Spleen infarction

A complex disease - spleen infarction - is a condition in which focal death of organ tissues is detected. Such a pathological process can be provoked by various factors, and not only the spleen suffers, but the patient's body as a whole.

The spleen plays the role of a kind of filter and directly affects the state of immunity. If it is damaged, the work of all internal systems deteriorates, and the patient feels the problem almost immediately. However, a heart attack of this organ is dangerous in that with minor injuries, symptoms may be practically absent. Why is there a violation, how to prevent, recognize and treat it? You can find out about this from our article.

Epidemiology

The spleen is an essential organ necessary for normal immune defense and hematopoiesis. In a healthy person, the weight of the spleen is about 150 g, and its size is about 11 cm. This organ is difficult to palpate - that is, it can usually be palpated only with pathological enlargement and exit from under the costal arch.

The physiological functions of the spleen are as follows:

• elimination of microorganisms and antigens from the circulatory system;
• production of IgG, tuftsin and factor P;
• use, processing of pathological erythrocytes;
• embryonic hematopoiesis.

The spleen plays the role of a depot for a third of all platelets in the body and a large number of neutrophils, which are produced in response to an infectious pathology or bleeding.

Spleen infarction is a fairly common pathology, although the foci of the disease in most cases are not large. For example, in the United States, the incidence is 2 to 5% of all organ diseases. The probability of mortality depends on many factors - in particular, on the size and number of foci of tissue necrosis. [1]

Pathology is equally often found in male and female patients, but more often affects older people over 60 years of age.

Mortality in spleen infarction is no more than 2%.

The disease can be detected by doctors of different profiles. Most often, pathology is diagnosed by gastroenterologists, therapists, hematologists, surgeons, immunologists, infectious disease specialists. It is these specialists that patients most often turn to when the first symptoms of a disorder appear.

Causes splenic infarction

In general, splenic infarction is a process of circulatory or angiogenic tissue necrosis, which may be the result of thrombosis, embolism, or prolonged spastic state of blood vessels. If the blood flow through the arteries is disturbed, an acute reaction occurs in the form of organ ischemia, which leads to the death of part or all of the spleen.

Spleen infarction can be caused by:

• directly diseases of this organ (twisting, cystic formations, or other pathologies, which are accompanied by an increase in pressure in the vessels, violation of trophism and ischemic processes);
• infectious or parasitic lesions, infectious toxic shock (circulatory disorders, septic conditions, vascular spasm);
• injuries complicated by closed or open damage to the abdominal organs, violation of the integrity of the ribs (development of vascular embolism);
• vascular pathologies of a systemic or inflammatory nature, capable of narrowing the lumen and blocking the vessel, causing the formation of a thrombus (breakage of a thrombus can lead to the development of embolism of the spleen vessels); [2]
• heart diseases, which negatively affect the quality of blood circulation and contribute to increased thrombus formation (inflammation of the endocardium, heart defects, arrhythmias, heart attacks); [3]
• violations of the blood picture (accelerated coagulation, prolonged use of oral contraceptives, anemia, etc.); [4]
• malignant blood diseases (leukemia, lymphoma, malignant granuloma).

Spleen infarction is observed against the background of complete or incomplete overlap of an organ artery or its auxiliary branches due to narrowing or blockage. [5]

Risk factors

Age is considered one of the predictive unfavorable factors for the development of spleen infarction, because the disease occurs much more often in older people. Most cases of pathology are diagnosed in patients over 60 years old.

The risk of developing a spleen infarction is also increased by such negative factors:

• diseases or disorders of the cardiovascular system;
• congenital disorders of immunity, immunodeficiency states;
• tendency to thrombus formation;
• atherosclerosis;
• hematological diseases.

When considering the risk factors that are related to the way people live, the following can be especially noted:

• smoking;
• the presence in the diet of a large amount of meat and fatty foods;
• drinking small amounts of liquids and plain water;
• excess weight;
• alcohol abuse.

Neutralization of the sounded factors can help prevent the development of spleen infarction.

In some cases, doctors fail to establish the real root cause of the development of the disease, since pathology can be provoked simultaneously by several unfavorable factors, and it is not possible to single out any one of them. [6]

Most often, the disease is associated with diseases of the cardiovascular system, typhoid, traumatic injuries of internal organs, mitral stenosis.

Pathogenesis

The spleen is an important and, nevertheless, little-studied human organ. It is located just next to the stomach, on the left side under the diaphragm.

The basic functional orientation of the spleen is to prevent the penetration of infection into the body, to participate in blood coagulation processes, and to cleanse the blood flow from toxic components.

How does a disorder such as a spleen infarction develop? Under the influence of provoking factors (in particular, spastic vasoconstriction, blockage by an embolus), oxygen transportation to the organ worsens. Prolonged oxygen starvation of tissues entails necrosis of their part (if the branching of the artery is affected), or of the whole spleen (if the base arterial trunk is affected), which acquires a pale yellowish tint and signs of an inflammatory process.

Perhaps the development of a heart attack due to a violation of the integrity of any of the splenic vessels. Against the background of impaired arterial blood flow, collateral blood circulation continues to function, an excess of pressure appears on the vascular walls. As a result, the membranes are damaged and bleeding occurs. The organ tissue acquires a red "blood" tint, zones of necrosis and infiltrates are highlighted. Spleen infarction significantly impairs its functionality, impaired immune and endocrine processes, suffers from erythro-leuko-lymphopoiesis.

Symptoms splenic infarction

The clinical picture in splenic infarction can be very different: in patients with small or single foci, symptoms may be absent altogether, while extensive or numerous foci of infarction are manifested by acute painful symptoms. [7]

One of the most common symptoms is pain localized in the upper left segment of the abdomen. Other common signs include fever, chills, chest pain radiating to the left shoulder region, and nausea and vomiting.

The severity of symptoms is directly related to the scale of the pathological process. In mild cases, splenic infarction does not manifest itself at all, or makes itself felt by constant fatigue and general malaise: since such symptoms are far from specific, they are often ignored, or ranked among other existing diseases.

In more complex cases, the first signs become more indicative:

• acute pain in the projection area of the spleen, or on the left side of the abdomen, sometimes with irradiation to the left arm (shoulder);
• increased body temperature;
• signs of general intoxication;
• dyspepsia (diarrhea, nausea, etc.);
• heart palpitations.

With massive splenic infarction, there is a sharp stabbing or cutting pain on the left side under the ribs, radiating to the region of the scapula, lower back, chest on the left. Diaphragmatic mobility decreases, diarrhea is replaced by constipation, intoxication symptoms increase. During palpation, an enlarged and painful spleen is found.

With the development of complications (numerous abscesses, bleeding, pseudocystic formations), the clinical picture expands and worsens.

Forms

In medicine, the following types of spleen infarction are distinguished:

• By the scale of damage:
  • small focal;
  • extensive.
• By the number of pathological foci:
  • plural (numerous);
  • single.
• By etiological factor:
  • non-infectious;
  • infectious (septic).

According to the type of damage to the splenic parenchyma, the infarction is divided into the following types:

• Ischemic splenic infarction, or white infarction, develops against the background of blockage of the main artery of the organ, or its branches, which provide blood flow to the parenchyma. In the case when the formation of numerous “bypass” blood flow paths becomes a reaction to the developing pathology, the vascular bed loses its filling and collapses. Microscopically, it looks like pale and yellowing of tissues, limitation of the peripheral area by inflammatory infiltration.
• Hemorrhagic infarction of the spleen, or red heart attack, develops as a result of blockage of the main arterial vessel and capillary oversaturation with blood. The dead tissues are soaked with blood, which is manifested by their bright red color. Another factor in the development of pathology can be stagnation in the veins, with impaired blood outflow. Microscopic signs of impairment are as follows: erythrocyte hemolysis, infiltrates and necrotic areas.

Complications and consequences

The intensity of the clinical picture depends on the extent of damage to the spleen tissue. Minor spleen infarctions often do not manifest themselves and are not complicated. With large pathological foci and large-scale tissue necrosis, the patient's condition worsens, pain syndrome and intoxication develop:

• there is a feeling of heaviness under the ribs on the left;
• pain occurs (dull, sharp - depending on the lesion);
• the digestive process is disturbed (dyspepsia, flatulence, vomiting, etc.);
• difficulty breathing;
• pulse quickens;
• the body temperature rises (to high rates).

An increase in the organ is possible - splenomegaly, which can be detected already during the initial medical examination.

If the site of necrosis becomes infected, then an inflammatory process develops, a separate cavity is formed, inside which purulent masses accumulate. This complication is called an abscess. The clinical picture of an abscess is manifested by a strong intoxication syndrome, and its prognosis is very unfavorable: in the absence of timely treatment, the probability of the patient's death is close to 100%. [8]

With spontaneous opening of an abscess, peritonitis and sepsis develop into the abdominal space.

Hemorrhagic infarction can be complicated by bleeding, as well as the formation of pseudocysts of significant size.

Diagnostics splenic infarction

Diagnostic measures begin with a thorough medical examination: palpation is carried out, anamnesis is taken. In all cases, additional diagnostics are required in the form of ultrasound, radiography, and magnetic resonance imaging. Laboratory diagnostics are also mandatory.

After a preliminary examination, the doctor prescribes laboratory tests:

• general and biochemical blood test;
• general urine analysis;
• PCR for the detection of certain types of viruses (hepatitis B and C, cytomegalovirus, etc.).

Sometimes, in addition to PCR, an immunogram is prescribed - a comprehensive analysis to assess the state of the immune system. However, the analyzes are not informative in all cases. With massive tissue damage and infectious and inflammatory reactions, inhibition of hematopoiesis is found, ESR increases, and there are signs of anemia.

The basic diagnostic method is palpation. Normally, the spleen should not be felt, and the procedure itself does not cause pain. With a heart attack, palpation is accompanied by unpleasant sensations, splenomegaly, an enlargement of the organ, may occur. As a rule, the procedure is carried out in two positions: the patient lies on his back, and then lies on his left side, bending and pulling his right leg to his stomach. In this case, the right hand is wound behind the head, and the bent left hand is placed on the chest. Along with palpation, percussion is also performed, which allows you to determine the size of the organ.

To clarify the details, instrumental diagnostics are necessarily used:

• Magnetic resonance imaging;
• computed tomography or multispiral CT;
• ultrasound procedure;
• biopsy with further histological examination of the biopsy.

MRI is one of the most informative diagnostic methods. The procedure does not require special training. True, during pregnancy, as well as in the presence of pacemakers, metal implants, prostheses, MRI is contraindicated.

Among X-ray studies, CT, or computed tomography, is the leader in informational content. You should prepare a little for the procedure: do not eat food 4 hours before the diagnosis, but exclude from the diet products that increase gas production (cabbage, peas, etc.) two days before the diagnosis. CT may be refused for pregnant women, patients with severe cardiovascular disease or obesity. [9]

Ultrasound examination is performed with preliminary preparation (as before CT scan), however, emergency diagnostics are also allowed. The main advantage of ultrasound is a reliable and fast result that does not require additional decoding.

Spleen infarction on ultrasound

The spleen belongs to a number of organs that are well defined during ultrasound. The splenic parenchyma has a greater echogenicity than the closely located kidney, but approximately similar in echogenicity to the hepatic tissue.

In a healthy person, the length of an organ can be 8-13 cm, with a thickness of up to 4.5 cm (sometimes up to five). A fairly common phenomenon is the accessory splenic lobes, which, however, most often do not have significant clinical significance.

With a spleen infarction in the initial stages, the ultrasound picture may not change. However, with the progression of the pathological process, a hypoechoic zone is formed, which is the infarction focus. Over time, this area can become hyperechoic. It decreases, taking on the appearance of a small hyperechoic area. With a hemorrhage into the infarcted area, the picture changes: the focus again acquires a hypoechoic appearance, or is a combination of hyper and hypoechoic areas. With repeated infarctions, a decrease in the size of the spleen can be observed, with numerous hyperechoic zones preserved from previous injuries.

Differential diagnosis

Pain in the spleen area are considered important initial signs of several hematological and other pathologies at once, therefore, they require careful diagnosis, including differential.

During palpation and examination, you need to pay attention to many points. So, respiratory displacements of the organ make it possible to identify splenic pathology from tumor processes in the kidneys or pancreas. With a slight splenomegaly, patients are examined in the supine position on the right side.

With an unclear etiology of the disease or with an overweight patient, they rely mainly on the results of ultrasound, which will demonstrate the structural picture of the affected organ. Computed tomography and splenic scintigraphy are also considered reliable research methods. [10]

It is important to focus on the size of the spleen. Infectious and inflammatory edema is often accompanied by a soft organ consistency, and increased density and tightness may indicate a long-term current pathology.

In general, differential diagnosis is carried out with the following diseases:

• circulatory disorders (portal hypertension syndrome);
• infectious and inflammatory processes;
• autoimmune pathologies, granulomatosis;
• hemolytic anemia;
• tumor processes in the spleen, cystic formations, metastases;
• lymphatic neoplasias;
• myeloid neoplasia;
• amyloidosis.

Among bacterial infections, typhus, miliary tuberculosis, brucellosis, leptospirosis, and Lyme disease require differentiation.

Among viral infections it is necessary to exclude hepatitis A, B and C, infectious mononucleosis, cytomegaly, AIDS.

The diagnosis of parasitic infections, such as malaria, leishmaniasis, Chagas disease, etc., requires special attention.

Treatment splenic infarction

Latent asymptomatic course of spleen infarction (this is the overwhelming majority of cases) does not require surgery. The patient is monitored and, if necessary, prescribed medication:

• pain relievers;
• anticoagulants;
• non-steroidal anti-inflammatory drugs;
• symptomatic drugs. [11]

Some patients with isolated abscesses undergo a percutaneous drainage procedure followed by antibiotic therapy.

With extensive splenic infarction and the development of complications in the form of numerous abscesses, bleeding, pronounced pseudocyst, surgical treatment is performed - complete or partial resection of the organ.

The operation can be performed with the usual access (planned or emergency, depending on the situation), or by laparoscopy. In the second case, ultrasound or radiofrequency ablation is used to separate the parenchyma.

If possible, the surgeon removes only the damaged part of the spleen, while preserving its function. Thus, the risk of postoperative complications is reduced, and the recovery period is accelerated.

After the operation, the patient is prescribed a restorative and rehabilitation course of drug therapy. The main drugs in this period are analgesics (Spazmalgon, Analgin), drugs that prevent increased thrombus formation (Warfarin), non-steroidal anti-inflammatory drugs (Ibuprofen), antibiotics (Ceftazidime, Erythromycin), as well as immunostimulants.

Surgery

Surgical intervention for splenic infarction can be represented by splenectomy (laparoscopic splenectomy, or complete removal of an organ) or resection, an organ-preserving operation that preserves a section of functionally capable tissue.

Laparoscopic splenectomy is a modern type of surgical treatment that has many advantages:

• there is no need for significant incisions, so there are no visible scars after the operation;
• minimal tissue damage;
• constant video surveillance during the operation;
• fast rehabilitation period with minimal complications and low pain syndrome.

Removal of the spleen is considered a complex surgical intervention that requires not only high-class specialization of personnel, but also technically equipped inpatient and operating conditions. During laparoscopy, it is possible not only to remove the diseased organ, but also to perform a biopsy at the same time (if necessary).

The choice of a therapeutic technique remains with the attending physician, after a thorough study of the diagnostic results. [12]

After splenectomy, the splenic functions are taken over by the bone marrow and liver. The patient is prescribed special dietary food, exercise therapy and the use of a bandage.

Postoperative recovery involves taking the following medications:

• analgesics and antispasmodics (Spazmalgon, Ketorol);
• antibiotics (macrolide series, cephalosporins, fluoroquinolones);
• non-steroidal anti-inflammatory drugs (ibuprofen);
• fibrinolytics (fibrinolysin);
• anticoagulants (Heparin);
• means to support the immune system (interferons, Imunorix).

After splenectomy, patients experience a sharp weakening of their immunity, so they are advised to limit social activity, avoid crowded places, and do not use public transport to prevent possible infection.

Prevention

Preventive measures to keep the spleen healthy are generally straightforward: eating right and maintaining a healthy lifestyle. This organ will function better with regular physical activity, as well as with the systematic performance of breathing exercises:

• Practice abdominal breathing with a deep breath. The hands are placed in the solar plexus area, the thumbs and little fingers are pressed inward, and the rest of the fingers are directed with their tips to the central part of the plexus. They press on him with their fingers, while exhaling they say "h-oo-oo-oo".
• Become free, feet are shoulder-width apart. Inhale and exhale gently, calmly. During inhalation, the arms are crossed and raised to the chest. On exhalation, one hand is raised with the palm upward, and the other is lowered with the palm downward (as if pushing the space apart). Next, the arms are crossed again at chest level and the exercise is repeated, changing the order. During the exercise, as you exhale, pronounce "x-y-y-y".
• As you inhale, your hands are raised forward, your wrists are crossed at head level. As you exhale, lower your arms.

In addition to exercise, it is important for any painful signs not to self-medicate and seek medical help on time.

Timely access to doctors will allow you to solve the problem at an early stage with minimal losses and violations.

What foods can harm the spleen? These are animal fats, salt, hot spices, alcohol, synthetic preservatives and flavorings. Preference should be given to vegetable dishes, low-fat dairy products, liquid cereals. Dishes made from beets, cabbage, apples, avocados, pomegranates, nuts, honey and sour berries will be especially beneficial. In general, properly organized nutrition will help protect our own health from many problems that, it would seem, do not depend on our dietary preferences. It is harmful to overeat, consume a lot of refined sugars. By the way, obesity is one of the risk factors for the development of many pathologies, including spleen infarction. [13]

No less harmful is dehydration, insufficient fluid intake during the day. It is useful to drink both ordinary clean water and fruit and berry compotes, fruit drinks, natural juices, herbal teas.

The spleen should be protected from injury, and any infectious processes in the body should be treated in time.

Forecast

The outcome of the disease can be different, which depends on the scale of the damage, on the timeliness of the diagnostic and therapeutic measures. If there is a small-sized spleen infarction, then with early seeking medical help and prescribing competent treatment, we can confidently speak of a favorable prognosis. A scar is formed in the area of tissue necrosis. The area of ischemia often softens with the further formation of a false cyst.

If the spleen infarction is significant in size, has complications in the form of a cystic or abscessing process, then there are risks of infectious spread and the development of septicemia. With such a development of events, emergency medical assistance should be provided. If this does not happen, then the patient will die.

Increasing organ dysfunction often becomes an indication for surgical treatment of splenic infarction. Nevertheless, even after splenectomy, the risk of developing bacterial infectious pathologies, up to sepsis, greatly increases, since in patients with the absence of a spleen, the immune defense is severely affected. In addition, there are stable life-long shifts in the blood picture - in particular, the number of leukocytes, reticulocytes and platelets increases.