What is the management approach for a patient with a splenic infarct?

Management of Splenic Infarction

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

Initial Assessment and Stabilization

Verify hemodynamic stability immediately by assessing blood pressure, heart rate, capillary refill, mental status, and shock index. 2 This determines whether conservative management is appropriate or immediate surgical intervention is required.

• Admit to a facility with 24/7 emergency surgical capability for at least the first 24 hours in a monitored setting. 3
• Implement bed rest for 48-72 hours with continuous clinical and laboratory observation, particularly for moderate to severe lesions. 1, 2, 3
• Monitor hemodynamic stability with frequent vital signs and serial hematocrit measurements. 1, 2

Diagnostic Imaging

CT scan with intravenous contrast is the gold standard for diagnosis, showing peripheral low-density, wedge-shaped areas with 90-95% sensitivity and specificity. 1, 2

• 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. 4, 2
• Doppler ultrasound should be added to evaluate splenic vascularization and detect vascular complications. 1

Conservative Management Protocol

The cornerstone of management is clinical and laboratory observation with bed rest for the first 48-72 hours, particularly in moderate and severe lesions. 4, 1

• Watch for signs of complications including persistent or recurrent fever, ongoing abdominal pain, and bacteremia, which suggest progression to splenic abscess. 1, 2
• Activity restriction for 4-6 weeks in minor injuries and up to 2-4 months in moderate and severe injuries is recommended. 2
• Complete healing typically occurs in 12.5 days for grades I-II and 37.2 days for grades III-V. 2

Differentiating Bland Infarction from Abscess

This distinction is critical as it determines whether conservative management can continue or surgery is required.

• Bland infarcts show clinical and radiographic improvement during appropriate antibiotic therapy (if underlying infection present). 1, 2
• Splenic abscess is suggested by ongoing sepsis, recurrent positive blood cultures, and persistence or enlargement of splenic defects on CT/MRI. 1, 2
• On imaging, abscesses appear as single or multiple contrast-enhancing cystic lesions, while infarcts are peripheral wedge-shaped low-density areas. 1, 2
• Repeat CT imaging at 48-72 hours if clinical deterioration occurs, persistent fever develops, or bacteremia recurs. 3

Absolute Indications for Splenectomy

Splenectomy must be performed immediately in the following scenarios:

• Splenic rupture with hemorrhage and hemodynamic instability requires immediate surgical intervention. 1, 2, 3
• Splenic abscess formation that responds poorly to antibiotics alone requires definitive treatment with splenectomy and appropriate antibiotics. 4, 1, 2, 3
• Failed non-operative management with continued hemodynamic instability or significant drop in hematocrit requiring continuous transfusions. 1, 2
• Persistent symptoms with complications including hemorrhage, pseudocyst formation, or organ-threatening conditions. 4, 1

Alternative Surgical Options

• Percutaneous drainage or aspiration 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

Context-Specific Management

Hematologic Malignancies (e.g., CML)

In patients with hematologic malignancies, cytoreductive therapy can lead to successful regression of splenic infarction without surgical intervention. 4, 1 Splenectomy should be limited to patients with persistent symptoms and complications. 4

Infective Endocarditis

Splenectomy should be performed before valve replacement surgery (if possible) to mitigate the risk of prosthetic valve infection from bacteremia. 1, 2 However, if cardiac surgery is urgent, proceed with valve replacement first. 1

• Splenic infarction occurs in 40% of left-sided endocarditis cases, but only 5% progress to splenic abscess. 2
• Persistent or recurrent bacteremia despite appropriate antibiotics mandates imaging evaluation for abscess. 2

Trauma-Related Infarction

Management of trauma-related splenic infarction follows trauma protocols based on hemodynamic stability and injury grade, with non-operative management preferred in stable patients. 4, 2

• Angiography/angioembolization may be performed in hemodynamically stable patients with vascular injuries at CT scan. 4, 2
• Non-operative management is contraindicated in the setting of unresponsive hemodynamic instability or other indications for laparotomy (peritonitis, hollow organ injuries, bowel evisceration, impalement). 4

Post-Splenectomy Protocols

If splenectomy is performed, lifelong infection prevention is mandatory:

• Vaccination protocol with pneumococcal, meningococcal, and Haemophilus influenzae type B vaccines. 3
• Lifelong antibiotic prophylaxis to prevent overwhelming post-splenectomy infection (OPSI), which carries significant mortality risk. 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
• Avoid nuclear medicine scans as they are obsolete and provide no diagnostic value. 1
• Delayed rupture can occur within the first 48 hours but more commonly between 4-10 days after the initial event, requiring vigilant monitoring. 2
• Monitor intra-abdominal pressure in patients at risk to detect abdominal compartment syndrome early. 3