurely: Most complications occur within the first 5 days, with hemorrhagic risk maximal in the first 24 hours 2
• Do not miss splenic abscess: Ongoing sepsis, recurrent positive blood cultures, and persistence/enlargement of splenic defects on repeat imaging distinguish abscess from bland infarction 2
• Do not underestimate mortality risk: Concomitant infarcts in other organ systems occur in 62% of thromboembolic cases 7
• Do not omit OPSI protocols if splenectomy is performed—this represents a lifelong risk of fulminant infection 8