Splenic abscess the lect.ppt

how can you diagnose splenic abscess and how to manage whether medical or surgical and what are the complications with pictures for diagnosis and treatment

1. ميحرلا نمحرلا الله مسب
ميظعلا الله قدص
ام لاإ انل ملع لا كناحبس اولاق
ميكحلا ميلعلا تنأ كنإ انتملع
ةروس ءاسنلاةيلآا نم :113

2. Splenic Abscess
Hamed Rashad
Professor of surgery Banha University -Egypt

3. Introduction
•Abscesses of the spleen have been reported
periodically since the time of Hippocrates. He
postulated that 1 of 3 courses was followed by a
patient with a splenic abscess:
•(1) the patient might die;
•(2) the abscess might heal; or
•(3) the abscess might become chronic and the
patient may live with the disease. 1

4. Introduction
Splenic abscess is a rare entity, with a reported
frequency of 0.05-0.7%.2,3
Its reported mortality rate is still high, up to 47%,
and can potentially reach 100% among patients
who do not receive antibiotic treatment.4
Appropriate management can decrease the
mortality to less than 10%.5

5. Etiology
•The most common is hematogenousspread
originating from an infective focus elsewhere in
the body. Infective endocarditis, a condition
associated with systemic embolization in 22-
50% of cases, has a 10-20% incidence of
associated splenic abscess.8Other infective
sources include typhoid, paratyphoid, malaria,
urinary tract infection, pneumonias,
osteomyelitis, otitis, mastoiditis, and pelvic
infections.

6. Etiology
•Pancreatic, other retroperitoneal, and subphrenic
abscesses, as well as diverticulitis, may
contiguously involve the spleen.
•Splenic trauma is another well-recognized etiologic
factor.
•Splenic infarction resulting from systemic
disorders (see the image below), such as
hemoglobinopathies(especially sickle cell disease),
leukemia, polycythemia, or vasculitis, can become
infected and evolve into splenic
abscesses.2,4,9,10,11,12,13

7. Splenic abscess

8. Differential diagnosis
Cystic lesions
•With or without cell debris?
•Solitary or multiple?
•With or without enhancement?
•Other associated findings?
•Correlating patient’s data and history

9. Diagnosis & Management
•Splenic abscess, suspecting secondary
•to chronic pancreatitis
•Cefamezine + Gentamicin
•Splenectomy
•Pus culture: no growth

10. Clinical Presentation
•Fever: 95%
•Abdominal pain: 60%
•LUQ pain: 38%
•Left chest pain: 17%
•Left shoulder pain:10%
•RUQ pain: 6%
•Weakness: 22%
•Chills: 22%
•Nausea/Vomiting: 16%
•Anorexia: 15%
•Diaphoresis: 12%
•Weight loss: 11%
•Change in bowel habits: 9%

11. Signs
•Abdominal tenderness: 59%
•Splenomegaly: 54%
•Hepatomegaly: 16%
•Abdominal distention: 13%
•Ascites: 7%
•Costovertebral angle tenderness: 5%
•Friction rub: 3%

12. Signs
•Dullness at left thoracic base: 33%
•Left basilar rales: 21%
•Elevated left diaphragm: 18%
•Left pleural friction rub: 5%

13. Complications
•The mortality ratein patients withuntreated
splenic abscess approaches 100%.
•The list of complications is long but most
importantly includesfree rupture into the
peritoneal cavity withgeneralized
peritonitis,rupture into the colon, erosion of
the abscess through the diaphragm,or, more
rarely, necessitation through theskin.

14. Lab Studies
•Leukocytosis: 70%
•Immunocompromised patients with fungal
•abscesses
•Elevated alkaline phosphatase level
•Positive blood culture: 60%

15. Image Studies
•CXR
--Abnormal in 80% of patients
--Elevated left hemidiaphragm: 33%
--Pleural effusion: 28%
•Abdominal radiograph
--Abnormal soft tissue density or gas pattern: 35%
•Radioisotope scanning: of little value

16. Image Studies
•Ultrasound
-Repeatable for interval change
-Nonspecific
-Highly variable and not easy to interpret
•CT
-Test of choice
-Sensitivity: ~100%
-Low-density lesions without enhancement
-CT-guided aspiration

17. Diagnosis
•Diagnostic procedure
-CT-guided or ultrasound-guided aspiration
-Proper antibiotic treatment

18. Ultrasound
•Splenic abscess

19. CT :Splenic abscess

20. CT Scan
Hypodense
lesion without
enhancement

21. CT Scan
Multiple
hypodense
lesions with
ill-defined
borders and
heterogenous
contents
Spleen
Stomach

22. CT Scan
Lesions
without
enhancement
Inflammatory
process

23. CT scan abdomen demonstrating A single
splenic abscess

24. Multiple tubercular splenic abscesses

25. CT Scan
Enlarged
pancreas
with
relatively
decreased
density

26. Indication
•Once identified, always treated!

27. Treatment
•Medical treatment
-Interventional treatment involving
antimicrobials
-Primary medical management
controversial
•Surgical treatment
-Percutaneous drainage or splenectomy +
antimicrobial therapy

28. Surgical Therapy
•The invasive treatment of splenic abscess includes 3 options: percutaneous drainage,
open or laparoscopic surgery (splenectomy), and open drainage.
Percutaneous drainage
•Percutaneous drainage is indicated for easily accessible uniloculated or biloculated
abscesses with otherwise favorable features, as described previously, and also for
surgical patients at very high risk who cannot tolerate general anesthesia or
surgery.21,22
The procedure includes a risk of iatrogenic injury of the spleen, colon (splenic flexure),
stomach, left kidney, and diaphragm.18
Calcified walls of the abscess, the presence of other intra-abdominal cysts with
intraluminal daughter cysts, and an origin from endemic areas (eg, the Mediterranean
basin, Eastern Europe) should raise a suspicion forEchinococcus
granulosus.19Percutaneous drainage of such suppurative cysts increases the risk of
hydatid seeding and anaphylaxis and is therefore contraindicated.
Other iatrogenic complications resulting from percutaneous drainage include
hemorrhage, pleural empyema, pneumothorax, and enteric fistula.6,23
•Splenectomy

29. Percutaneous drainage
•Uniloculate solitary abscess
•Not contraindicated
•splenic flexure of the colon and the pleural
spacerisk of injury
•Patients with cavities that have calcified
walls or patients with a history of travel to
endemic areas Echinococcus

30. Percutaneous drainage
Complications:
•Haemorrhage
•Pleural empyema
•Pneumothorax
•Fistula formation
Contraindications:
•Contiguous process
•A phlegmonous or poorly
differentiated lesion on CT
scan
•Multiloculated or debris-
filled abscess
•Uncontrollable coagulopathy

31. Treatment
•Splenectomy
•Splenotomy:
Reserved for only the sickest patients who
have contraindications to both splenectomy
and percutaneous drainage

32. Splenectomy
•Splenectomy has long been considered the standard
treatment of splenic abscess. Depending on the
patient population, open splenectomy has a mortality
rate of 0-17% and a morbidity rate of 28-43%.24
•The method removes the septic source and the
diseased organ. The surgeon can explore and
manage coexisting septic collections.
Laparoscopic splenectomy is safe and effective in
selected patients. It can be performed with no
morbidity or mortality, and patients who have
undergone the procedure reportedly have a shorter
hospital stay.25

33. Splenectomy
Very infrequently, the perisplenicadhesions are so
severe that safe dissection between the spleen and
the surrounding structures is impossible. The only
choice in this scenario is to perform an open
splenotomyand drain the collection.

34. Splenectomy
Open drainage
Open drainage is used when the abscess cannot be drained
percutaneously. Depending on the location of the abscess, 1 of 3
access routes can be employed:
•Transpleural-Usually requires resection of the 12th rib in the
posterior axillary line and drainage of the abscess through the
diaphragm
•Abdominal extraperitoneal -Accesses the abscess through the
lateral abdominal wall and between the peritoneum and the flat
abdominal muscles
•Retroperitoneal -Used when the abscess extends to the flank

35. Complications
•Mortality rate: 100% if left untreated
•Rupture:
-Most commonperitonealcavity: 6.6%
-Rupture into the bowel, bronchus, or pleural space
•Colon obstruction
•Splenocutaneousfistula

36. Complications of Treatment
•Atelectasis
•Left-sided pleural effusion
•Pneumonia
•Subphrenic abscess
•Pancreatic injury with fistula or pseudocyst
•Thrombocytosis
•Overwhelming postsplenectomy sepsis

37. FOLLOW UP
•Follow-up is an essential element of the
management of patients undergoing treatment of
splenic abscess. Patients must be screened for the
following:
•Lateiatrogenic complications, such as residual
intra-abdominal abscesses, pancreaticor enteric
collections, or fistulas
•Intestinal obstruction and ventral hernia
•Recurrent splenic abscess
•Overwhelming postsplenectomy sepsis

38. THANK YOU