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PubMed1998

Splenic abscess and sickle cell disease.

This is a report of our experience with 10 cases of splenic abscess in patients with sickle cell disease (SCD). All presented with fever and abdominal pain and were found to have a tender enlarged spleen. Two were found to have a ruptured spleen and five of them were septicemic on presentation. Although both ultrasound and CT-scan of the abdomen were of diagnostic value, we found CT-scan more accurate and reliable in the diagnosis of splenic abscess. Ultrasound and/or CT-scan should be used routinely in the evaluation of SCD patients who present with fever and abdominal pain, especially if they have a tender enlarged spleen. Diagnostic aspiration under CT-scan or ultrasound guidance should be used in doubtful cases to differentiate between splenic abscess and a large splenic infarct. All our patients were managed by peri operative antibiotics and splenectomy with no mortality. Salmonella was the commonest causative organism. Although CT-guided aspiration of splenic abscess is being advocated recently, we feel splenectomy should be the treatment of choice in patients with SCD as there is no point in preserving a non-functioning spleen that is present in the majority of patients. CT-guided aspiration may be employed as a temporary measure for those patients who are at high surgical risk with unilocular abscess.

Abscess↗
PubMed2000

Splenic rupture in children with hematologic malignancies.

BACKGROUND: Splenic rupture is an uncommon but life-threatening complication of leukemias and lymphomas, and is reported mostly in adults. The authors investigated the frequency with which splenic rupture is diagnosed in pediatric patients with hematologic malignancies and reviewed its clinical profile and outcome. METHODS: The data base of St. Jude Children's Research Hospital was searched for cases coded as splenic laceration or rupture, splenic infarction, or splenectomy in patients diagnosed with lymphoma or leukemia between January 1962 and December 1997. The medical records of patients with histopathologic or radiologic evidence of splenic rupture were reviewed. The time spanned by the study was divided into early (1962-1990) and recent (1991-1997) eras to reflect the availability of modern diagnostic imaging techniques. RESULTS: Seven children experienced splenic rupture. They were between ages 5-17 years. There were four males and three females. Primary diagnoses included acute myeloid leukemia (four patients), acute lymphoblastic leukemia (two patients), and Hodgkin lymphoma (one patient). Five patients were diagnosed in the recent era and two in the early era. Four patients had radiologic or bacteriologic evidence of fungal infection concomitant with the splenic event. Of five deaths, only two were related causally to splenic rupture; these occurred in the early era. All seven acute episodes of splenic rupture were managed conservatively without surgery. CONCLUSIONS: The overall frequency with which splenic rupture was detected in children with hematologic malignancy at the study institution was 0.18%. In the recent era, the frequency of detection was 9-fold higher (0.55%) than that of the early era (0.06%). Improved imaging techniques and increased utilization of imaging studies may account for the increased incidental detection of "preclinical" splenic rupture. Adolescent age group, acute myeloid leukemia (especially acute promyelocytic leukemia), a high leukocyte count, thrombocytopenia, and coagulopathy may predispose children with leukemia to pathologic splenic rupture. Fungal infection frequently was associated with splenic rupture and may play a role in its pathogenesis.

Adolescent↗
PubMed1999

[Multiple cholesterol emboli syndrome: beneficial effects of early heparin therapy. A case report].

The multiple cholesterol emboli syndrome (MCES) is a rare, multi-organ disease than can occur spontaneously or after arterial or cardiac catheterization, arteriography, angioplasty, cardiovascular surgery, oral or intravenous anticoagulation, systemic fibrinolysis and cardiorespiratory resuscitation, predominantly in male subjects with disseminated atherosclerosis over the age of 60 years. Clinical signs of MCES vary considerably depending on the organs involved, but the signs most frequently encountered are renal failure, skin lesions (livedo reticularis, purple toc, ulcers, etc) and transient eosinophilia. Optimal treatment of this syndrome is controversial and is often symptomatic. However, the most effective measure remains prevention based on identification of high-risk patients, treatment with platelet antiaggregants and careful handling of catheters. This syndrome has a serious prognosis in the majority of cases. In this article, the authors describe a case of MCES. After thoracic aortography, this 73-years-old patient presented typical clinical sign of MCES (angina, cerebrovascular accident, bilateral blindness, transient renal failure and splenic infarction). The clinical course was favourable in response to heparin therapy and splenectomy and caudal pancreatectomy. Histology confirmed the presence of cholesterol emboli in the lumen of splenic arterioles. Except in the case of severe bleeding diathesis, the authors recommend early heparin therapy for MCES caused by catheterization, angioplasty or cardiovascular surgery. However, complementary studies must be performed to more clearly define the effects of heparin on MCES.

Aged↗
PubMed1978

Splenic visualization using 99mTc-methylene diphosphonate in a patient with sickle cell disease.

Splenic visualization with a bone-seeking agent 99mTc-methylene diphosphonate (99mTc-MDP) with absence of splenic uptake using sulfur colloid was seen in a 15-year-old boy in sickle cell crisis. Uptake of 99mTc-MDP is probably due to splenic infarction and calcification. This represents a potentially sensitive method for following the functional auto-splenectomy process in sickle cell disease and may also detect the presence of splenic tissue when it is not visualized in a sulfur colloid liver/spleen scan. Splenic visualization by bone-seeking agents should not be confused with skeletal lesions or indicate the presence of an abnormal left upper quadrant mass lesion.

Adolescent↗
PubMed1996

Current management of visceral artery aneurysms.

BACKGROUND: Visceral artery aneurysms are an uncommon but important form of abdominal vascular disease. This study reviews a contemporary experience with special emphasis on newer methods of diagnosis and treatment. METHODS: From 1980 to 1994, 37 patients were diagnosed with 46 visceral artery aneurysms. These consisted of 22 splenic, 10 hepatic, 4 superior mesenteric, 2 gastroduodenal, 3 celiac, 2 left gastric, 1 pancreatoduodenal, 1 jejunal-ileal, and 1 inferior mesenteric artery aneurysms. Follow-up was complete for 28 patients, average of 37.7 months. There were 17 asymptomatic and 29 symptomatic aneurysms, including 11 presenting with rupture. RESULTS: Seventeen patients were treated surgically, with no surgical deaths. Surgical complications included splenic abscess (two) and failure to thrombose (one). Transcatheter embolization was used in 12 patients. Complications included splenic infarction (one) and recurrence (two), successfully treated with repeat embolization. Nine patients were treated with observation. Eight experienced no complications during follow-up; one died of a ruptured splenic artery aneurysm before treatment was initiated. CONCLUSIONS: The widespread use of computed tomography has led to increased detection of asymptomatic visceral artery aneurysms. Although surgery remains necessary in many patients, transcatheter embolization is effective in the treatment of selected visceral artery aneurysms with few complications and low recurrence.

Adult↗
PubMed1996

Hepatic tumors: predisposing factors for complications of transcatheter oily chemoembolization.

PURPOSE: To elucidate major complications and their predisposing factors in transcatheter oily chemoembolization (TOCE) for hepatic tumors. MATERIALS AND METHODS: In a retrospective study of 351 patients (aged 26-82 years) with hepatic tumors, TOCE was performed 942 times with an emulsion of iodized oil (3-40 mL) and doxorubicin hydrochloride (20-60 mg). In 126 patients, TOCE was followed by absorbable gelatin sponge embolization. RESULTS: Complications were severe postembolization syndrome (n = 53); hepatic insufficiency (n = 20), infarction (n = 1), or abscess (n = 1); intrahepatic biloma formation (n = 3); tumor rupture (n = 3); septicemia (n = 9); coagulopathy (n = 1); gastrointestinal bleeding (n = 10); gallbladder (n = 5) or splenic infarction (n = 4); pulmonary oil embolism (n = 6); and spinal cord injury (n = 1). Important predisposing factors were major portal vein obstruction, compromised hepatic functional reserve, biliary obstruction, previous biliary surgery, excessive amount (> 20 mL) of iodized oil, hepatic arterial occlusion after repeated TOCE, and nonselective embolization. CONCLUSION: Most patients with major complications after TOCE had preexisting risk factors.

Adult↗
PubMed1995

Changes in platelet kinetics after a partial splenic arterial embolization in cirrhotic patients with hypersplenism.

We performed a partial splenic arterial embolization in 22 patients with cirrhosis associated with thrombocytopenia and then evaluated the changes in platelet kinetics after undergoing the procedure using 111In-tropolone-labeled platelets. The controls consisted of eight chronic hepatitis patients who showed a normal platelet count and normal spleen size. The mean splenic infarction ratio after the procedure was 54.9%. A platelet kinetics study was performed before and 2 months after the procedure. Before the procedure, the cirrhotic patients showed increases in the splenic volume and the spleen/liver uptake ratio of the 111In-labeled platelets on both the third and seventh days, and a decrease in the platelet recovery compared with the controls, which suggested an increased platelet pool in the spleen. In addition, the platelet survival time in cirrhotic patients was shortened, whereas the platelet-associated immunoglobulin G (PA-IgG) was higher than that of the controls, which suggested the involvement of immunologic mechanisms in the thrombocytopenia. With an increase of the platelet count after a partial splenic arterial embolization, the spleen/liver uptake ratio of the 111In-labeled platelets decreased, whereas the platelet recovery increased. Furthermore, the platelet survival time was prolonged, whereas the PA-IgG decreased. The platelet count showed a positive correlation with the platelet survival time and a negative correlation with PA-IgG before and after the procedure. These results suggest that a transcatheter splenic arterial embolization not only may reduce the increased platelet pool in the spleen but also may improve the thrombocytopenia induced by immunologic mechanisms in patients with cirrhosis.

Adult↗
PubMed1996

Pathologic rupture of the spleen in hematologic malignancies: two additional cases.

Pathologic rupture of the spleen in hematologic malignancies is rare. We present two cases of splenic rupture which occurred in a man with a secondary high-grade non-Hodgkin's lymphoma and a woman with chronic lymphocytic leukemia (CLL). In a review of the literature, we have been able to identify 136 cases of pathologic splenic rupture since 1861; 34% have occurred in acute leukemias, 34% in non-Hodgkin's lymphomas, and 18% in chronic myelogenous leukemia (CML). We find a male-to-female ratio of 3:1, with considerable differences for the specific diseases encountered. Pathologic rupture of the spleen has happened almost exclusively in adults and the ruptured spleens are generally moderately to severely enlarged. It seems that, apart from splenic infiltration by a hematologic disease, splenic infarcts and coagulation disorders (which have previously been advanced as the most important pathophysiologic factors leading to rupture), male sex, adulthood, severe splenomegaly, and cytoreductive chemotherapy may increase the risk for pathologic splenic rupture. We briefly discuss symptoms preceding the event, diagnostic possibilities, and the outcome with operative and conservative approaches.

Fatal Outcome↗
PubMed2003

Splenic trauma: evaluation with contrast-specific sonography and a second-generation contrast medium: preliminary experience.

OBJECTIVE: To report our experience in the assessment of splenic trauma with contrast-coded sonography and a second-generation contrast medium. METHODS: From January to May 2002, 120 patients were studied with sonography for suspected splenic trauma. Twenty-five were selected for further imaging because of sonographic findings positive for splenic injury, findings positive for peritoneal fluid only, indeterminate findings, and negative findings with high clinical or laboratory suspicion. These patients underwent contrast-enhanced harmonic sonography and contrast-enhanced helical computed tomography. RESULTS: Among the 25 patients studied, 6 had no spleen trauma at initial and follow-up evaluation. One patient had a hypoperfused spleen without parenchymal damage, and 18 had splenic injuries; these 19 patients were considered positive. Hemoperitoneum was identified by sonography, contrast-enhanced sonography, and contrast-enhanced computed tomography in 74% of the 19 positive cases. Perisplenic clots were recognized in 58% of the cases by computed tomography and in 42% by baseline and enhanced sonography. Splenic infarctions were found in 11% of cases by contrast-enhanced sonography and computed tomography; none was found by unenhanced sonography. Parenchymal traumatic lesions were identified in 12 of 18 patients with splenic injuries by unenhanced sonography, in 17 cases by contrast-enhanced sonography, and in all 18 cases by contrast-enhanced computed tomography. A minimal splenic lesion was found in the single patient with a false-negative contrast-enhanced sonographic finding. Contrast-enhanced sonography correlated appreciably better than unenhanced sonography in detecting injuries and in estimating their extent. Findings undetectable on unenhanced sonography were also noted: splenic hypoperfusion in 11% of positive cases on both contrast-enhanced sonography and contrast-enhanced computed tomography, contrast medium pooling in 21% of cases on both contrast-enhanced sonography and computed tomography, and contrast extravasation in 11% of cases on computed tomography and 5% on contrast-enhanced sonography. CONCLUSIONS: Contrast-enhanced sonography is a promising tool in the assessment of splenic trauma. In institutions where sonography is used as the initial procedure, this technique may increase its effectiveness.

Abdomen↗
PubMed2005

[Splenic artery aneurysm: case report].

Splenic artery aneurysms are rare and occur predominantly in women. Most of them are asymptomatic until rupture. We report a previously healthy 73 year-old woman who presented with non specific symptoms: dyspepsia and constipation. Laboratory tests were normal. Subsequent examinations (ultrasound and CT) showed a large aneurysm of the splenic artery without any sign of rupture. Endovascular treatment remained successfully performed using coil embolization. During a 12-months follow-up period, the patient was asymptomatic and no evidences of complications or splenic infarction were observed on CT scans.

Aged↗
PubMed1978

The scintigraphic diagnosis of splenic cysts.

In four patients, each of whom had a different type of splenic cyst, 99mTc-sulphur colloid images revealed non-specific, intrasplenic "cold" lesions. The rim of splenic tissue surrounding the cyst was incomplete in three out of four patients and caused appearances similar to those of splenic infarction. Repeat spleen imaging with 99mTc-RBC revealed an additional cyst in one out of four patients. 113m indium blood pool images provided preoperative information on lesion vascularity. The scintigraphic diagnosis of splenic cysts should ideally combine 99mTc-sulphur colloid imaging, 99mTc-RBC imaging, and 113m Indium blood pool imaging.

Adult↗
PubMed2000

The feasibility of spleen-preserving pancreatectomy for end-stage chronic pancreatitis.

BACKGROUND: It is considered difficult to preserve the spleen at the time of distal or total pancreas resection for chronic pancreatitis (CP). The aim of this study was to assess the feasibility of preserving the spleen in patients requiring total or completion pancreatectomy for CP. METHODS: All patients having total or completion pancreatectomy for CP were evaluated postoperatively in terms of morbidity, mortality, and pain relief. To assess splenic vascularity, all patients underwent abdominal ultrasound and power doppler imaging to assess splenic perfusion and the patency of the remaining splenic vessels. RESULTS: Of 35 patients having total pancreatectomy, the spleen was preserved in 30 patients (19 women, 11 men; median age 40 years). The etiology of CP was mainly idiopathic (n = 14) or alcohol related (n = 12). All patients presented with chronic abdominal pain (median 5 years) requiring opiate-derived analgesia for pain relief. Fifteen patients (50%) had undergone previous therapeutic intervention for pain relief. The spleen was preserved with either an intact splenic artery and vein in 19 patients and or the short gastric vessels (n = 11). The mean duration of the procedure was 7 hours (range 5 to 11) and mean blood loss was 1,090 mL. The 30-day mortality was 3.8% (n = 1). Five patients had splenic complications (17%). These included splenectomy (n = 2), intrasplenic collection (n = 2), and a wedge splenic infarct (n = 1). Two of these complications were related to intrasplenic islet autotransplants. Follow-up with abdominal ultrasound and power doppler scanning showed no other abnormalities; blood flow was demonstrable in all patients with intact splenic arteries and vein (n = 19). The mean hospital stay was 25 days. Of the 24 patients who were beyond 6 months' follow-up, 82% (n = 20) have complete relief of pain, and 4 still require opiate analgesia. CONCLUSIONS: Spleen-preserving pancreatectomy is a feasible procedure for chronic pancreatitis, providing complete pain relief in 80% of patients. When the splenic artery and vein cannot be preserved, there is a minimal risk of splenic complications that may require further treatment; but for the majority of patients, splenectomy is avoided.

Adult↗
PubMed2000

Dermatomyositis with splenic and renal infarctions during corticosteroid therapy.

A 60-year-old woman was admitted to our hospital with complaints of muscle weakness and erythema on her extremities. Gottron's sign, heliotrope rash, elevation of serum myogenic enzymes, electromyography and magnetic resonance imaging findings established a diagnosis of dermatomyositis (DM). She was treated with 60 mg of daily prednisolone. One week later, she suddenly developed splenic and renal infarctions, which were considered to have resulted from vasculopathy associated with DM. Cyclophosphamide and anticoagulants along with increasing the dosage of corticosteroid were effective. This is the first report describing splenic and renal infarctions in a patient with adult-onset DM.

Anti-Inflammatory Agents↗
PubMed1997

Results of using the recipient's splenic artery for arterial reconstruction in liver transplantation in 23 patients.

BACKGROUND: Arterial reconstruction is essential in liver transplantation. In some patients there may be an inadequate flow as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. METHODS: This study analyzes our experience with 23 patients in whom arterial anastomosis was performed using the splenic artery due to the inadequacy of the hepatic artery. During the same period an aortoiliac conduit was used in 12 liver transplantations due to the same problem. RESULTS: No splenic infarction, pancreatitis, or other related complications were found. Artery thrombosis developed in only two patients in the aortoiliac conduit group. One- and three-year patient actuarial survival were 78% vs. 80% and 72% vs. 80%, respectively, for the splenic artery group and the aortoiliac conduit group. CONCLUSIONS: Anastomosis with the splenic artery is an alternative in liver transplantation and is particularly suitable when splenomegaly is present.

Anastomosis, Surgical↗
PubMed2003

Mass at the splenic hilum: a clue to torsion of a wandering spleen located in a normal left upper quadrant position.

Wandering spleen is an extremely rare condition in which the spleen is lacking its normal ligamentous attachments and therefore can move to an ectopic position in the abdomen or pelvis. Wandering spleen predisposes the patient to life-threatening complications due to torsion of the spleen's vascular pedicle, with resulting splenic infarction, portal hypertension, and bleeding. Because of the nonspecific symptoms, imaging plays an important role. To our knowledge, only a few case reports describing wandering spleen in the pediatric population have been published, including 2 cases in infancy. We report a case of splenic torsion in an infant with a preoperative diagnosis made on the basis of color and power Doppler sonography. The diagnosis was confirmed by contrast-enhanced helical computed tomography (CT) and proved at surgery. On sonography, a diffusely hypoechoic spleen and a mass at the splenic hilum representing the torsed splenic pedicle were shown. The splenic hilar mass correlates with the CT "whirl" sign indicative of torsion.

Choristoma↗
PubMed1986

Computed tomography follow-up of nonsurgical treatment for hypersplenism.

For the treatment of hypersplenism, transcatheter embolization of the splenic artery and collateral vessels is an alternative to splenectomy, notably in high-risk or immunosuppressed patients. After arterial occlusion and thrombosis, follow-up computed tomography scans depict progressive changes in the extent and appearance of splenic infarcts, such that these changes correlate with improved platelet counts. Computed tomography thus performs the unique role of identifying specific patterns of infarction and also differentiating internal defects, such as suppurative, gaseous, or liquefaction necrosis.

Adult↗
PubMed1997

Localised thrombus in the distal aortic arch: its aetiology analysed by three-dimensional mould model of the thoracic aorta.

Isolated thrombus of the thoracic aorta without aneurysmal change or dissection is a relatively rare event. A case presenting with aortic thrombus and successive distal embolism is reported herein and the aetiology of the thrombus of the distal aortic arch is analysed by a three dimensional aortic model. A 61-year-old man suffered acute ischaemia in his right leg on January 26, 1994. Enhanced computed tomography (CT) showed a localized thrombus in the distal aortic arch expanding towards the descending aorta, and partial infarction of the left kidney and the spleen. Angiography demonstrated abrupt occlusion of the right superficial femoral artery. Immediate anticoagulation with heparin and coumadin was administered, and the thrombus in the aorta disappeared following 1 month of this medical treatment, leaving the renal and splenic infarction unchanged. The unresolved occlusion of the superficial femoral artery and the popliteal artery was treated with a bypass from the right superficial femoral artery to the peroneal artery using a reversed saphenous vein graft. The mould model of the thoracic aorta was reconstructed from CT, and the thrombus was found to be at the most distal and medial site of the lesser curvature of the aortic arch. This specific location is referred mostly as the site for thrombus formation in the literature. The case is reported briefly and the risk of this specific region of the thoracic aorta for thrombus formation is discussed using this mold model.

Angiography↗