Splenic infarction

The most disturbing adverse reaction to clofazimine is a red-brown discoloration of the skin, especially in light-skinned persons. A rare but serious adverse reaction is acute abdominal pain significant enough to warrant exploratory laparotomy or laparoscopy. Other infrequent side effects include splenic infarction, bowel obstruction, paralytic ileus, and upper GI bleeding. 

A 55-year-old woman with a history of chronic pancreatitis developed epigastric pain and melena and was found to have a splenic artery pseudoaneurysm expanding a pseudocyst. She was given an intravenous bolus of octreotide followed by an infusion of 50 micrograms/ hour. A CT scan subsequently suggested thrombosis of the pseudoaneurysm, with segmental splenic infarction. Nine months later the pseudoaneurysm had recanalized. 

Splenic infarction related to cocaine abuse is extremely rare and has been reported as a possible complication in patients with sickle cell hemoglobinopathies. 

A 17-year-old cocaine abuser was found dead in bed. Autopsy showed signs of sepsis, splenic infarctions of different ages, and splenic necrosis with abscesses. The splenic abscesses and microabscesses in various other organs showed mixed bacterial infections (188). 

Dettmeyer R, Schlamann M, Madea B. Cocaine-associated abscesses with lethal sepsis after splenic infarction in a 17-year-old woman. Forensic Sci Int 2004 140 210-3. 

See micro. Splenic infarct, 1/4 Pneumonia, granulomatous, 1/4 Pneumonitis, chronic 1/4... 

Friction rub A respiratory friction sound above the liver is an indication of perihepatitis. This inflammation of the liver occurs in tumours, liver abscesses or bacterial perihepatitis (e. g. Fitz-Hugh-Curtis syndrome) and, in rare cases, temporarily after a liver biopsy. Perisplenic rubbing is occasionally discernible after splenic infarction. When pressure is applied to the stethoscope, the rubbing sound increases. 

Each laparoscopy should aim at a visual assessment of the spleen in terms of (7.) size, (2.) colour, (i.) shape, and (4.) identifiable spleen diseases. Special mention should be made of capsular fibrosis, hyalinosis ( sugar-coated spleen ), tumours (e. g. Hodgkin s disease, retothelial sarcoma), tuberculosis, splenic cysts, splenic infarction (s. fig. 35.10) and splenic haematoma. Given appropriate positioning, the spleen is visible in 80% of cases. In the case of myeloproliferative diseases, a biopsy of the spleen (e. g. by means of the Menghini technique) can provide a definitive diagnosis, (s. pp 135,253) (s. figs. 11.1 14.7) (see chapter 11)... 

Fig. 35.10 Splenic infarction in splenomegaly due to complete liver cirrhosis. (Postpartum blood transfusion into the umbihcal vein, with subsequent severe viral hepatitis B and rapid transition into early infantile cirrhosis)...

Nevertheless, cases of myocardial infarction, mesenteric ischemia, and ischemic colitis have been described, as has splenic infarction (14). 

A 48-year-old woman with a low risk of atherosclerotic disease who was not taking oral contraception was admitted with sudden heavy pain in the left hypochon-drium. Routine tests were normal, but there was a triangular hypodensity in the spleen on computerized tomography consistent with a splenic infarct. There was a history of postoperative venous thrombosis 15 years before, but tests for thrombophilia were all normal. No source of embolism was identified in the heart or proximal arteries. She had repeatedly taken zolmitriptan over the previous few months for migraine, and the symptoms started 3 hours after the most recent dose. 

Bellaiche G, Radu B, Boucard M, Ley G, Slama JL. Infarctus splenique associe a la prise de zolmitriptan. [Splenic infarction associated with zolmitriptan use.] Gastroenterol Clin Biol 2002 26(3) 298. 

Denaturated RBC Spleen imaging Splenic infarcts Accessory spleen(s) localization Assessment of splenic function and size Space-occupying disease GI bleeding... 

Splenic infarction and abscess has been reported in a 68-year-old woman who had received two inj ections of a solution of hjrper-tonic saline plus adrenaline 1 day apart during endoscopy on separate occasions for a bleeding gastric ulcer [66" ]. The authors recommended the use of adhesive agents, small amounts of sclerosants, and a slow injection speed for endoscopic injection therapy. 

Oida T, Mimastu K, Kawasaki A, Kuboi Y, Kano H, Amano S. Splenic infarction and abscess after endoscopic injection of hypertonic saline-epinephrine solution administered for bleeding gastric ulcer. Endoscopy 2008 40(Suppl 2) E239. 

A 58-year-old man had a gastric varix injected twice with a mixture of enbucrilate plus hpiodol and subsequently needed anticoagulant therapy for four episodes of venous thromboembolism. A CT scan showed a linear hyper-dense lesion in the left renal vein due to the presence of enbucrilate and renal vein thrombosis. The thrombus extended into the inferior vena cava and there was splenic infarction [37 ]. 

A 56-year-old man had a bleeding ulcerative gastric tumor injected with a 50/50 mixture of enbucrilate plus hpiodol and 3 days later a CT scan showed high-density material extending from the gastric wall to the splenic hilum, near-total occlusion of the splenic artery and its branches, and a cystic mass with an air-fluid cavity in the spleen, due to splenic infarction with abscess formation [40 ]. 

Chang CJ, Su CW, Hou MC. Abdominal pain after endoscopic hemostasis of gastric tumor bleeding. Splenic infarction with abscess formation. Gastroenterology 2009 137(5) e7-8. 

Haan et al. further explored the CT finding of air within areas of infarction after splenic artery embolization [45]. They found that air in areas of splenic infarction was associated with infection in only 17% of patients but that this rate increased to 33% in symptomatic patients [45]. Clearly, this implies that air is not pathognomonic of infection and that further investigation must be performed in these patients prior to splenectomy. While asymptomatic patients can likely be observed, patients with symptoms and a minimal amount of air should be treated with antipyretics. Aspiration and percutaneous drainage should be considered, as should splenectomy, in patients with large areas of infarct air and/or severe symptoms [45]. 

Coil embolization is technically easy and successful. Coils should be sized slightly larger than the vessel lumen. Smaller coils or Gelfoam can be used to sandwich or nest between the flanking coils. This will ensure a compact and occlusive embolus. Patients should be observed for splenic infarction, although short gastric or other small collateral vessels can perfuse portions of the spleen distal to the occluded main renal artery. 

Complications of the embolization procedure include those of diagnostic angiography with the addition of aneurysm rupture, nontarget embolization, splenic infarction, abscess formation, and rarely sepsis (Fig. 8.5). Total splenic infarction can occur, which puts the patient at an increased risk of infection with encapsulated bacteria such as pneumococcus. Older literature suggests that bland splenic artery aneurysms rupture at a rate of approximately 2% [30]. However, in pregnant patients, rupture occurs in nearly every case with mortality rates for mother and fetus 70% and 95% respectively [31]. Obviously, any aneurysm in the pregnant female should be addressed since over 95% will rupture if left untreated [30, 32]. 

During the past three decades, splenic arterial embolization has been advocated in the nonoperative treatment of patients with these difficult clinical scenarios by intentionally infarcting splenic tissue and reducing its consumptive activity. In 1973, Maddison [97] reported the initial clinical experience of splenic artery embolization, but severe complications that resulted from complete splenic infarction prevented acceptance of the technique as a viable treatment option. Since this initial descrip-... 

Hemodynamic andhematologic responses and the severity of complications correlate with the amount of splenic tissue that is infarcted after embolization [110]. Therefore, PSE has been advocated to reduce complication rates after splenic infarction. Ablation of more than 80% of the splenic mass has been reported, but most authors have attempted to embo-lize 60%-70% of the parenchyma [115,118-120]. This amount of embolization allows for reduced sequestration and destruction of the blood elements while maintaining the spleen s immunologic function and preserving antegrade flow within the splenic vein. 

Wholey MH, Chamorro HA, Rao G, Chapman W (1978) Splenic infarction and spontaneous rupture of the spleen after therapeutic embolization. Cardiovasc Radiol 1 249-253... 

Rentsch J, McCoU G. Splenic infarction in Wegener s granulomatosis. J Rheumatol 2000 27(6) 1554-1555. 

Fig. 6.2.14a,b. Direct invasion of the stomach by neighbouring tumour, a Oblique coronal reformation through the pancreas demonstrates the direct invasion of the stomach by an adenocarcinoma of the pancreatic tail (arrow). There is a splenic infarct (white arrowhead) and splenic hypoperfusion (black arrowhead) due to tumour obstruction of the splenic artery and vein, b Parasagittal reformation through the gastroesophageal junction demonstrates surgical proved direct infiltration of the stomach by oesophageal carcinoma (arrows)... 

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