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PubMed1998

Coeliac axis thrombosis associated with the combined oral contraceptive pill: a rare cause of an acute abdomen.

We report a case of coeliac axis thrombosis and splenic infarction presenting in a girl of 14 years who had been on the oral contraceptive pill (OCP), Marvelon (ethinyloestradiol 30 microg plus desogestrel 150 microg, Organon, Cambridge, UK), for 3 weeks. She had no other risk factors for thrombo-embolism. Diagnosis was made with duplex Doppler ultrasound and confirmed with dynamically-enhanced comput-ed tomography and magnetic resonance angiography, thus avoiding the need for percutaneous arteriography. Though mesenteric thrombo-embolic disease is recognised in association with use of the combined OCP, it has not previously been reported to affect the coeliac axis. Paediatricians and surgeons should be aware of the risks to young girls on the OCP, and consider it in their differential diagnosis of the acute abdomen.

Abdomen, Acute↗
PubMed1995

Impact of magnetic resonance imaging on the diagnosis of abdominal complications of paroxysmal nocturnal hemoglobinuria.

Magnetic resonance (MR) imaging is a method of choice for assessing vascular patency and parenchymal iron overload. During the course of paroxysmal nocturnal hemoglobinuria (PNH), it is clinically relevant to differentiate abdominal vein thrombosis from hemolytic attacks. Furthermore, the study of the parenchymal MR signal intensity adds informations about the iron storage in kidneys, liver, and spleen. Twelve PNH patients had 14 MR examinations of the abdomen with spin-echo T1- and T2-weighted images and flow-sensitive gradient echo images. Vessels patency and parenchymal signal abnormalities--either focal or diffuse--were assessed. MR imaging showed acute complications including hepatic vein obstruction in five patients, portal vein thrombosis in two patients, splenic infarct in one patient. In one patient treated with androgens, hepatocellular adenomas were shown. Parenchymal iron overload was present in the renal cortex of eleven patients with previous hemolytic attacks. On the first MR study of the remaining patient with an acute abdominal pain showing PNH, no iron overload was present in the renal cortex. Follow-up MR imaging showed the onset of renal cortex iron overload related to multiple hemolytic attacks. Despite the fact that all our patients were transfused, normal signal intensity of both liver and spleen was observed in three of them. MR imaging is particularly helpful for the diagnosis of abdominal complications of PNH.

Abdominal Pain↗
PubMed2001

Structural similarities between hematoidin crystals and asteroid bodies: evidence of lipid composition.

Hematoidin crystals (HC) are found in tissues where extravasated erythrocytes undergo degradation. Previous studies have determined that hematoidin is composed, in part, of a bilirubin-like pigment. In a previous study (Papadimitriou and Drachenberg, Ultrastruct. Pathol. 16, 413-421, 1992), we demonstrated that giant cell asteroid bodies (AB) are formed by membrane lipid bilayers. We evaluated three cases in which HC developed within splenic infarcts. The crystals were analyzed by light microscopy (LM), electron microscopy (EM), and X-ray microanalysis. A case of sarcoidosis with multiple epithelioid granulomas containing AB was studied for comparison. By LM the HC demonstrated intense, golden-color, fine threads, both intracellularly and extracellularly, in small and large clusters, and in radiating, star-shape patterns ranging in size from 2 to 200 microm. By EM the HC were composed of a core of empty clefts, consistent with dissolved lipids, suggestive of cholesterol crystals, and were surrounded by myelinoid membrane aggregates. The AB showed by LM significant morphological similarities with the intracellular HC. By EM, the AB were composed of a core of dense phospholipid bilayer tubes surrounded by a halo of myelinoid membranes. No accumulation of specific elements was found in either HC or AB by X-ray microanalysis. HC and AB show a similar star-shape morphology by both LM and EM. We postulate that this shape is due to the physicochemical properties of the accumulated lipids which originate from superfluous cell membranes created during cell fusion in the case of AB and after cellular (predominantly red cell) breakdown in the case of HC. The golden color of the HC likely results from adsorption of hydrophobic bilirubin-like pigments left over from erythrocyte breakdown into the accumulated lipids. Thus, this study shows two different (patho)physiological processes that lead to a markedly similar morphological end-product and provides further support to our proposed mechanism for AB formation.

Bilirubin↗
PubMed2000

[Secondary splenic rupture after thrombolysis for acute myocardial infarction]

Secondary splenic rupture after thrombolysis for acute myocardial infarction. HISTORY AND ADMISSION FINDINGS: A 67-year-old male patient was admitted with acute chest pain and signs of an acute anterior myocardial infarction in the ECG. The usual contraindications were excluded and after a systemic lysis with rt-PA the ECG-alterations as well as the symptoms of angina resolved completely. 2 hours later the patient developed an acute abdomen with a severe circulatory shock. INVESTIGATIONS: On ultrasound and CT a massive intraabdominal bleeding was found. TREATMENT AND COURSE: Emergency laparotomy revealed a splenic rupture. Retrospectively, 6 weeks before admission, the patient had fallen from a ladder to his left side. This is a rare case of a secondary splenic rupture during thrombolysis for acute myocardial infarction. 2 weeks later the patient developed rein-farction with angiographically shown two vessel disease. After angioplasty of the ramus interventricularis anterior (RIVA) he was stable. CONCLUSIONS: Intravenous thrombolysis in case of acute myocardial infarction is the method of choice. In the past a great number of patients were excluded from thrombolysis because of an extensive interpretation of contraindications. The aim to reach an alteration in this use may not risk health of patients by insufficient history.

Journal Article↗
PubMedDate not supplied

Wegener granulomatosis simulating bacterial endocarditis.

Cardiac involvement in Wegener granulomatosis is uncommon. We report a case of Wegener granulomatosis that presented as culture-negative endocarditis with aortic valvular vegetation. The clinical manifestations included gingival hyperplasia, gangrenous digital infarcts, mononeuritis multiplex, high fever, inflammatory arthritis, pansinusitis, splenic infarct, and aortic valvular vegetation, which underscore the difficulty of distinguishing systemic vasculitis from bacterial endocarditis. Contrary to the common notion that valvular vegetation is invariably associated with bacterial endocarditis, this case proves that such findings can occur in Wegener granulomatosis as well. Clinicians are guided toward early treatment with corticosteroids and cyclophosphamide to prevent fatal complications.

Aortic Valve↗
PubMed1996

Changes in splenic volume after partial splenic embolization in children.

AIM: The authors studied changes in splenic volume after partial splenic embolization (PSE) in children who had thrombocytopenia caused by splenomegaly. MATERIALS AND METHODS: Five children with hypersplenism (ages of 1, 6, 7, 10, and 14 years) underwent PSE. The follow-up period ranged from 1 month to 8 years 9 months. Whole and infarcted splenic volumes were measured from computed tomography images obtained before and after PSE. RESULTS: Within 2 weeks after PSE, the whole splenic volume increased to 110% to 140% of the pre-PSE volume. The infarcted area disappeared 3 to 4 months after PSE, and the whole splenic volume decreased markedly. The decreased volume tended to be stable during the follow-up period. The splenic enlargement before PSE ranged from 7.2 to 14.2 times the standard splenic volume for a corresponding body weight. The splenic volume did not become normal after PSE; it remained between 2 and 7 times larger than standard. Platelet counts stayed above 10 x 10(4) /mm3 when the splenic volume reduced to 2 times the standard volume. CONCLUSION: The first 4 weeks after PSE is the most dangerous period for the development of splenic capsule. The infarcted parenchyma is absorbed 3 to 4 months after PSE, and the whole splenic volume is reduced. Thereafter, the splenic volume is stable for several years. Reembolization is not likely to be necessary in the majority of patients who have had splenic embolization with an infarction rate of > or = 80%.

Adolescent↗
PubMed1991

Polysplenia syndrome: a case with congenital heart block, infarction of a splenic mass, and a short pancreas.

A case of polysplenia with congenital heart block, infarction of a splenic mass, and a short pancreas was reported. The infant died of severe heart failure at the age of 28 days. Deformity of the SA node was suspected to be the cause of congenital heart block but could not be demonstrated because of some limitations of autopsy procedure. Redundant splenic pedicle might cause infarction of a splenic mass after birth. The author suggests that, in addition to the semi-annular pancreas, the pancreatic anomalies of this syndrome should include the short pancreas.

Abnormalities, Multiple↗
PubMedDate not supplied

Improved graft function in liver-transplanted patients after partial splenic embolization: reversal of splenic artery steal syndrome?

AIM: To describe the functional effect of partial splenic embolization (PSE) in liver-transplanted (LT) patients with hypersplenism and hepatitis C virus (HCV) recurrence. PATIENTS AND METHODS: From May 2002 to May 2005, five LT patients with persistent hypersplenism, viral recurrence and graft dysfunction underwent PSE prior to pegylated interferon/ribavirin (peg-IFN/RBV). RESULTS: The mean splenic size was 19.5 cm (16-21) and there was evidence of an enlarged splenic artery (10.7+/-1 mm). PSE produced a median splenic infarction of 90% and a significant reduction in the splenic artery diameter to 5.8+/-0.4 mm (p=0.04). PSE significantly improved hematologic parameters, bilirubin levels, prothrombin activity, international normalized ratio and the Model for End-stage Liver Disease (MELD) score despite high HCV-RNA (6.2 log10 IU/mL). It was demonstrated histologic amelioration of ischemic changes in all subjects. PSE allowed the safe use of full-dose peg-IFN plus RBV in all subjects. CONCLUSIONS: In HCV LT patients with chronic graft dysfunction and cholestasis the improvement in the liver function following PSE might be due to the reversal of an undiagnosed splenic artery steal syndrome related to chronic hypersplenism masked by HCV recurrence.

Adult↗
PubMed2001

Clinical correlates of splenic histopathology and splenic karyotype in myelofibrosis with myeloid metaplasia.

Splenic extramedullary hematopoiesis is an integral component of myelofibrosis with myeloid metaplasia (MMM) and may be classified into 3 distinct histologic patterns of infiltration by myeloid precursors: diffuse, nodular, and a predominance of immature granulocytes. These 3 histologic patterns occurred in 121 (56.8%), 75 (35.2%), and 17 (8%), respectively, of 213 patients with MMM who underwent splenectomy at a single institution. In general, karyotypic findings in splenic tissue (n = 92) were similar to those seen in the bone marrow. The histologic pattern of immature granulocyte predominance, the presence of microscopic splenic infarcts (26 patients), or the detection of an abnormal splenic karyotype (52 patients) was significantly associated with decreased postsplenectomy survival. These adverse features were also associated with characteristics of advanced disease. These observations support the bone marrow origin of the myeloid progenitor pool in the spleen of patients with MMM and suggest a prognostic value for splenic histopathology and karyotype. (Blood. 2001;97:3665-3667)

Bone Marrow Cells↗
PubMed1995

Splenic involvement in pancreatitis: spectrum of CT findings.

The pancreas is located deep within the retroperitoneum in the anterior pararenal space. The distal portion of the pancreatic tail extends along the course of the splenic artery and vein (Fig. 1) and enters the splenic hilum contained within the splenorenal ligament. Because of these anatomic relationships, the spleen and splenic vessels may be involved by pancreatitis. Although rare (frequency, 1-5%), splenic involvement by pancreatitis includes intrasplenic pseudocyst, abscess, hemorrhage, infarction, splenic rupture, and vascular injury. Because these complications can be life-threatening, the extent and course of the disease are closely monitored with CT to determine whether and when aggressive intervention is necessary to avoid catastrophic clinical outcomes. The purpose of this essay is to illustrate the spectrum of CT findings in cases of pancreatitis with splenic involvement.

Humans↗
PubMed2006

Multiple lesions of the spleen: differential diagnosis of cystic and solid lesions.

Lesions in the spleen may be encountered in a variety of clinical settings ranging from asymptomatic patients to patients who are critically ill. Etiologies for multifocal splenic lesions include infectious and inflammatory processes, primary vascular and lymphoid neoplasms, metastatic disease, vascular processes, and systemic diseases. There is often overlap in the imaging appearance alone, so the clinical setting is very helpful in differential diagnosis. In the immunocompromised patient, multiple small splenic lesions usually represent disseminated fungal disease and microabscesses. The spleen is a relatively rare site for metastatic disease; patients with metastatic lesions in the spleen usually have disease in other sites as well. Breast, lung, ovary, melanoma, and colon cancer are common primary tumors that metastasize to the spleen. Vascular neoplasms of the spleen represent the majority of the nonhematologic/nonlymphoid neoplasms and commonly produce multifocal lesions. Splenic infarcts may be seen with localized processes such as portal hypertension or pancreatitis, or may arise from an embolic source. Radiologists should be aware of the spectrum of processes that may involve the spleen and the clinical context in which they occur.

Abscess↗
PubMed2002

[Acute pancreatitis caused by atrial fibrillation?].

HISTORY: We report three male patients who had atrial fibrillation with a rapid and irregular ventricular rate, aged 60, 69 and 70 years, respectively, in whom development of acute pancreatitis occurred simultaneously with other ischaemic events. INVESTIGATIONS: One of these patients simultaneously suffered from a transient ischaemic attack (TIA), another developed a stroke and an infarction of the spleen, while the third one had a splenic infarction and an embolism in the region of the mesenteric arteries. Two patients had paroxysmal atrial fibrillation, while the third suffered from ischemic cardiomyopathy with chronic atrial fibrillation. DIAGNOSIS AND TREATMENT: Oedematous pancreatitis occurred in one patient while, in the two others, the diagnosis of severe necrotizing pancreatitis was made. CONCLUSION: Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice and a recognized risk factor for the development of peripheral embolism, which often takes the form of an ischaemic stroke. It is a major cause of stroke, especially in the elderly. Because of the simultaneous occurrence of thromboembolic events in all three patients, an ischaemic cause for the acute pancreatitis can be assumed with a high degree of probability. This is one of the first reports of acute ischaemic pancreatitis probably caused by microembolization secondary to atrial fibrillation. Because of the relatively frequent occurrence of atrial fibrillation, this factor deserves increased attention in the differential diagnosis of supposedly idiopathic pancreatitis.

Acute Disease↗
PubMed1989

Distal pancreatectomy with and without splenectomy. A comparative study.

Twenty-one patients undergoing distal pancreatectomy from January 1980 through April 1987 were studied retrospectively. Group I (n = 10) had distal pancreatectomy with splenectomy, and Group II (n = 11) had distal pancreatectomy with splenic preservation. The groups were comparable in mean age and extent of pancreatic resection. Operative time in Group I patients who did not require additional major procedures was 3.74 +/- 1.01 hours, compared with 2.86 +/- 1.68 hours for similar Group II patients. The overall complication rate in Group I was 40 per cent, including two pancreatic fistulas, one subphrenic abscess, and one gastric fistula. In Group II the overall complication rate was 36.4 per cent, with one pancreatic fistula, one subphrenic abscess, and one colonic fistula. Splenic infarction occurred in only one patient (Group II), in whom both splenic vessels were ligated. No patient developed insulin-dependent diabetes. There were no deaths. The mean hospitalization time was 18.8 days in Group I, and 17.5 days in Group II. Splenectomy should not be considered a routine part of distal pancreatic resection. Splenic preservation can be achieved in selected cases with no increase in complication rate, operative time, or length of postoperative hospitalization.

Adult↗
PubMed1984

Splenic torsion. An unusual cause of splenomegaly.

A 28-year-old woman who presented with acute abdominal pain and splenomegaly was found to have little functioning splenic tissue on liver-spleen scan but a large homogeneous spleen by computerized axial tomography. Laparotomy revealed torsion of the splenic pedicle and extensive splenic infarction. The presentation, pathophysiology, and diagnostic difficulties of this case are discussed. Splenic torsion should be considered in the differential diagnosis of painful splenomegaly.

Adult↗
PubMed2005

Is endovascular therapy the preferred treatment for all visceral artery aneurysms?

Endovascular intervention can provide an alternative method of treatment for visceral artery aneurysms. We conducted a retrospective review of all patients with visceral artery aneurysms at a single university medical center from 1990 to 2003, focusing on the outcome of endovascular therapy. Sixty-five patients with visceral artery aneurysms were identified: 39 splenic (SAA), 13 renal, seven celiac, three superior mesenteric (SMA), and three hepatic. Eleven patients (16.9%) had symptoms attributable to their aneurysms, which included a total of four ruptures (6.2%): three splenic and one hepatic. Management consisted of 18 (27.7%) endovascular interventions, nine (13.9%) open surgical repairs, and 38 (58.5%) observations. Mean aneurysm diameter for patients treated expectantly was significantly less than for those who underwent intervention (p = 0.001). Endovascular interventions included 15 (83.3%) embolizations (11 SAA, three renal, one hepatic) and three (16.7%) stent grafts (two SMA, one renal). The initial technical success rate of the endovascular procedures was 94.4% (17/18). However, there were four patients (22.2%) with major endovascular procedure-related complications: one late recurrence requiring open surgical repair, two large symptomatic splenic infarcts, and one episode of severe pancreatitis. These four patients had distal splenic artery aneurysms at or adjacent to the splenic hilum. There were no endovascular procedure-related deaths. Reasons for performing open surgical repair included three SAA ruptures diagnosed at laparotomy and complex anatomy not amenable to endovascular intervention (six patients). One surgical patient had a postoperative small bowel obstruction treated nonoperatively; and there was one perioperative death in a patient operated on emergently for rupture. Endovascular management of visceral artery aneurysms is a reasonable alternative to open surgical repair in carefully selected patients. Individual anatomic considerations play an important role in determining the best treatment strategy if intervention is warranted. However, four of 11 (36.4%) patients with distal splenic artery aneurysms treated with endovascular embolization developed major complications. Based on our experience, traditional surgical treatment of SAA with repair or ligation and concomitant splenectomy when necessary may be preferred in these cases.

Adult↗
PubMed2006

Nonvascular complications in pediatric liver recipients: multidetector computed tomography evaluation.

In pediatric liver transplantation postoperative diagnosis of complications is crucial for graft salvage. Multidetector computed tomography (MDCT) is a technique to evaluate complications. In this study we present nonvascular abdominal complications encountered in pediatric recipients after liver transplantation. We retrospectively examined 113 MDCT examinations in 43 pediatric patients who underwent liver transplantation between 1997 and 2005. Computed tomography (CT) examinations were made by a 16-detector multislice CT scanner. The pathological findings on CT images were: intraperitoneal free fluid, intrahepatic bile duct dilatation, graft liver infarction, perihepatic and intraperitoneal fluid collections (six biloma), colonic and/or intestinal dilatation, splenic infarction, perihepatic hematoma, right adrenal hemorrhage, perihepatic abscess, incisional hernia, intrahepatic biloma and periportal collar. In one patient intestinal hemorrhage was suspected. Intestinal perforation was suspected in three patients. Among these three patients, one patient died before any surgical intervention. In two patients the diagnosis was confirmed at surgery. In pediatric patients, the short examination time, brief sedation duration, and high-resolution images make MDCT an effective radiological method to evaluate nonvascular transplant complications.

Adolescent↗