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.[1]. 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. [2].
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.[1]. The pain was dull and dragging becoming sharp on deep breathing.[2].
Nausea and vomiting Fever, nausea, vomiting may be also present in various combinations.[1].
Anorexia Detected in patients with abscess of spleen.[1].
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.[2].
Rupture of abscess Single abscesses were usually large and susceptible to easy rupture.The large splenic abscess with rupture presents the picture of peritonitis [2].
References
  1. FOTIADIS C, LAVRANOS G, PATAPIS P, KARATZAS G. Abscesses of the spleen: Report of three cases World J Gastroenterol [online] 2008 May 21, 14(19):3088-3091 [viewed 16 August 2014] Available from: doi:10.3748/wjg.14.3088
  2. IHEKWABA FN. Splenic Abscess in a Tropical Zone J Natl Med Assoc [online] 1978 Apr, 70(4):259-262 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609632

Examination

Fact Explanation
Splenomegaly About 66% present with the classical triad of fever, splenomegaly and left upper quadrant pain.[2]
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.[1].
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.[1].
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.[1].
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.[1].
Fluid thrill In large abscesses, the organ may become fluctuant. If the splenic pus has undergone colliquative change, a fluid thrill may be elicited.[1].
References
  1. IHEKWABA FN. Splenic Abscess in a Tropical Zone J Natl Med Assoc [online] 1978 Apr, 70(4):259-262 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609632
  2. NAGEM RG, PETROIANU A. Subtotal splenectomy for splenic abscess Can J Surg [online] 2009 Aug, 52(4):E91-E92 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724814

Differential Diagnoses

Fact Explanation
Lyphoma Lymphoma represents the most common malignant tumour of the spleen.Isolated primary splenic lymphoma represents less than 2 % of all lymphomas. In patients with lymphoma, the spleen is usually involved secondarily. On contrast-enhanced CT images, it may be challenging to differentiate lymphoma nodules from sarcoidosis or fungal abscesses, which frequently occur in lymphoma patients due to immunodeficiency. However, in such cases, the presence of hilar lymphadenopathy is suggestive of splenic lymphoma. But should not be confused with sarcoidosis. Lymphoma of the spleen can present as splenomegaly without focal lesions, multiple small (<1 cm) or large (<10 cm) lesions, or a single solitary lesion. The diagnosis of splenic lymphoma can be most easily made in the context of the clinical history and in knowledge of the disease.[1].
Splenic infarction Splenic infarction is caused by a lack of perfusion of either certain regions of the spleen or the entire organ. The most common event leading to infarctions of the spleen is partial or total occlusion of the splenic artery or its branches. Patients typically present with left upper quadrant abdominal pain, but without fever. Large splenic infarctions are usually caused by thromboembolic conditions mostly originating from atrial fibrillation, whereas micro-infarctions can be seen in patients with sickle cell anaemia, lymphoma and leukaemia.[1].
Cyst Splenic cysts can be divided into true and false cysts. True splenic cysts can be further divided into parasitic and non-parasitic cysts.While true cysts have epithelial lined walls, the borders of false cysts are composed of dense, fibrous tissue without an epithelial lining.However, in clinical routine this differentiation is usually not relevant, because cysts without inherent solid components, wall-thickening or contrast-enhancement can be safely considered benign. However, it is important to note that cysts may cause complications, including infection, rupture and haemorrhage, and thus may cause clinical symptoms such as fever, upper left quadrant pain or jaundice.[1].
References
  1. KARLO CA, STOLZMANN P, DO RK, ALKADHI H. Computed tomography of the spleen: how to interpret the hypodense lesion Insights Imaging [online] , 4(1):65-76 [viewed 16 August 2014] Available from: doi:10.1007/s13244-012-0202-z

Investigations - for Diagnosis

Fact Explanation
FBC (full blood count) Can see signs of on-going bacterial infection such as leukocytosis.[1]. 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.[2]
Blood picture Laboratory data suggested the presence of a chronic inflammatory focus.The blood picture of some patients showed anisocytosis and polychromasia.[2].
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.[1].
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.[3].
USS Imaging is a necessary tool for establishing the diagnosis, with a choice between ultrasound and computed tomography.[1].Abdominal ultrasonography is cost-effective, noninvasive and very useful for percutaneous drainage. With a sensitivity of 96%.[3].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).[4].
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.[4].
CT (Computer tomography) The lesion is usually revealed via computed tomography (CT).[1].CT is presently the gold standard to establish a diagnosis of splenic abscess.[3].
References
  1. FOTIADIS C, LAVRANOS G, PATAPIS P, KARATZAS G. Abscesses of the spleen: Report of three cases World J Gastroenterol [online] 2008 May 21, 14(19):3088-3091 [viewed 16 August 2014] Available from: doi:10.3748/wjg.14.3088
  2. IHEKWABA FN. Splenic Abscess in a Tropical Zone J Natl Med Assoc [online] 1978 Apr, 70(4):259-262 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609632
  3. NAGEM RG, PETROIANU A. Subtotal splenectomy for splenic abscess Can J Surg [online] 2009 Aug, 52(4):E91-E92 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724814
  4. CAREMANI M, OCCHINI U, CAREMANI A, TACCONI D, LAPINI L, ACCORSI A, MAZZARELLI C. Focal splenic lesions: US findings J Ultrasound [online] , 16(2):65-74 [viewed 16 August 2014] Available from: doi:10.1007/s40477-013-0014-0

Management - General Measures

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.[2]. 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.[1].
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.[3].
References
  1. NAGEM RG, PETROIANU A. Subtotal splenectomy for splenic abscess Can J Surg [online] 2009 Aug, 52(4):E91-E92 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724814
  2. IHEKWABA FN. Splenic Abscess in a Tropical Zone J Natl Med Assoc [online] 1978 Apr, 70(4):259-262 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609632
  3. BHANDARKAR D, KATARA A, SHANKAR M, MITTAL G, UDWADIA TE. Laparoscopic splenectomy for tuberculous abscess of the spleen J Minim Access Surg [online] 2010, 6(3):83-85 [viewed 17 August 2014] Available from: doi:10.4103/0972-9941.68582

Management - Specific Treatments

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.[1].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.[3]. However the current policy is to limit their use in centers with adequately trained surgeons and only for a selected subgroup of patients.[1].
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.[2].
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.[3]. 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.[4].
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.[4].
References
  1. FOTIADIS C, LAVRANOS G, PATAPIS P, KARATZAS G. Abscesses of the spleen: Report of three cases World J Gastroenterol [online] 2008 May 21, 14(19):3088-3091 [viewed 16 August 2014] Available from: doi:10.3748/wjg.14.3088
  2. NAGEM RG, PETROIANU A. Subtotal splenectomy for splenic abscess Can J Surg [online] 2009 Aug, 52(4):E91-E92 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724814
  3. BHANDARKAR D, KATARA A, SHANKAR M, MITTAL G, UDWADIA TE. Laparoscopic splenectomy for tuberculous abscess of the spleen J Minim Access Surg [online] 2010, 6(3):83-85 [viewed 17 August 2014] Available from: doi:10.4103/0972-9941.68582
  4. BAUMAN Z, LIM J. Pneumoperitoneum as a result of a ruptured splenic abscess J Surg Case Rep [online] 2013 Dec, 2013(12):rjt111 [viewed 17 August 2014] Available from: doi:10.1093/jscr/rjt111