SPONTANEOUS RUPTURE OF THE SPLEEN WITH SUBACUTE BACTERIAL ENDOCARDITIS.
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Adolescent↗
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Computed tomography of focal splenic lesions in patients presenting with fever.
INTRODUCTION: There is an awareness of the increased incidence of splenic abscess in Southeast Asia giving rise to unexplained fever. This study looks at the role of computed tomography (CT) in evaluating focal splenic lesions in patients presenting with fever. METHODS: 37 patients presenting with fever of unknown origin underwent CT and this study retrospectively analyses the findings in these patients. 13 patients also had associated abdominal pain. Patients with conditions at high risk for splenic infection include: diabetes mellitus in ten patients, leukaemia in seven patients, human immunodeficiency virus infection in five patients, intravenous drug abuse in six patients, and steroid therapy in two patients. No risk factors could be identified in seven patients. RESULTS: Splenic abscess was diagnosed in 28 patients. A range of infecting organisms was isolated but the most frequent were Staphylococcus aureus (eight), tuberculosis (four), Streptococcus (four), fungal (four) and melioidosis (four). No infecting organism could be identified in ten cases though in patients with leukaemia with multiple low attenuation areas, the cause was presumed to be fungal. Six patients were diagnosed to have splenic infarcts though differentiation from splenic abscess could be difficult; these patients were treated for an abscess and all had endocarditis. Three patients were subsequently diagnosed with lymphoma. Percutaneous abscess drainage was performed in five patients and splenectomy was carried out in six patients. CONCLUSION: CT proved to be very useful as it not only revealed the size and extent of any splenic abnormality but it assisted with guidance for percutaneous drainage, determined the site for biopsy, and provided follow-up after treatment.
Abscess↗
Chronic recurring infarction of the spleen: sonographic patterns and complications.
PURPOSE: Splenic infarction is a major problem of splenic pathology but is characterized by a high tendency for complete healing. The purpose of this study is to describe frequency, sonographic patterns, and complications of chronic infarction (CI) METHODS: Between 1980-2001 550 patients with focal splenic lesions were diagnosed by ultrasound. Eighty patients had an acute infarction, and in 14 cases a chronic infarction was diagnosed and confirmed by cytohistology/splenectomy (n = 3) or sonographic follow-up examination (n = 11). All patients with Cl had been investigated by B-mode sonography and colour Doppler sonography (CDS). Data were retrospectively evaluated. RESULTS: Two types of Cl could be discriminated. Type I morphology (n =8) was predominantly found in homozygous sickle-cell anaemia (n= 6) and sonographically characterized by a small or normal sized spleen (n = 6), with diffuse enhanced echogenicity (n= 8), and foci with diminished echogenicity (n=5). Type II morphology (n = 6) was predominantly found in myeloproliferative diseases (n = 4) and characterized by an enlarged spleen with a homogeneous echotexture (n = 7), and a solitary (n = 6), triangular (n=4), hyperechoic (n=4) splenic foci near the splenic surface. On CDS CI were characterized by absent flow signals (n = 7) or by reduced flow signals (n= 7). Spontaneous splenic ruptures occurred as infarction related complications in 3 of 14 cases (21%). CONCLUSIONS: CI develops in 17.5% of patients with infarctions. It occurs predominantly in patients with sickle-cell anaemia and myeloproliferative disease. Two characteristic morphologic patterns were found and associated with an increased risk of spontaneous splenic rupture: Therefore sonographic follow-ups might be useful.
Acute Disease↗
Gastric necrosis after an infarction of the spleen: report of a case.
Gastric necrosis is a rare and often fatal condition. A few reports of gastric necrosis of various etiologies have been published in the literature. This report deals with a case in which gastric necrosis and perforation occurred several years after an infarction of the spleen. Preoperative computed tomography showed the existence of splenic vein thrombosis accompanying splenic infarction. A laparotomy revealed an 8-cm-long laceration with ragged margins in the posterior of the stomach along the greater curvature. Furthermore, massive venous thrombosis was found in the major omentum. As a result, the reduced arterial blood supply and insufficient venous drainage due to splenic venous thrombosis may have together played a major role in the development of gastric necrosis.
Biopsy, Needle↗
Left diaphragmatic eventration with a suprapubic spleen: report of a case.
Diaphragmatic defects such as eventration and hernia are known to be associated with a high-sited, sometimes intrathoracic spleen. We report here a unique case of an 8-year-old boy found to have a left congenital diaphragmatic eventration and a suprapubic wandering spleen after presenting with symptoms of an "acute abdomen" due to torsion of the splenic pedicle. To our knowledge only one other case of a similar paradoxical association of these anomalies has been reported before; interestingly, in this patient splenic infarction had also resulted secondary to splenic torsion. We recommend careful evaluation of the location and vascular status of the spleen in all patients with congenital diaphragmatic defects due to the common occurrence of splenic vascular insult.
Child↗
Thromboembolic complications after endovascular aortic aneurysm repair.
PURPOSE: To evaluate the frequency and significance of thromboembolic complications following endovascular treatment of aortic aneurysms. METHODS: One hundred seventy-four patients (153 men; mean 71.4 years, range 26-90) underwent endovascular repair of aneurysms of the thoracic (n = 38) or abdominal (n = 136) aorta using a variety of endografts. All patients were examined preprocedurally using 3-phase helical computed tomography (CT) to determine appropriate endograft size. To exclude the occurrence of infarction in parenchymal organs, the first postprocedural CT scan was compared with preoperative findings. Newly recognized perfusion deficits were taken as evidence of procedure-related infarction. RESULTS: Infarctions were detected in 16 (9.2%) patients: 13 in the kidneys, 2 in the spleen, with 1 in the mesentery; only the mesenteric infarction was clinically symptomatic. Both splenic infarctions were associated with deployment of stent-grafts in the thoracic aorta (5.3% of the 38 patients), while the mesenteric and 13 renal infarctions were seen in patients with infrarenal abdominal aortic aneurysms (0.7% and 9.6%, respectively, of 136 patients). One patient experienced complete thromboembolic occlusion of a renal artery, which was partially recanalized with intraoperative lysis. CONCLUSIONS: Thromboembolic complications of endovascular aortic aneurysm repairs are not uncommon, and although usually asymptomatic, these sequelae have the potential to be life threatening. Perfusion abnormalities may respond to immediate lytic therapy with complete dissolution of the thrombus in certain isolated cases.
Aged↗
Computed tomography of the spleen.
Computed tomography is a very useful method in the diagnosis of splenopathy--any anomalies, inflammatory, neoplastic as well as traumatic states of the spleen. Although these processes are not too frequent, their correct determination is an important part of radiodiagnosis. Computed tomography is so far the best method used for the identification of the congenital varieties of the spleen that may be mistaken, in another examination, for a pathological process of an adjacent organ. In the study a total of 185 pathological spleen findings was evaluated. These were obtained from the total of 18,960 CT examinations of the abdomen. The most frequent finding was splenomegaly (69.2%), less frequent were haematomas and splenic cysts (12.4%) and congenital varieties of the spleen (8.1%). Sporadically, splenic infarction (2.7%), thrombosis of the splenic vein (3.8%), tumour (2.2%) and splenic abscess (1.6%) were demonstrated.
Humans↗
CT findings after embolization for blunt splenic trauma.
PURPOSE: To determine complications after transcatheter embolization for blunt splenic injury as recognized with computed tomography (CT). MATERIALS AND METHODS: From March 1997 to January 2000, 80 patients underwent transcatheter embolization after blunt splenic injury, of whom 53 underwent abdominal CT examination before and after embolization. Preembolization CT scans were reviewed to determine grade of injury, and postembolization CT scans were reviewed to identify complications secondary to embolization. Arteriography results were reviewed to determine findings and method and location of embolization. RESULTS: Splenic infarcts occurred in 63% of patients after proximal embolization and in 100% of patients after distal embolization. Infarcts after distal embolization tend to be larger and occur just distal to the embolization material, whereas infarcts after proximal embolization tend to be smaller, multiple, and located in the periphery. Most infarcts resolved without sequelae. Seven patients developed gas within an infarct or subcapsular fluid collection. Two collections were drained and found to be sterile and one patient had a splenic abscess at laparotomy. CONCLUSIONS: Infarcts are common after splenic embolization. Gas may be present within an infarct after embolization with Gelfoam; however, the presence of air/fluid level is a better predictor of abscess.
Adult↗
Computed tomography of liver infarction.
Liver infarcts are relatively rare and uncommonly are diagnosed before autopsy. The CT appearance of hepatic infarction was studied in five patients. In four of these, well-defined, wedge-shaped, low-attenuation zones extending to the liver surface were seen on contrast-enhanced scans. The infarcts involved the right lobe of the liver in all patients, and the left lobe as well in two. Associated splenic infarcts were present in three patients and renal infarcts in two. While the clinical and laboratory findings in hepatic infarction can be completely mimicked by hepatic abscess, the different CT appearance of these lesions should permit noninvasive distinction in most patients.
Adult↗
Splenic accumulation of 99mTc-diphosphonate in a patient with sickle cell disease: case report.
Splenic accumulation of 99mTc-diphosphonate is shown in the bone scan of a patient with sickle cell disease. This uptake is assumed to result from splenic infarction and subsequent calcification. The conventional liver-spleen scan with 99mTc-sulfur colloid shows no splenic activity, and a radiograph shows calcification in the left upper quadrant of the abdomen in the expected anatomic location of the spleen.
Anemia, Sickle Cell↗
Thrombocytosis, coronary thrombosis and acute myocardial infarction.
Clinical and morphologic findings are described in a 22 year old man with prolonged thromboyctosis, and coronary and splenic arterial thrombi causing myocardial and splenic infarcts. The absence of preexistent extensive coronary atherosclerosis, the presence of thrombus in more than one epicardial artery and in multiple intramural coronary arteries, the presence of arterial thrombosis in a noncoronary artery (splenic) and the absence of another apparent cause of the arterial thromboses are evidences that the intraarterial clotting in this patient was related to the severe thrombocytosis. A reveiw of the reported cases of vascular occlusion associated with thrombocytosis indicates that thrombi have infrequently been confirmed as the mechanism of the vascular occlusion. Although the frequency of vascular thrombi in patients with thrombocytosis has not been established, it is clear that vascular thrombosis can be a consequence of thrombocytosis and, as demonstrated by the present patient, that the coronary artery may be the site of the vascular occlusion, a heretofore unconfirmed event.
Adult↗
The value of MR angiography in predicting the risk of torsion of a pelvic spleen during pregnancy.
A case of an enlarged pelvic spleen, studied with MRI and MR angiography (MRA), is presented in a 32-year-old female wishing to become pregnant. An ectopic located spleen may be complicated by an acute abdomen due to torsion of the splenic vascular pedicle, resulting in splenic infarction. Displacement of the spleen and splenic pedicle during pregnancy may further increase the risk of torsion. Urgent splenectomy during pregnancy is associated with a high fetal and maternal mortality and morbidity. On the other hand, elective splenectomy of a pelvic spleen before pregnancy can result in adhesion formation, compromising the patient's fertility. The abilities of MRI and MRA in predicting the risk of these life-threatening complications during pregnancy are discussed, in order to evaluate the benefit-risk ratio of surgical treatment by splenectomy of splenopexia.
Adult↗
Pancreas resection and islet autotransplantation for end-stage chronic pancreatitis.
OBJECTIVE: To assess the safety and efficacy of islet autotransplantation (IAT) combined with total pancreatectomy (TP) to prevent diabetes. SUMMARY BACKGROUND DATA: There have been recent concerns regarding the safety of TP and IAT. This is thought to be related to the infusion of large volumes of unpurified pancreatic digest into the portal vein. Minimizing the volume of islet tissue by purifying the pancreatic digest has not been previously evaluated in terms of the postoperative rate of death and complications, pain relief, and insulin independence. METHOD: During a 54-month period, 24 patients underwent pancreas resection with IAT. Islets were isolated using collagenase and a semiautomated method of pancreas digestion. Where possible, islets were purified on a density gradient and COBE processor. Islets were embolized into the portal vein, within the spleen and portal vein, or within the spleen alone. The total median volume of digest was 9.9 mL. RESULTS: The median number of islets transplanted was 140,419 international islet equivalents per kilogram. The median increase in portal pressure was 8 mmHg. Early complications included duodenal ischemia, a wedge splenic infarct, partial portal vein thrombosis, and splenic vein thrombosis. Intraabdominal adhesions were the main source of long-term problems. Eight patients developed transient insulin independence. Three patients were insulin-independent as of this writing. Patients had significantly decreased insulin requirements and glycosylated hemoglobin levels compared with patients undergoing TP alone. Of the patients alive and well as of this writing, four had failed to gain relief of their abdominal pain and were still opiate-dependent. CONCLUSION: Combined TP and IAT can be a safe surgical procedure. Unfortunately, almost all patients were still insulin-dependent, but they had decreased daily insulin requirements and glycosylated hemoglobin levels compared with patients undergoing TP alone. A prospective randomized study is therefore needed to assess the long-term benefit of TP and IAT on diabetic complications.
Adult↗
Prevalence and type of splenic diseases in cats: 455 cases (1985-1991).
Retrospective data on the type and prevalence of splenic disease in cats were evaluated in a large number of feline splenic tissues (n = 455) submitted as surgical and necropsy specimens from private veterinary hospitals in California during a period of approximately 5.5 years. Primary and metastatic neoplasia accounted for 37% of all feline splenic lesions. Mastocytoma, lymphosarcoma, myeloproliferative disease, and hemangiosarcoma, in that order, accounted for the bulk of neoplasia. Submission of accessory splenic tissue from either the omentum or pancreas accounted for 4% (17/455), whereas hyperplastic nodules, hematomas, and the combination of these changes in the spleen accounted for 4% (19/455). Splenitis was found in 2% (8/455) of submissions. Thromboembolism with regional splenic infarction accounted for 1% (4/455) of splenic lesions in cats. The remaining splenic lesions each accounted for less than 1% of total splenic submissions, and as such, were considered incidental and of questionable clinical importance.
Animals↗
Intrasplenic pancreatic pseudocyst complicating severe acute pancreatitis.
Since 13 cases of intrasplenic pancreatic pseudocysts have been previously described in the world literature, an additional case is reported. The mechanisms for the development of this lesion are: 1. direct extension of the pancreatic cyst into the splenic hilum; 2. digestive effects of pancreatic enzymes on splenic vasculature and parenchyma; 3. pancreatitis occurring in ectopic intrasplenic pancreatic tissue and 4. liquefaction of splenic infarcts secondary to thrombosis of the splenic vessels. Criteria for diagnosis and current available diagnostic methods are discussed. Early surgical intervention with splenectomy and possibly caudal pancreatectomy, is advocated.
Acute Disease↗
Noninfectious gas accumulation in an infarcted spleen.
BACKGROUND: Intentional selective occlusion of the arterial blood supply to tumors of abdominal organs is a well established therapeutic procedure. Several reports described gas accumulation at the infarcted sites. These gas collections are usually nonsuppurative; however, the differential diagnosis should include abscess formation. CASE REPORT: We present a 59-year-old patient in whom the splenic artery was accidentally ligated during gastrectomy surgery, with resultant splenic infarction. Gas accumulation was diagnosed by sonography and CT studies. To the best of our knowledge this is the first report ever published in the English medical literature describing nonsuppurative gas formation within an abdominal organ, caused by accidental ligation of its main arterial supply during surgery. SUMMARY: Possible theories regarding this noninfectious gas accumulation are discussed and the differential diagnosis between abscess formation and noninfectious gas accumulation is emphasized. Establishing the correct diagnosis is of big clinical importance as the treatment of choice is completely different in each one of these entities although the imaging features, in ultrasound as well as in CT, are somewhat similar.
Diagnosis, Differential↗
Hemolysis, hemorrhage, headache, and hidden abortion: imaging findings in antiphospholipid syndrome.
Antiphospholipid antibodies are associated with arterial and venous thromboses, recurrent pregnancy loss, and organ infarction. Any vascular region can be affected. We present a 20-year-old woman suffering from secondary antiphospholipid syndrome with a unique combination of multifocal venous thromboses, pulmonary embolism, spontaneous abortion, and splenic infarction. Diversity of clinical symptoms and diagnostic imaging modalities are discussed with emphasis on cross-sectional imaging. The syndrome should be suspected in patients with thromboses and organ infarctions of otherwise undetermined etiology.
Abortion, Spontaneous↗
Splenic parenchymal complications of pancreatitis: CT findings and natural history.
PURPOSE: Splenic parenchymal complications of pancreatitis are unusual and potentially life threatening. They usually require splenectomy in patients in poor condition. The present study describes natural history of splenic parenchymal complications and the role of CT scan in diagnosis and follow-up. METHOD: A retrospective study of 16 consecutive patients with splenic complications diagnosed by CT during staging of pancreatitis was performed. The presence and importance of splenic infarct, abscess, subcapsular collection, and hemoperitoneum were correlated with the patients' symptoms, type of management, and follow-up. RESULTS: No specific symptomatology was observed except in two cases of acute and massive hemoperitoneum. Fourteen infarcts, 11 subcapsular collections, 1 abscess, and 3 hemoperitoneums were observed. Four patients underwent splenectomy including two as an emergency for hemodynamic instability. Twelve patients were conservatively and successfully managed. CONCLUSION: Most splenic parenchymal complications of pancreatitis regress spontaneously and may be managed conservatively. Surgical indication is based mainly on clinical findings. CT is useful for detection and follow-up of these complications.
Abscess↗