Abscess of spleen - Clinicals, Diagnosis, and Management

Trauma

Clinicals - History

Fact Explanation
Fever Splenic abscess is most usually associated with trauma and infections of the spleen.The latter are more common in the presence of a different primary site of infection, especially endocarditis or in cases of ischemic infarcts that are secondarily infected. Moreover, immunosuppression is a major risk factor.They are usually present with fever.. Feve may be continuous or remittent, in most cases over 38C. A few cases may present with normal or nearly normal temperature, in these cases the result of uncontrolled antibiotic self-medication. . Fever
Splenic abscess is most usually associated with trauma and infections of the spleen.The latter are more common in the presence of a different primary site of infection, especially endocarditis or in cases of ischemic infarcts that are secondarily infected. Moreover, immunosuppression is a major risk factor.They are usually present with fever.. Feve may be continuous or remittent, in most cases over 38C. A few cases may present with normal or nearly normal temperature, in these cases the result of uncontrolled antibiotic self-medication. .
Abdominal pain The clinical manifestation of splenic abscesses usually include abdominal pain, exclusively located or, at least, more intensely described in the upper-left-quadrant area.. The pain was dull and dragging becoming sharp on deep breathing.. Abdominal pain
The clinical manifestation of splenic abscesses usually include abdominal pain, exclusively located or, at least, more intensely described in the upper-left-quadrant area.. The pain was dull and dragging becoming sharp on deep breathing..
Nausea and vomiting Fever, nausea, vomiting may be also present in various combinations.. Nausea and vomiting
Fever, nausea, vomiting may be also present in various combinations..
Anorexia Detected in patients with abscess of spleen.. Anorexia
Detected in patients with abscess of spleen..
Malaise and loss of appetite Malaise and loss of appetite is frequent.Malaise and loss of appetite extending over a period of up to 40 days before sought medical attention has been observed in some patients.. Malaise and loss of appetite
Malaise and loss of appetite is frequent.Malaise and loss of appetite extending over a period of up to 40 days before sought medical attention has been observed in some patients..
Rupture of abscess Single abscesses were usually large and susceptible to easy rupture.The large splenic abscess with rupture presents the picture of peritonitis . Rupture of abscess
Single abscesses were usually large and susceptible to easy rupture.The large splenic abscess with rupture presents the picture of peritonitis .

Clinicals - Examination

Fact Explanation
Splenomegaly About 66% present with the classical triad of fever, splenomegaly and left upper quadrant pain. Splenomegaly
About 66% present with the classical triad of fever, splenomegaly and left upper quadrant pain.
Percussion dullness Dyspnea, with left-sided pleuritic pain
and a dull percussion note in the left
lower chest can detect in some patients and it suggested left basal pneumonitis and/or effusion..
Percussion dullness
Dyspnea, with left-sided pleuritic pain
and a dull percussion note in the left
lower chest can detect in some patients and it suggested left basal pneumonitis and/or effusion..
left basal chest signs Diagnosis depended on the history
of pain and tenderness, splenomegaly, fever,anemia, leukocytosis, and left basal chest signs.A left pleural effusion with signs of basal consolidation is of added significance and would suggest subdiaphragmatic inflammation..
left basal chest signs
Diagnosis depended on the history
of pain and tenderness, splenomegaly, fever,anemia, leukocytosis, and left basal chest signs.A left pleural effusion with signs of basal consolidation is of added significance and would suggest subdiaphragmatic inflammation..
Tenderness Left upper quadrant pain and tenderness is elicitable in a majority of the patients. Indeed this was the major
complaint that brought the patients to
hospital.Tenderness at the left hypochondrial area also observed. Tenderness and guarding over this hypochondrial mass may make deeper palpation difficult..
Tenderness
Left upper quadrant pain and tenderness is elicitable in a majority of the patients. Indeed this was the major
complaint that brought the patients to
hospital.Tenderness at the left hypochondrial area also observed. Tenderness and guarding over this hypochondrial mass may make deeper palpation difficult..
Left hypochondrial mass A left hypochondrial mass is usually
present in the majority of cases. This
mass is either the enlarged spleen or the result of inflammatory adhesion involving the omentum, spleen,stomach,
and colon..
Left hypochondrial mass
A left hypochondrial mass is usually
present in the majority of cases. This
mass is either the enlarged spleen or the result of inflammatory adhesion involving the omentum, spleen,stomach,
and colon..
Fluid thrill In large abscesses, the organ may become fluctuant. If the splenic pus has undergone colliquative change, a fluid thrill may be elicited.. Fluid thrill
In large abscesses, the organ may become fluctuant. If the splenic pus has undergone colliquative change, a fluid thrill may be elicited..

Investigations - Diagnosis

Fact Explanation
FBC (full blood count) Can see signs of on-going bacterial infection such as leukocytosis.. Leukocytosis was a constant finding, the range lying between 8,400 to 26,400. The differential count was of normal pattern. Some were found to be anemic with hematocrit values in the range 18-32 percent. FBC (full blood count)
Can see signs of on-going bacterial infection such as leukocytosis.. Leukocytosis was a constant finding, the range lying between 8,400 to 26,400. The differential count was of normal pattern. Some were found to be anemic with hematocrit values in the range 18-32 percent.
Blood picture Laboratory data suggested the presence of a chronic inflammatory focus.The blood picture of some patients showed anisocytosis and polychromasia.. Blood picture
Laboratory data suggested the presence of a chronic inflammatory focus.The blood picture of some patients showed anisocytosis and polychromasia..
Percutaneous aspiration of the lesion and culture Laboratory findings are consistent with the acute phase of infection, but their exact nature is determined by the pathogen isolated from the abscess. The most common pathogens detected include Staphylococcus and Streptococcus.. Percutaneous aspiration of the lesion and culture
Laboratory findings are consistent with the acute phase of infection, but their exact nature is determined by the pathogen isolated from the abscess. The most common pathogens detected include Staphylococcus and Streptococcus..
X ray A plain abdominal radiograph can show a Soft tissue mass in the left upper quadrant, displacement of the gastric bubble, elevation of the left hemidiaphragm or a left pleural effusion.. X ray
A plain abdominal radiograph can show a Soft tissue mass in the left upper quadrant, displacement of the gastric bubble, elevation of the left hemidiaphragm or a left pleural effusion..
USS Imaging is a necessary tool for establishing the diagnosis, with a choice between ultrasound and computed tomography..Abdominal ultrasonography is cost-effective, noninvasive and very useful for percutaneous drainage. With a sensitivity of 96%..Gray-scale US imaging of a splenic abscess is not specific; the image shows a hypo-echoic lesion with a thick irregular wall, but this aspect may vary depending on the etiology and the size of the lesion. Abscesses are therefore classified in three types according to the US pattern. First one is Hypo- or iso-echoic lesions, often solitary and larger than 2–3 cm in diameter with septa or areas of hyperechogenicity, maybe with reverberation artifacts due to the presence of gas (bacteria). The Second are Lesions, sometimes multiple and smaller than 2 cm in diameter, hypo-echoic, with “target” appearance, “wheel within a wheel” appearance or hyperechoic (fungus, Pneumocystis carinii, Bartonella). Third is Multiple, homogenously hypo-echoic lesion 10–20 mm in diameter (mycobacteria).. USS
Imaging is a necessary tool for establishing the diagnosis, with a choice between ultrasound and computed tomography..Abdominal ultrasonography is cost-effective, noninvasive and very useful for percutaneous drainage. With a sensitivity of 96%..Gray-scale US imaging of a splenic abscess is not specific; the image shows a hypo-echoic lesion with a thick irregular wall, but this aspect may vary depending on the etiology and the size of the lesion. Abscesses are therefore classified in three types according to the US pattern. First one is Hypo- or iso-echoic lesions, often solitary and larger than 2–3 cm in diameter with septa or areas of hyperechogenicity, maybe with reverberation artifacts due to the presence of gas (bacteria). The Second are Lesions, sometimes multiple and smaller than 2 cm in diameter, hypo-echoic, with “target” appearance, “wheel within a wheel” appearance or hyperechoic (fungus, Pneumocystis carinii, Bartonella). Third is Multiple, homogenously hypo-echoic lesion 10–20 mm in diameter (mycobacteria)..
CEUS (contrast enhanced ultrasound) At CEUS, there is no uptake of contrast agent in the larger abscesses at any stage, but there may sometimes be ring enhancement and enhancement of the perilesional tissue and septa. The perilesional enhancement may be replaced in the late phase by a hypo-echoic area due to washout of contrast agent.Also in small abscesses, no uptake of contrast agent is observed but there may be slight ring enhancement. Differential diagnosis between abscess and lymphoma may be difficult even at CEUS, especially in infectious lesions of small dimensions.. CEUS (contrast enhanced ultrasound)
At CEUS, there is no uptake of contrast agent in the larger abscesses at any stage, but there may sometimes be ring enhancement and enhancement of the perilesional tissue and septa. The perilesional enhancement may be replaced in the late phase by a hypo-echoic area due to washout of contrast agent.Also in small abscesses, no uptake of contrast agent is observed but there may be slight ring enhancement. Differential diagnosis between abscess and lymphoma may be difficult even at CEUS, especially in infectious lesions of small dimensions..
CT (Computer tomography) The lesion is usually revealed via computed tomography (CT)..CT is presently the gold standard to establish a diagnosis of splenic abscess.. CT (Computer tomography)
The lesion is usually revealed via computed tomography (CT)..CT is presently the gold standard to establish a diagnosis of splenic abscess..

Management - Supportive

Fact Explanation
Antibiotics Successful treatment has varied from the purely medical to surgical. Early workers advised antibiotic therapy, either because the diagnosis was in doubt or the patient judged not too ill.Medical treatment, although successful in many cases, still left the patient at risk, since a residual focus of
infection could persist. This focus could reactivate and seed bacteria to
other organs.. The initial management of splenic abscess involves administering empiric broad-spectrum antibiotics that can later be changed according to culture results. Nonetheless, even surgery patients should receive at least a 2-week course of antibiotics..
Antibiotics
Successful treatment has varied from the purely medical to surgical. Early workers advised antibiotic therapy, either because the diagnosis was in doubt or the patient judged not too ill.Medical treatment, although successful in many cases, still left the patient at risk, since a residual focus of
infection could persist. This focus could reactivate and seed bacteria to
other organs.. The initial management of splenic abscess involves administering empiric broad-spectrum antibiotics that can later be changed according to culture results. Nonetheless, even surgery patients should receive at least a 2-week course of antibiotics..
Total Splenectomy Traditionally open splenectomy has been found to be the most effective and definitive procedure for most patients with splenic abscess. The mortality rates of this surgery are reported to vary from 0% to 16.9% and the morbidity rates from 28% to 43%.The high rates of morbidity and mortality are likely to be a reflection of the predisposing disease states.. Total Splenectomy
Traditionally open splenectomy has been found to be the most effective and definitive procedure for most patients with splenic abscess. The mortality rates of this surgery are reported to vary from 0% to 16.9% and the morbidity rates from 28% to 43%.The high rates of morbidity and mortality are likely to be a reflection of the predisposing disease states..

Management - Specific

Fact Explanation
Percutaneous imaging guided drainage More recent studies have also referred to alternative options, including spleen-preserving protocols, such as percutaneous imaging-guided drainage.In children and in cases of solitary abscesses with a thick wall, percutaneous catheter drainage may be attempted..Several authors have reported the use of aspiration of splenic abscesses under ultrasonographic or CT guidance in a select group of patients with the aim of avoiding splenectomy and preserving immunological function.Although an attractive option, image guided drainage is only likely to succeed when the collection is unilocular or bilocular with a discrete wall and no internal septations, or when its content is liquefied enough to be drained ,and if it is located at the periphery or at the middle or lower pole of the spleen.. However the current policy is to limit their use in centers with adequately trained surgeons and only for a selected subgroup of patients.. Percutaneous imaging guided drainage
More recent studies have also referred to alternative options, including spleen-preserving protocols, such as percutaneous imaging-guided drainage.In children and in cases of solitary abscesses with a thick wall, percutaneous catheter drainage may be attempted..Several authors have reported the use of aspiration of splenic abscesses under ultrasonographic or CT guidance in a select group of patients with the aim of avoiding splenectomy and preserving immunological function.Although an attractive option, image guided drainage is only likely to succeed when the collection is unilocular or bilocular with a discrete wall and no internal septations, or when its content is liquefied enough to be drained ,and if it is located at the periphery or at the middle or lower pole of the spleen.. However the current policy is to limit their use in centers with adequately trained surgeons and only for a selected subgroup of patients..
Subtotal splenectomy Total splenectomy was considered the best surgical procedure until recently. Today, susceptibility to infection and thromboembolic events after splenectomy have made more conservative procedures quite common. In subtotal splenectomy, the spleen is resected and its upper part is kept in place, with viability warranted by splenogastric vessels.Current treatment places importance on preserving splenic function whenever possible and subtotal splenectomy has chance to preserve some splenic tissue.. Subtotal splenectomy
Total splenectomy was considered the best surgical procedure until recently. Today, susceptibility to infection and thromboembolic events after splenectomy have made more conservative procedures quite common. In subtotal splenectomy, the spleen is resected and its upper part is kept in place, with viability warranted by splenogastric vessels.Current treatment places importance on preserving splenic function whenever possible and subtotal splenectomy has chance to preserve some splenic tissue..
Laparoscopic Splenectomy LS (Laparoscopic Splenectomy) for splenic abscess is sparsely reported in the literature.Dissection of the splenic vessels within the hilum covered with adhesions and engulfed in inflammation could be challenging, and control of the vessels using either an energy source such as the bipolar vessel sealing device or a vascular stapler may be required. LS is a feasible alternative to open splenectomy in patients with tuberculous abscess of the spleen, but this technically demanding procedure is best undertaken by experienced laparoscopic surgeons. In this clinical setting, LS is likely to result in a higher postoperative morbidity than when performed for other indications.. However the current literature supports the laparoscopic splenectomy as a safe and effective procedure in patients with splenic abscess demonstrating an average length of stay of 14 days.. Laparoscopic Splenectomy
LS (Laparoscopic Splenectomy) for splenic abscess is sparsely reported in the literature.Dissection of the splenic vessels within the hilum covered with adhesions and engulfed in inflammation could be challenging, and control of the vessels using either an energy source such as the bipolar vessel sealing device or a vascular stapler may be required. LS is a feasible alternative to open splenectomy in patients with tuberculous abscess of the spleen, but this technically demanding procedure is best undertaken by experienced laparoscopic surgeons. In this clinical setting, LS is likely to result in a higher postoperative morbidity than when performed for other indications.. However the current literature supports the laparoscopic splenectomy as a safe and effective procedure in patients with splenic abscess demonstrating an average length of stay of 14 days..
Open splenectomy Open laparotomy is the best approach because it allows for better visualization and irrigation of the abdominal cavity. Sometimes laparoscopic splenectomy has to convert to an open splenectomy due to the gross contamination and adhesions from the splenic abscess.
However in a case of ruptured splenic abscess resulting in hemodynamic instability, it is still debatable Whether it is better to perform the laparoscopic splenectomy or open splenectomy..
Open splenectomy
Open laparotomy is the best approach because it allows for better visualization and irrigation of the abdominal cavity. Sometimes laparoscopic splenectomy has to convert to an open splenectomy due to the gross contamination and adhesions from the splenic abscess.
However in a case of ruptured splenic abscess resulting in hemodynamic instability, it is still debatable Whether it is better to perform the laparoscopic splenectomy or open splenectomy..

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