Management Of Splenic Abscess Research Articles

2127 Splenic Abscess Management With a Lumen Apposing Metal Stent: Case Report

INTRODUCTION: Splenic abscess is an uncommon infection (incidence 0.5%) that if left untreated, could be fatal. The most common source of splenic abscesses is usually hematogenous spread from an infected source from another part of the body. The patient typically presents with fever, left upper quadrant pain, and/or splenomegaly. CT scan is the imaging modality of choice for diagnosing splenic abscess. Management of splenic abscess consists of antibiotic treatment and splenectomy. The use of percutaneous CT-guided drainage is a safer spleen-conserving alternative to surgery. In this case report , we describe novel approach, to treat splenic abscess via endoscopic ultrasound-guided (EUS) placement of a lumen apposing metal stent (AXIOS). CASE DESCRIPTION/METHODS: This is a 44 year old male with a past medical history significant for necrotizing pancreatitis and gastric varicies who presented to our center with fever and weakness. He was previously admitted 3 months prior with post ERCP necrotizing pancreatitis which was managed successfully with endoscopic therapy. The patient reported that on the day of admission, he developed a low-grade fever and lethargy. The abdomen was soft, mildly distended, with tenderness to palpation in the left and right lower quadrants. CT of the abdomen revealed a formation of a splenic abscess measuring 5 cm × 6.5 cm. Blood cultures were positive for ESBL and the patient was started on antibiotics. An EUS was performed that showed a splenic abscess and an abscessgastrostomy was successfully performed using a 10 × 10 mm lumen-apposing metal stent (LAMS). One week later a repeat EGD with debrivement and lavage of the abscess cavity was performed and a 10 F × 5 cm double pigtail stent was exchanged for the LAMS. On month later, a CT scan showed complete splenic abscess resolution and the double pigtail was removed. Six month CT scan showed no abscess recurrence. DISCUSSION: EUS has been described in the drainage of pelvic, mediastinal and intrabdominal abcess. In this report we describe the first use of lumen apposing metal stent for endoscopic management of a splenic abscesses. Lee et al first reported the use of EUS guided splenic abscess drainage with the use of a double pigtail stent. This approach showed to be safe and less invasive alternative to the standard of care. In cases of worsening clinical status and reported morbidities as high as 79% with surgical and percutaneous drainage procedures, endoscopic therapies should be considered in the management of splenic abscess.

Management of Splenic Abscess after Splenic Arterial Embolization in Severe Acute Pancreatitis: A 5-Year Single-Center Experience.

Objective To describe the management and prognosis of splenic abscess after splenic arterial embolization in severe acute pancreatitis (SAP) patients. Methods This is a retrospective observational study. From August 2012 to August 2017, SAP patients with infected pancreatic necrosis (IPN) who underwent splenic arterial embolization after massive hemorrhage of the splenic artery were screened and those who developed splenic abscess were included for analysis. The demographic characteristics, etiology, treatment of splenic abscess, and clinical outcomes of these cases were collected and analyzed. Results A total of 18 patients with splenic abscess formed after splenic arterial embolization were included for data analysis. The median age of the 18 patients was 46 years. The etiologies included biliary AP, hypertriglyceridemic AP (HTG-AP), and other causes. Ten patients underwent minimally invasive percutaneous drainage only for splenic abscess while the other eight patients received splenectomy. One patient died due to uncontrolled infection and another patient died due to massive bleeding, and the remaining sixteen patients survived. Conclusion The incidence of splenic abscess was high in patients requiring splenic arterial embolization due to massive bleeding. Our data showed that most splenic abscess could be successfully managed with minimally invasive interventions, and traditional splenectomy should serve as a backup treatment.

Non-interventional management of splenic abscess

Splenic abscess is not an uncommon entity in tropics. In Indian subcontinent, where the incidence of enteric fever is high, abscess formation in spleen is frequently seen in clinical practice. In view of immunological functions, splenic preservation is preferred over splenectomy, especially in children and young adults. Medical management with antibiotics alone is considered inadequate for management of splenic abscess. Hereby, we report an unusual case of complete resolution of a florid splenic abscess with antibiotics alone without the need for any invasive intervention.

Management of splenic abscess: report on 16 cases from a single center

Splenic abscess is an uncommon disease, with a reported incidence of 0.14-0.7% in autoptic series. The best treatment option remains unclear. We report our experience of percutaneous drainage of splenic abscess under ultrasound (US) guidance. From 1979 to 2005, 16 consecutive patients (12 male and four female; mean age 39.9 years, range 16-72 years) were diagnosed with splenic abscess by means of US, and were treated with medical therapy alone or combined with US-guided percutaneous aspiration or catheter drainage. Ten of 16 patients had bacterial abscesses (including one case of tubercular abscess), two had an amebic abscess, and four had fungal abscesses. Seven of ten patients with bacterial abscesses were successfully treated with fine needle aspiration alone, one patient was successfully treated with fine needle aspiration for one abscess and catheter drainage for another, and one patient, who subsequently required a splenectomy for an abdominal trauma, successfully underwent percutaneous catheter drainage alone. Four patients with fungal lesions were treated with medical therapy alone, and two patients later required a splenectomy. One patient with a bacterial abscess due to endocarditis was treated with medical therapy alone, and his recovery was uneventful. US-guided percutaneous aspiration of splenic abscesses is a safe and effective procedure. It can be used as a bridge to surgery in patients who are critically ill or have several comorbidities. Percutaneous aspiration may allow complete non-operative healing of splenic abscesses or temporize patients at risk for surgery.

Splenic Abscess After Laparoscopic Nissen Fundoplication

A 53-year-old male patient underwent a Nissen fundoplication with short gastric vessel (SGV) division for gastroesophageal reflux disease. During the procedure, the upper pole of the spleen was noted to have discrete color changes suggesting ischemia of this area. One month later he presented with a splenic abscess, which required splenectomy. The clinical presentation and management of this case is reported and comments are made on surgical aspects of SGV division during fundoplication to prevent this potentially dangerous situation. Issues such as the surgical management of splenic abscesses, the limitations of laparoscopic splenectomy in these cases, and the risks and benefits of SGV division, are also discussed in this article.

Management of splenic abscess in children by percutaneous drainage

Background/Purpose Isolated splenic abscesses are rare in pediatric patients. The recommended treatment in the literature has been in favor of splenectomy, although conservative treatment with splenic preservation is being increasingly reported. We report successful management of 4 pediatric patients with splenic abscess by needle aspirations and antibiotics. Materials and Methods Four children (aged 7-11 years; male-female, 3:1) were admitted in our institution with history of high-grade fever with chills, anorexia, left hypochondrial pain, and splenomegaly. One child was a known case of thalassemia, and one had a history of typhoid fever. The others did not have any predisposing condition. Ultrasonography (USG) and computed tomographic scan of the abdomen showed a solitary abscess in the spleen in 2 patients and multiple abscesses in the other 2. Ultrasonography-guided needle aspiration in 3 cases revealed purulent fluid, which, on culture, grew Escherichia coli in 1 case, Salmonella paratyphi A in 1 case, but sterile in 1 case. Blood culture was sterile in all the cases, but Widal's test was positive in 2 patients. Treatment protocol included USG-guided needle aspiration of pus along with intravenous ceftriaxone, metronidazole, and amikacin for 3 to 12 weeks. Results All 4 patients showed a good response to conservative treatment. Serial USG showed gradual resolution of abscess, and none was subjected to splenectomy. Conclusion Isolated splenic abscess in children can be successfully treated with needle aspirations and intravenous antibiotics, thereby avoiding splenectomy.

Management of splenic abscess in immunocompromised children

Splenic abscess is an infrequent complication in the immunocompromised patient. Six patients underwent splenectomy for presumed splenic abscess from 1987 to 1991. Chemotherapy altered the immune system of four patients; the human immunodeficiency virus (HIV) rendered the other two vulnerable to infection. Five presented with fever but none had leukocytosis; only one exhibited palpable splenomegaly; three had abdominal pain. Cultures documented systemic infection in all but one, an HIV-positive individual. Respiratory embarrassment was the indication for surgery in one patient. In five cases the decision for surgical intervention was made after computed tomography (CT) indicated the presence of multiple splenic lesions and systemic antibiotics failed to resolve the fevers. CT additionally showed hepatic and/or renal microabscesses in four patients. Signs and symptoms experienced preoperatively resolved with splenectomy in all six patients. No additional surgery was required for the patients with extrasplenic abscesses. Surgical pathology determined that three spleens had fungal and two had mycobacterial abscesses. The other was shown to be a spindle cell sarcoma; no abscess was present. This patient had preoperative blood cultures positive for mycobacteria, and the same organism was recovered from retroperitoneal nodes sampled at the time of splenectomy for the sarcoma. Follow-up indicates that no patients experienced surgical complications or sequelae related to their splenic pathology. Splenectomy is necessary and effective in treating splenic abscesses in immunocompromised patients and is appropriate for diagnosis as well as therapy.

Splenic abscess: Presentation, treatment options, and results

Pyogenic splenic abscess is a rare condition that tends to occur in patients with predisposing factors. The use of splenectomy or computed tomography guided percutaneous drainage in 10 patients with splenic abscess is presented. In 8 of 10 cases, the diagnosis was based on abdominal computed tomography scan. Seven of 10 patients were treated with splenectomy, and 3 were managed with computed tomography-guided drainage. Abscess cultures included Escherichia coli, Enterobacter, Streptococcus viridans, Staphylococcus aureus, and Bacteroides fragilis. There were two morbidities and one death in the splenectomy group and no complications in those treated with percutaneous drainage. This review suggests a flexible approach in the management of splenic abscess. Although splenectomy remains the traditional treatment for bacterial splenic abscess, CT-guided drainage may be appropriate in carefully selected patients.

The Management of Splenic Abscess

We report three patients with splenic abscess whom we attempted to treat without recourse to open surgery. Medical treatment alone was successful in one case, and medical treatment combined with percutaneous drainage was successful in the second. Splenectomy was required in the third case after failure of medical treatment and complications of percutaneous drainage. The difficulties in diagnosing splenic abscess are reviewed and the indications for splenectomy or percutaneous drainage, as opposed to medical treatment are considered.

Surgical Management of Splenic Abscess in Endocarditis-Reply

—We studied the necrosis of 78 active cases of infectious endocarditis (IE) between 1968 and 1979. Five splenic abscesses were found (6%), an incidence of 0.5% per year.1 In our clinical series of 120 patients with IE between 1974 and 1982, the spleen was clinically important in only five cases: one spleen rupture, one suspect spleen with persistent fever (spleen culture negative), one splenic abscess discovered at necropsy, another seen on computed tomographic (CT) scan, and a case of multiple septic infarcts. This yields 0.8% prevalence and an incidence of 0.07% per year. Thus, the frequency of such abscesses in IE seems to be low, but that of the infarcts seems to be underestimated. The differentiation between infarct and abscess is difficult with the current imaging methods. Moreover, infarcts frequently become abscesses (32% in our necropsy series). The precise diagnosis relies then on a careful clinical and biological follow-up.