Splenic abscess

Rare entity, 0.14-0.7% incidence at autopsy.

Incidence in Denmark .056 per 1000 hospital discharges per year or 0.049% per year of all hospital deaths.

Mortality rate about 47%.

Most commonly related to hematogenous spread from an infectious focus elsewhere in the body.

Infective endocarditis has a 10-20% incidence of associated splenic abscess.

May be a complication of pneumonia, urinary tract infection, otitis, mastoiditis, pelvic infections, malaria, typhoid or paratyphoid.

Can be a contiguous infection of pancreatic abscess, retroperitoneal abscess, subphrenic abscess and diverticulitis.

May follow splenic trauma.

May result from splenic infarction due to sickle cell disease, leukemia, polycythemia or vasculitis with secondary infection.

Patients most susceptible include immunosuppressed patients, alcoholics and diabetics.

Studies suggest preexisting splenic injury and bacteremia are required to form an abscess, although hematogenous embolization to a previously normal spleen con occur with immunosuppression or overwhelming sepsis.

Most cases involve: Gram positive organisms- Streptococci, Staphylococci, Enterococci, Gram negative organisms-E. coli, Klebsiella, Proteus, Pseudomonas species, Salmonella species, anaerobes-Peptostreptococcus, Bacteroides, Fusobacterium, Clostridium, Propionibacterium acnes, fungal-Candida, and up to 50% have multiple organisms.

Diagnosis requires high index of suspicion.

Classical triad of left upper quadrant pain, fever and splenomegaly occurs in only one third of cases.

Symptoms vary with the location and size of the abscess and on the rapidity of presentation of the process.

Presentation may be acute, subacute or chronic.

Small lesions may be asymptomatic.

90% of patients present with fever, but it may be moderate, intermittent or absent.

Abdominal pain typical in 60% of patients and usually has a sudden onset.

The presence of abdominal pain indicates perisplenitis.

Shoulder pain may occur if the diaphragm is involved (Kehr sign).

15% of patients have pleuritic chest pain in the left lung base.

Splenomegaly observed in less than 50% of patients.

More than 30% have dullness to percussion at the left lung base, left basilar rales in grater than 20% and the diaphragm may be elevated in more than 15% of cases.

Antibiotics are the primary treatments for the initial management.

Percutaneous drainage may be effective in selected patients, with a success rate of 67-100%.

Percutaneous drainage is typically useful in the presence of one or two cysts.

When there are multiple abscesses, ill-defined cavities, presence of septations, and necrosis the benefit of percutaneous drainage is not likely to proved benefit.

Laparoscopic or open surgical management is reserved for stable patients who will not benefit from percutaneous drainage.

Small solitary or multiple abscesses tend to be contained by surrounding spleen capsule, while advanced lesions can fistularize to the pleura, the splenic flexure of the colon, the stomach or the pancreas.

Contraindications to percutaneous drainage include: multiloculated or debris filled abscesses, multiple small abscesses. uncontrolled coagulopathy, poorly defined abscess and diffuse ascites

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