Splenic infarction

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Splenic infarction
SplenicInfarctMark.png
Splenic infarct seen on CT
Specialty General surgery
Healed splenic infarcts, the largest is the pale area, upper surface Healed splenic infarcts.jpg
Healed splenic infarcts, the largest is the pale area, upper surface

Splenic infarction is a condition in which blood flow supply to the spleen is compromised, [1] leading to partial or complete infarction (tissue death due to oxygen shortage) in the organ. [2] Splenic infarction occurs when the splenic artery or one of its branches are occluded, for example by a blood clot. [3]

Contents

In one series of 59 patients, mortality amounted to 5%. [3] Complications include a ruptured spleen, bleeding, an abscess of the spleen (for example, if the underlying cause is infective endocarditis) or pseudocyst formation. Splenectomy may be warranted for persistent pseudocysts due to the high risk of subsequent rupture. [4]

Diagnosis

Although it can occur asymptomatically, the typical symptom is severe pain in the left upper quadrant of the abdomen, sometimes radiating to the left shoulder. Fever and chills develop in some cases. [3] It has to be differentiated from other causes of acute abdomen.

An abdominal CT scan is the most commonly used modality to confirm the diagnosis, [3] although abdominal ultrasound can also contribute. [5] [6] [7]

Treatment

There is no specific treatment, except treating the underlying disorder and providing adequate pain relief. Surgical removal of the spleen (splenectomy) is only required if complications ensue; surgical removal predisposes to overwhelming post-splenectomy infections. [8]

Causes

Splenic infarct seen on CT SplenicInfarctUpMark.png
Splenic infarct seen on CT
Healed splenic infarct Healed splenic infarct.jpg
Healed splenic infarct

Several factors may increase the tendency for clot formation, such as specific infections (such as infectious mononucleosis, [9] [ dubious – discuss ][ better source needed ] cytomegalovirus infection, [10] malaria, [11] or babesiosis [12] ), inherited clotting disorders (thrombophilia, such as Factor V Leiden, antiphospholipid syndrome), malignancy (such as pancreatic cancer) or metastasis, or a combination [13] of these factors.

In some conditions, blood clots form in one part of the circulatory system and then dislodge and travel to another part of the body, which could include the spleen. These emboligenic disorders include atrial fibrillation, patent foramen ovale, endocarditis or cholesterol embolism.

Splenic infarction is also more common in hematological disorders with associated splenomegaly, such as the myeloproliferative disorders. Other causes of splenomegaly (for example, Gaucher disease or hemoglobinopathies) can also predispose to infarction. Splenic infarction can also result from a sickle cell crisis in patients with sickle cell anemia. Both splenomegaly and a tendency towards clot formation feature in this condition. In sickle cell disease, repeated splenic infarctions lead to a non-functional spleen (autosplenectomy).

Any factor that directly compromises the splenic artery can cause infarction. Examples include abdominal traumas, aortic dissection, torsion of the splenic artery (for example, in wandering spleen) or external compression on the artery by a tumor. It can also be a complication of vascular procedures. [14]

Splenic infarction can be due to vasculitis or disseminated intravascular coagulation. Various other conditions have been associated with splenic infarction in case reports, for example granulomatosis with polyangiitis [15] or treatment with medications that predispose to vasospasm or blood clot formation, such as vasoconstrictors used to treat esophageal varices, sumatriptan [16] or bevacizumab. [17]

In a single-center retrospective cases review, people who were admitted to the hospital with a confirmed diagnosis of acute splenic infarction, cardiogenic emboli was the dominant etiology followed by atrial fibrillation, autoimmune disease, associated infection, and hematological malignancy. [18] In spite of those already had risk factors of developing splenic infarction, there were nine beforehand healthy people. And among them, 5 of 9 hitherto silent antiphospholipid syndrome or mitral valve disease had been identified. [18] Two remained cryptogenic. [18]

Therapeutic infarction

Splenic infarction can be induced for the treatment of such conditions as portal hypertension or splenic injury. [19] It can also be used prior to splenectomy for the prevention of blood loss.

Related Research Articles

<span class="mw-page-title-main">Spleen</span> Immune organ that filters blood

The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The native Old English word for it is milt, now primarily used for animals; a loanword from Latin is lien.

<span class="mw-page-title-main">Waterhouse–Friderichsen syndrome</span> Adrenal gland failure from internal bleeding, often due to infection

Waterhouse–Friderichsen syndrome (WFS) is defined as adrenal gland failure due to bleeding into the adrenal glands, commonly caused by severe bacterial infection. Typically, it is caused by Neisseria meningitidis.

<span class="mw-page-title-main">Thrombosis</span> Formation of blood clots inside the blood vessels

Thrombosis is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets (thrombocytes) and fibrin to form a blood clot to prevent blood loss. Even when a blood vessel is not injured, blood clots may form in the body under certain conditions. A clot, or a piece of the clot, that breaks free and begins to travel around the body is known as an embolus.

<span class="mw-page-title-main">Splenectomy</span> Surgical removal of the spleen

A splenectomy is the surgical procedure that partially or completely removes the spleen. The spleen is an important organ in regard to immunological function due to its ability to efficiently destroy encapsulated bacteria. Therefore, removal of the spleen runs the risk of overwhelming post-splenectomy infection, a medical emergency and rapidly fatal disease caused by the inability of the body's immune system to properly fight infection following splenectomy or asplenia.

<span class="mw-page-title-main">Hereditary spherocytosis</span> Genetic disorder causing red blood cells to be spherical

Hereditary spherocytosis (HS) is a congenital hemolytic disorder wherein a genetic mutation coding for a structural membrane protein phenotype causes the red blood cells to be sphere-shaped (spherocytosis), rather than the normal biconcave disk shape. This abnormal shape interferes with the cells' ability to flex during blood circulation, and also makes them more prone to rupture under osmotic stress, mechanical stress, or both. Cells with the dysfunctional proteins are degraded in the spleen, which leads to a shortage of erythrocytes and results in hemolytic anemia.

Asplenia refers to the absence of normal spleen function and is associated with some serious infection risks. Hyposplenism is used to describe reduced ('hypo-') splenic functioning, but not as severely affected as with asplenism.

<span class="mw-page-title-main">Splenomegaly</span> Enlargement of the spleen

Splenomegaly is an enlargement of the spleen. The spleen usually lies in the left upper quadrant (LUQ) of the human abdomen. Splenomegaly is one of the four cardinal signs of hypersplenism which include: some reduction in number of circulating blood cells affecting granulocytes, erythrocytes or platelets in any combination; a compensatory proliferative response in the bone marrow; and the potential for correction of these abnormalities by splenectomy. Splenomegaly is usually associated with increased workload, which suggests that it is a response to hyperfunction. It is therefore not surprising that splenomegaly is associated with any disease process that involves abnormal red blood cells being destroyed in the spleen. Other common causes include congestion due to portal hypertension and infiltration by leukemias and lymphomas. Thus, the finding of an enlarged spleen, along with caput medusae, is an important sign of portal hypertension.

An autosplenectomy is a negative outcome of disease and occurs when a disease damages the spleen to such an extent that it becomes shrunken and non-functional. The spleen is an important immunological organ that acts as a filter for red blood cells, triggers phagocytosis of invaders, and mounts an immunological response when necessary. Lack of a spleen, called asplenia, can occur by autosplenectomy or the surgical counterpart, splenectomy. Asplenia can increase susceptibility to infection. Autosplenectomy can occur in cases of sickle-cell disease where the misshapen cells block blood flow to the spleen, causing scarring and eventual atrophy of the organ. Autosplenectomy is a rare condition that is linked to certain diseases but is not a common occurrence. It is also seen in systemic lupus erythematosus (SLE).

Primary myelofibrosis (PMF) is a rare bone marrow blood cancer. It is classified by the World Health Organization (WHO) as a type of myeloproliferative neoplasm, a group of cancers in which there is activation and growth of mutated cells in the bone marrow. This is most often associated with a somatic mutation in the JAK2, CALR, or MPL genes. In PMF, the bony aspects of bone marrow are remodeled in a process called osteosclerosis; in addition, fibroblast secrete collagen and reticulin proteins that are collectively referred to as (fibrosis). These two pathological processes compromise the normal function of bone marrow resulting in decreased production of blood cells such as erythrocytes, granulocytes and megakaryocytes, the latter cells responsible for the production of platelets.

<span class="mw-page-title-main">Splenic vein</span> Vein that drains blood from the spleen, stomach and pancreas

In human anatomy, the splenic vein is a blood vessel that drains blood from the spleen, the stomach fundus and part of the pancreas. It is part of the hepatic portal system.

<span class="mw-page-title-main">Splenic injury</span> Injury to the spleen

A splenic injury, which includes a ruptured spleen, is any injury to the spleen. The rupture of a normal spleen can be caused by trauma, such as a traffic collision.

<span class="mw-page-title-main">Portal vein thrombosis</span> Formation of a blood clot in the hepatic portal vein, reducing blood to the liver

Portal vein thrombosis (PVT) is a vascular disease of the liver that occurs when a blood clot occurs in the hepatic portal vein, which can lead to increased pressure in the portal vein system and reduced blood supply to the liver. The mortality rate is approximately 1 in 10.

Felty's syndrome (FS), also called Felty syndrome, is a rare autoimmune disease characterized by the triad of rheumatoid arthritis, enlargement of the spleen and low neutrophil count. The condition is more common in those aged 50–70 years, specifically more prevalent in females than males, and more so in Caucasians than those of African descent. It is a deforming disease that causes many complications for the individual.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">Wandering spleen</span> Medical condition

Wandering spleen is a rare medical disease caused by the loss or weakening of the ligaments that help to hold the spleen stationary.

Juvenile myelomonocytic leukemia (JMML) is a rare form of chronic leukemia that affects children, commonly those aged four and younger. The name JMML now encompasses all diagnoses formerly referred to as juvenile chronic myeloid leukemia (JCML), chronic myelomonocytic leukemia of infancy, and infantile monosomy 7 syndrome. The average age of patients at diagnosis is two (2) years old. The World Health Organization has included JMML as a subcategory of myelodysplastic and myeloproliferative disorders.

<span class="mw-page-title-main">Sickle cell disease</span> Medical condition

Sickle cell disease (SCD), also simply called sickle cell, is a group of hemoglobin-related blood disorders that are typically inherited. The most common type is known as sickle cell anemia. Sickle cell anemia results in an abnormality in the oxygen-carrying protein haemoglobin found in red blood cells. This leads to the red blood cells adopting an abnormal sickle-like shape under certain circumstances; with this shape, they are unable to deform as they pass through capillaries, causing blockages. Problems in sickle cell disease typically begin around 5 to 6 months of age. A number of health problems may develop, such as attacks of pain in joints, anemia, swelling in the hands and feet, bacterial infections, dizziness and stroke. The probability of severe symptoms, including long-term pain, increases with age. Without treatment, people with SCD rarely reach adulthood but with good healthcare, median life expectancy is between 58 and 66 years. All the major organs are affected by sickle cell disease. The liver, heart, kidneys, gallbladder, eyes, bones, and joints also can suffer damage from the abnormal functions of the sickle cells, and their inability to flow through the small blood vessels correctly.

Congenital hemolytic anemia (CHA) is a diverse group of rare hereditary conditions marked by decreased life expectancy and premature removal of erythrocytes from blood flow. Defects in erythrocyte membrane proteins and red cell enzyme metabolism, as well as changes at the level of erythrocyte precursors, lead to impaired bone marrow erythropoiesis. CHA is distinguished by variable anemia, chronic extravascular hemolysis, decreased erythrocyte life span, splenomegaly, jaundice, biliary lithiasis, and iron overload. Immune-mediated mechanisms may play a role in the pathogenesis of these uncommon diseases, despite the paucity of data regarding the immune system's involvement in CHAs.

Cold autoimmune hemolytic anemia caused by cold-reacting antibodies. Autoantibodies that bind to the erythrocyte membrane leading to premature erythrocyte destruction (hemolysis) characterize autoimmune hemolytic anemia.

<span class="mw-page-title-main">Spleen pain</span> Human pain from the area of the spleen

Spleen pain is a pain felt from the left upper quadrant of the abdomen or epigastrium where the human spleen is located or neighboring.

References

  1. ↑ Chapman, J; Bhimji, SS (2018), "article-29380", Splenic Infarcts, Treasure Island (FL): StatPearls Publishing, PMID   28613652 , retrieved 2019-02-27
  2. ↑ Jaroch MT, Broughan TA, Hermann RE (October 1986). "The natural history of splenic infarction". Surgery. 100 (4): 743–50. PMID   3764696.
  3. 1 2 3 4 Nores M, Phillips EH, Morgenstern L, Hiatt JR (February 1998). "The clinical spectrum of splenic infarction". Am Surg. 64 (2): 182–8. PMID   9486895.
  4. ↑ Pachter HL, Hofstetter SR, Elkowitz A, Harris L, Liang HG (September 1993). "Traumatic cysts of the spleen--the role of cystectomy and splenic preservation: experience with seven consecutive patients". J Trauma. 35 (3): 430–6. doi:10.1097/00005373-199309000-00016. PMID   8371303.
  5. ↑ Görg C, Seifart U, Görg K (2004). "Acute, complete splenic infarction in cancer patient is associated with a fatal outcome". Abdom Imaging. 29 (2): 224–7. doi:10.1007/s00261-003-0108-9. PMID   15290950. S2CID   31332720.
  6. ↑ O'Keefe JH, Holmes DR, Schaff HV, Sheedy PF, Edwards WD (December 1986). "Thromboembolic splenic infarction". Mayo Clin. Proc. 61 (12): 967–72. doi:10.1016/s0025-6196(12)62638-x. PMID   3773568.
  7. ↑ Frippiat F, Donckier J, Vandenbossche P, Stoffel M, Boland B, Lambert M (1996). "Splenic infarction: report of three cases of atherosclerotic embolization originating in the aorta and retrospective study of 64 cases". Acta Clin Belg. 51 (6): 395–402. doi:10.1080/22953337.1996.11718537. PMID   8997756.
  8. ↑ Salvi PF, Stagnitti F, Mongardini M, Schillaci F, Stagnitti A, Chirletti P (2007). "Splenic infarction, rare cause of acute abdomen, only seldom requires splenectomy. Case report and literature review". Ann Ital Chir. 78 (6): 529–32. PMID   18510036.
  9. ↑ Suzuki Y, Shichishima T, Mukae M, et al. (June 2007). "Splenic infarction after Epstein-Barr virus infection in a patient with hereditary spherocytosis". Int. J. Hematol. 85 (5): 380–3. doi:10.1532/IJH97.07208. PMID   17562611. S2CID   36770769.
  10. ↑ Rawla, P; Vellipuram, AR; Bandaru, SS; Raj, JP (2017). "Splenic Infarct and Pulmonary Embolism as a Rare Manifestation of Cytomegalovirus Infection". Case Reports in Hematology. 2017: 1850821. doi: 10.1155/2017/1850821 . PMC   5660763 . PMID   29158925.
  11. ↑ Bonnard P, Guiard-Schmid JB, Develoux M, Rozenbaum W, Pialoux G (January 2005). "Splenic infarction during acute malaria". Trans. R. Soc. Trop. Med. Hyg. 99 (1): 82–6. doi:10.1016/j.trstmh.2004.06.005. PMID   15550267.
  12. ↑ Florescu D, Sordillo PP, Glyptis A, et al. (January 2008). "Splenic infarction in human babesiosis: two cases and discussion". Clin. Infect. Dis. 46 (1): e8–11. doi: 10.1086/524081 . PMID   18171204.
  13. ↑ Breuer C, Janssen G, Laws HJ, et al. (December 2008). "Splenic infarction in a patient hereditary spherocytosis, protein C deficiency and acute infectious mononucleosis". Eur. J. Pediatr. 167 (12): 1449–52. doi:10.1007/s00431-008-0781-3. PMID   18604554. S2CID   2702794.
  14. ↑ Almeida JA, Riordan SM (2008). "Splenic infarction complicating percutaneous transluminal coeliac artery stenting for chronic mesenteric ischaemia: a case report". J Med Case Rep. 2: 261. doi: 10.1186/1752-1947-2-261 . PMC   2533016 . PMID   18684317.
  15. ↑ Langlois, V; Lesourd, A; Girszyn, N; Ménard, JF; Levesque, H; Caron, F; Marie, I (January 2016). "Antineutrophil Cytoplasmic Antibodies Associated With Infective Endocarditis". Medicine (Baltimore). 95 (3): e2564. doi:10.1097/MD.0000000000002564. PMC   4998285 . PMID   26817911.
  16. ↑ Arora A, Arora S (September 2006). "Spontaneous splenic infarction associated with sumatriptan use". J Headache Pain. 7 (4): 214–6. doi:10.1007/s10194-006-0291-5. PMC   3476041 . PMID   16767537.
  17. ↑ Malka D, Van den Eynde M, Boige V, Dromain C, Ducreux M (December 2006). "Splenic infarction and bevacizumab". Lancet Oncol. 7 (12): 1038. doi:10.1016/S1470-2045(06)70980-9. PMID   17138227.
  18. 1 2 3 Ami, S; Meital, A; Ella, K; Abraham, K (2015-09-11). "Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome". Medicine. 94 (36): e1363. doi:10.1097/MD.0000000000001363. PMC   4616622 . PMID   26356690.
  19. ↑ Haan JM, Bochicchio GV, Kramer N, Scalea TM (March 2005). "Nonoperative management of blunt splenic injury: a 5-year experience". J Trauma. 58 (3): 492–8. doi:10.1097/01.TA.0000154575.49388.74. PMID   15761342.
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