Is it possible that there's hematoma (blood clot) formation after aspiration of a splenic abscess in a patient with a recent history of aspiration and underlying infective endocarditis, given that it's only days after the procedure?

Hematoma Formation After Splenic Abscess Aspiration

Yes, hematoma formation is a recognized complication after splenic abscess aspiration, and this risk is explicitly acknowledged in clinical guidelines as a reason to carefully select patients for percutaneous procedures.

Understanding the Risk of Hemorrhage

The ACR Appropriateness Criteria specifically state that percutaneous catheter drainage (PCD) carries a risk of hemorrhage if a nontarget puncture occurs, which is why splenectomy is often performed when there is no favorable window for intervention or when the patient is at high risk of bleeding 1. This hemorrhagic risk applies to both aspiration and catheter drainage procedures.

Why Hematoma Can Occur

• Splenic tissue is highly vascular and fragile, particularly when inflamed or infected, making it susceptible to bleeding during needle puncture 2
• The spleen receives approximately 5% of cardiac output, creating a high-pressure vascular environment that increases bleeding risk with any percutaneous intervention 3
• Subcapsular abscesses pose particularly high risk for capsular disruption and subsequent hemorrhage, as the splenic capsule becomes weakened by the infectious process 2

Clinical Presentation in Your Scenario

In a patient only days after aspiration with underlying infective endocarditis, several factors increase concern:

• Endocarditis-related splenic abscesses have inherently fragile tissue due to septic embolic injury and infarction, with 40% of left-sided IE cases developing splenic complications 1
• The American Heart Association notes that splenic rupture with hemorrhage is a rare but recognized complication of splenic infarction and abscess in IE patients 1
• Post-procedure hematoma can present with new or worsening left upper quadrant pain, falling hematocrit, hemodynamic instability, or enlarging perisplenic fluid collection on imaging 4

Immediate Diagnostic Approach

Obtain urgent CT scan with IV contrast to differentiate between hematoma, persistent/enlarging abscess, or bland infarction, as this modality has 90-95% sensitivity and specificity for identifying splenic pathology 1, 3. The CT will show:

• Hematoma: High-density perisplenic or intrasplenic fluid collection without enhancement
• Persistent abscess: Contrast-enhancing cystic lesion with possible air-fluid levels
• Active bleeding: Contrast extravasation or sentinel clot sign

Management Algorithm Based on Findings

If Hematoma Without Active Bleeding:

• Monitor hemodynamic stability with serial hematocrit measurements every 4-6 hours and maintain strict bed rest 3
• Continue broad-spectrum IV antibiotics targeting S. aureus and viridans streptococci (40% each in IE-related cases) 1
• Avoid anticoagulation and antiplatelet agents; if the patient requires these for IE management, this creates a critical clinical dilemma requiring multidisciplinary discussion 1

If Hemodynamic Instability or Expanding Hematoma:

• Proceed immediately to splenectomy, as the American College of Surgeons recommends this for splenic rupture with hemorrhage and hemodynamic instability 3, 5
• The American Heart Association emphasizes that splenectomy should ideally be performed before valve replacement surgery to prevent reinfection of the valve prosthesis from bacteremia 1

If Persistent Abscess Rather Than Hematoma:

• Consider catheter drainage rather than repeat aspiration, as the ACR guidelines show catheter drainage has 80-90% success rates versus aspiration alone 1, 3
• Continue drainage until output is <10-20cc daily and repeat imaging confirms resolution 1, 3

Critical Pitfalls to Avoid

• Do not attempt needle aspiration of a suspected hematoma, as this risks introducing infection into a sterile blood collection and can worsen bleeding 1
• Do not rely on clinical examination alone—splenomegaly is present in only 30% of IE cases with splenic complications and is not a reliable sign 1, 3, 5
• Avoid premature reassurance—persistent or recurrent bacteremia, ongoing fever, or worsening abdominal pain days after aspiration should trigger immediate reimaging 1
• The Society of Interventional Radiology warns that low-molecular-weight heparin predisposes to hematoma formation and should be avoided in the immediate post-procedure period 1

Special Consideration for IE Context

Given the underlying infective endocarditis, maintain heightened vigilance for ongoing septic embolization that could create new splenic lesions independent of the aspiration procedure 3, 5. The American Heart Association notes that differentiation between complications of the procedure versus disease progression can be challenging and requires serial imaging 1.