Splenic abscess

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Synonyms and Keywords: Abscess of spleen
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Overview

Splenic abscess is an uncommon and life-threatening condition. Clinical presentation, etiological factors, natural history, treatment and prognosis depends on whether the abscess was solitary or multiple.[1] It is always fatal if left untreated. Most commonly associated with immunodeficient patients especially and hematological disorders such as leukemia and sickle cell disease. Diagnostic needle aspiration is very important in the management with antibiotics as blood culture may not be the best correlate as abscess culture. Antibiotic of choice depends on the organism but aggressive and early surgical intervention of splenic abscess should be encouraged especially when the risk factors are present. High suspicion of splenic abscess with history of risk factors, broad-spectrum empirical antibiotic therapy should be initiated.[2]

Definition

Splenic abscess is defined as any infectious suppurative process involving identifiable macroscopic filling defects either in the parenchyma of the spleen or in the sub-capsular space.[3]

Historical Perspective

  • Since the times of Hippocrates, splenic abscess has been reported several times and he described the natural history and prognosis of splenic abscess.[4]
  • In the early days of 20th century, splenic abscess most commonly caused by typhoid and then followed by malaria.[5]
  • Ooi et al described significant etiological differences such increase in the percentage of abscess cases due to anaerobics as compared to aerobics (7 vs 18-28%), fungi (1 vs 18-41%) as well as mycobacterium tuberculosis (0.8 vs. 14%) in the second half of 20th century.[6]

Classification

Classification by Mechanism of pathogenesis Classification by Etiology Classification by Pathological Findings

Splenic abscess is classified traditionally by Chun and colleagues based on the predisposing causes as follows:[7][1][8]

Classification of splenic abscesses based on the etiological factors is as follows:[6]

Lawhorne and Zuidema classified splenic abscees based on pathological findings as follows:[9]

  • Unilocular abscess
  • Bilocular abscess

Pathophysiology

Splenic abscess can result from various sources such as:[10]

Pathogenic Mechanism Description
Hematogenous Dissemination
Secondary infection of splenic infarction
Contiguous spread of bacteria
Trauma or Surgery
  • Secondary infections may developed due to splenic trauma during any intra-abdominal procedures.[6]
  • Trauma leads to hematoma formation.
  • In case of penetrating trauma to the spleen or intraabdominal surgery, direct inoculation of the spleen with pathogens may form a septic focus which, left untreated, may lead to formation of an abscess.
Immunodeficiency
  • It is major factor involved in the course of splenic abscess especially if the causative organism is fungi or any other atypical organism.

Gross Findings

Solitary splenic abscess

  • Enlarged spleen with due to large solitary abscesses with thick wall around the abscess to prevent dissemination is seen

Multiple splenic abscess

  • At the time of autopsy, spleen present as large and soft, and pus extruded organ from the cut surface.

Microscopic Findings

Solitary splenic abscess

Multiple splenic abscess

Association

Splenic abscess is commonly associate with:[11]

Causes

Splenic abscess is caused mostly by monomicrobial but some times it can be caused by polymicrobial agents. Bacteria is more common than other microbial agents such as fungi, protozoa which can cause splenic abscess in immunocompromised patients.

Common causes

The most common causative bacteria of the splenic abscess in 50% of the cases is the aerobic bacteria.[3][12]

Other common causes of splenic abscess includes:[3]

Aerobes Anaerobes Fungal Parasite

Less common causes

Differentiating Splenic abscess from Other Diseases

Splenic abscess should be differented from other causes of left upper quadrent pain:[11]

Epidemiology and Demographics

Incidence

Incidence of splenic abscess varies between 0.1% to 0.7% based on population based autopsy studies.[7][13] Incidence of splenic abscess due to hematogenous spread is gradually declining due to increased antibiotic use, but incidence due to fungal infection is increasing due to aggressive chemotherapeutic methods.[14][15]

Prevalence

Prevalence of splenic abscess is increasing gradually due to increased risk factors and increased imaging modalities that can diagnose more accurately.[16]

Case Fatality Rate

Splenic abscesses are associate with increased morbidity and mortality. If left untreated, mortality is definite (100%).[3] Mortality rate also varies with treatment of choice such as splenectomy, percutaneous drainage, anti microbial therapy carries 8%, 29%, 20% of mortality rate respectively.[17]

Age

Splenic abscess shows bimodal distribution in age of the patients, with peak incidence seen in thirties and sixties.[3] First peak of age group is people < 40 years of age who are immunosuppressed or intravenous drug abusers, who commonly present multilocular abscesses. Second peak of age group patients > 70 years with diabetes or nonendocardic septic focus and commonly develop a unilocular abscess.

Gender

Splenic abscess is more predominant in male compared to female (~2 folds).[3][7][18]

Developing Countries

In Africa, splenic abscess is common due to prevalence of hemoglobinopathies such as sickle cell disease, which is a common risk factor for this disease.[19]

Risk Factors

Spleen abscess often co-exists with several risk factors, but the major one is the patient’s immunodeficiency. Common risk factors of splenic abscess include:[11]

Infectious risk factors Non infectious risk factors

Screening

No specific screening test for splenic abscess.

Natural History, Complications and Prognosis

Natural History

Splenic abscess is a rare cause of abdominal abscesses, but life-threatening. Because of it's rarity, splenic abscess usually diagnosed at the late stages or after the onset of complications.[1] Solitory abscess present with delayed onset of presentation with history of trauma, sepsis, or adjacent organ disease with fever, abdominal pain, nausea and vomiting where as multiple splenic abscess most commonly present with generalized sepsis because of an ineradicable septic focus remote from the spleen. Early diagnosis, prompt treatment can prevent complications.[1] Mortality rate is very high if left untreated.

Complications

Life threatening complications Common complications Less common complications

Prognosis

Prognosis of splenic abscess depends on the time of diagnosis and treatment. Delay in the management can lead to splenic rupture followed by spilling into peritoneal cavity or an adjacent organ which can lead to septicemia and death in severe cases.

Diagnosis

Splenic abscess commonly present with a triad of symptoms include fever, nausea, vomiting and abdominal pain along with palpable spleen on examination. Early diagnosis with imaging studies and prompt drainage is required to reduce morbidity and mortality. Presence of fever, left upper abdominal pain, leukocytosis and radiologic evidence shows pathology in the left chest X-ray especially in immunocompromised patients are the indications for high suspicion of splenic abscess.

History and Symptoms

Common symptoms of splenic abscess include:[3][6]

Other symptoms include:[1]

Physical Examination Findings

Appearance

Patient with splenic abscess appear ill appearing and diaphoretic

Vital signs

If patient present with sepsis:

Signs of sepsis indicate that splenic abscess is most likely due to bacterial cause than fungal source.[3]

Heart

  • New onset murmur may be present

Lungs

Abdomen

Palpation

Auscultation

Laboratory Tests

Blood Tests

Blood tests such leukocytosis are increased but not significant in the diagnosis of splenic abscess because these tests may not be appropriate in immunocompromised patients.

Diagnostic Evaluation of Splenic abscess

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspicion of splenic abscess
(Patients with immunodeficiency disorders, fever, changes in chest X-ray, abdominal pain)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood culture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with immunodeficiency disorders?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If immunodeficent patient
Initiate wide spectrum antibiotics + antifungal medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If immunocompetent patient
Initiate wide spectrum antibiotics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrasound of abdominal cavity, CT scan with contrast
 
 
If imaging shows negative or equivocal with high clinical suspicion of splenic abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Arteriography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of indications for minimally invasive procedures
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Absence of indications for minimally invasive procedures
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aspiration or abscess drainage under US or CT guidance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy
 
 
 
 
 
 
 
 
 
 
If ineffective drainage or recurrent abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spleenectomy or Open abscess drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abscess cavity content culture, modification of antibiotic therapy according to culture results; Prolonged antibiotic therapy
 
 
 
 
 
 
 
 

Imaging Findings

As the clinical features of splenic abscess are non specific and vague such as abdominal pain, fever and vomiting, that makes diagnosis is challenging and relied on imaging modalities. Imaging studies such as ultrasound, computerized tomography made the diagnosis early and more accurate that reduces morbidity and mortality.[23]

X-ray

Advantages

Common chest x- ray findings includes:

Common abdominal x- ray findings includes:

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 19149

Ultrasound

Ultrasound shows lesions of mixed echogenicity i.e anechoic central zone with a surrounding hyperechoic area.[24][25]

Advantages

CT images

Computerised tomography with contrast is both diagnostic and therapeutic test of choice for splenic abscess.[27][28]
Advantages

  • High sensitivity (88-100%)
  • Can differentiate unolocular and multilocular abscesses
  • Can identify the contents of abscess
  • Can determine the density index of abscess.
  • Can differentiate splenic abscess from splenic cysts and splenic hematomas
  • More precise and accurate than ultrasonography, in identifying the location of abscess in relation to other internal organs during percutaneous drainage.
  • It is superior to all other diagnostic tests for splenic abscess.

|valign=top| Scintigraphic studies include technetium-99m liver and spleen scans, gallium scans, and indium scans. Splenic scan is diagnostic modality to identify abscesses which relies upon splenic uptake of the radionuclide 99m technetium which shows abscess as a negative or filling defect.

Advantages

  • High specificity: If patient showing high suspicion of splenic abscess and scan supports the diagnosis, then splenectomy can be performed.

Disadvantages:

  • Scan can not identifie or visualize incurable small abscesses.[1]
  • Less sensitive: If the scan shows negative or equivocal results for splenci abscess but clinical suspicion remains, an arteriogram should be ordered.

Other Imaging Studies

Scintigraphic studies

Scintigraphic studies include technetium-99m liver and spleen scans, gallium scans, and indium scans. Splenic scan is diagnostic modality to identify abscesses which relies upon splenic uptake of the radionuclide 99m technetium which shows abscess as a negative or filling defect.

Advantages

  • High specificity: If patient showing high suspicion of splenic abscess and scan supports the diagnosis, then splenectomy can be performed.

Disadvantages:

  • Scan can not identifie or visualize incurable small abscesses.[1]
  • Less sensitive: If the scan shows negative or equivocal results for splenic abscess but clinical suspicion remains, an arteriogram should be ordered.

Arteriography

Arteriography is the technique that involves injection of contrast material through a catheter passed retrograde into the splenic artery followed by rapid exposure of sequential x-ray films which shows abscesses as filling defects in the spleen.

Advantages:

More reliable and precise than splenic scan in diagnosing small abscesses.

Disadvantages:

  • Invasive technique

Treatment

Medical Therapy

Antibiotic regimen should start before the procedure and continue until 7 days after the procedure. Diagnostic needle aspiration is very important in the management with antibiotics as blood culture may not be the best correlate as abscess culture. Antibiotic of choice depends on the organism, but aggressive and early surgical intervention of splenic abscess should be encouraged especially when the risk factors are present. High suspicion of splenic abscess with history of risk factors, broad-spectrum empirical antibiotic therapy should be initiated. [2] Empiric antibiotic should cover streptococci, staphylococci, and aerobic gram-negative rods such as vancomycin or oxacillin plus an aminoglycoside, a third- or fourth-generation cephalosporin, fluoroquinolone or carbapenem. If culture shows fungi as causative organism, start Amphotericin B immediately and continue for 6-24 weeks and during the procedure amphotericin B should be administered directly into the abscess.[29]

Surgery

Treatment of splenic abscess depends on etiology. In bacterial abscesses, splenectomy combined with post-operative antibiotic therapy is the most appropriate treatment of choice with least mortality rate when compared to percutaneous drainage or antimicrobial therapy.[17]

Percutaneous Drainage

Percutaneous drainage is the initial tretament of choice for splenic abscess even though splenectomy is the definitive treatment because of increased risk of infections in splenectomised patient.[10][30] It is genereally done under the guidance of imaging studies such as ultrasound or computerised tomography and under the guidence of imaging efficy of percuteneous drainage is equivalent to splenectomy.[31][32]

  • First line of treatment for splenic abscess
  • Safe and effective than surgery in both unilocular and bilocular abscesses, especially in peripherally located abscesses.
  • Preferred in critically ill patient and patients unfit for general anesthesia

Advantages

  • Preserves spleen so, it became the treatment of choice in children to prevent post-splenectomy septicemia[33]
  • No abdominal spillage of abscess contents
  • Less expensive, high acceptance rate and less operative risk

Complications

Contraindications or limitations

Splenectomy

Splenectomy is the most effective and definitive treatment of choice for splenic abscess. Splenectomy can be performed either from left subcostal incision or from midline epigastric entry.
Advantages

Disadvantages

Complications

Prevention

Primary Prevention

Primary prevention for splenic abscess can prevent in specific cases especially patients who are at high risk such as immunocompromised patients (e.g. recipients of renal transplants or patients on immunosuppressive drugs for other reasons).

References

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  2. 2.0 2.1 2.2 ZATZKIN HR, DRAZAN AD, IRWIN GA (1964). "ROENTGENOGRAPHIC DIAGNOSIS OF SPLENIC ABSCESS". Am J Roentgenol Radium Ther Nucl Med. 91: 896–9. PMID 14139921.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Nelken N, Ignatius J, Skinner M, Christensen N (1987). "Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature". Am J Surg. 154 (1): 27–34. PMID 3300398.
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  33. Kang M, Saxena AK, Gulati M, Suri S (2004). "Ultrasound-guided percutaneous catheter drainage of splenic abscess". Pediatr Radiol. 34 (3): 271–3. doi:10.1007/s00247-003-1068-5. PMID 14530888.
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