Treatment
Medical Therapy
Early supportive care and parenteral broad-spectrum antibiotics are of paramount importance while further diagnostic and therapeutic arrangements are made.2 Antibiotic coverage should target the presumed bacterial strains. Medical management as the only treatment of selected splenic abscesses has been advocated in several studies but remains controversial. The published literature suggests that most patients in this category have contiguous infections in the abdomen; the mortality rate in this group has been reported to be approximately 50%.11
Besides the more common organisms isolated from splenic abscesses, mycobacteria, Candida, and Aspergillus should also be considered; these organisms account for a small but significant number of splenic abscesses in patients who are immunocompromised. Fungal abscesses are known to respond more favorably to antifungal treatment, because they result more often from a disseminated infection.3,14,16 A retrospective, multicenter French study of 10 pediatric and adult patients investigated the effect of corticosteroid therapy on individuals with symptomatic chronic disseminated candidiasis that persisted despite the administration of antifungal treatment.20 In addition to finding evidence that corticosteroid therapy can effectively resolve the symptoms and inflammatory response associated with the infection, the study's authors also reported that hepatosplenic microabscesses in the patients decreased or disappeared.
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 for Echinococcus granulosus.19 Percutaneous 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
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
Very infrequently, the perisplenic adhesions 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 splenotomy and drain the collection.
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
Preoperative Details
The difficult location of the spleen increases the risk of iatrogenic hemorrhage or hollow organ injury. Patients with splenic abscess must be typed and screened, and massive blood transfusion must be anticipated. Prophylactic, broad-spectrum antibiotic coverage is essential. A nasogastric tube must be used to decompress the stomach. The risk of injury to the colon requires preoperative bowel preparation in nonemergency cases. Administration of polyvalent vaccines must be planned.
Intraoperative Details
The operating room must be warm in order to decrease the risk of coagulopathy and wound infection. Blood products must be readily available.
A splenectomy can be performed through various abdominal incisions, as follow:
- A midline incision is preferred in adult patients by most surgeons, because it provides easy access to all 4 quadrants.
- A left subcostal incision sparing the rectus abdominis muscle (Singleton) is preferred in pediatric patients.
- A thoracoabdominal incision is rarely required in massive pleural involvement by the abscess requiring open thoracic access.
Massive perisplenitis with adhesions carries a significant risk of iatrogenic splenic rupture. The spleen is mobilized carefully by dividing the ligamentous attachments. Special care must be taken to avoid injury to the pancreas and resulting pancreatic fistula.
In laparoscopic splenectomy, the spleen must be morselized intra-abdominally to allow retrieval of the specimen through a limited incision. Prophylactic peritoneal drainage is at the discretion of the surgeon.
Postoperative Details
As stated above, interventions for splenic abscess are potentially morbid. Patients must be placed under close observation, especially during the first 24 hours, when the risk of postoperative hemorrhage is high.
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:
- Late iatrogenic complications, such as residual intra-abdominal abscesses, pancreatic or enteric collections, or fistulas
- Intestinal obstruction and ventral hernia
- Recurrent splenic abscess
- Overwhelming postsplenectomy sepsis
Complications
The mortality rate in patients with untreated splenic abscess approaches 100%. The list of complications is long but most importantly includes free rupture into the peritoneal cavity with generalized peritonitis, rupture into the colon, erosion of the abscess through the diaphragm, or, more rarely, necessitation through the skin.
The complications of treated splenic abscesses depend on the topography and treatment method. They can include the following:
- Life-threatening hemorrhage from the splenic parenchyma or hilar vessels
- Pneumothorax
- Left-sided pleural effusion
- Subphrenic abscess
- Perforation of the colon, stomach, or small intestine
- Pancreatic pseudocyst or fistula
- Postsplenectomy thrombocytosis
- Overwhelming, postsplenectomy sepsis
- Atelectasis or pneumonia
Knowledge of the anatomy, careful preoperative planning, optimal exposure, and attention to the details of the technique can substantially reduce the incidence of iatrogenic complications.23,18,5
Respiratory complications are minimized or avoided by incentive spirometry and chest physical therapy.
Subphrenic abscess, although uncommon after splenic surgery, is a recognized consequence of pancreatic or hollow organ injury. The condition requires prompt diagnosis and drainage.
In cases of splenectomy, thrombocytosis occurs in more than 50% of cases. A very high platelet count (>1,000,000/μ L) requires an intervention to minimize the incidence of thrombotic complications. Platelet apheresis or anticoagulants can be used in this regard.
Overwhelming, postsplenectomy sepsis carries a significant mortality risk, especially for young patients who have undergone splenectomy. Whenever splenectomy is considered, patients should undergo immunization against Streptococcus pneumoniae, Meningococcus, and Haemophilus influenzae type b. The administration of oral antibiotics to splenectomized individuals is the mainstay of prophylaxis (and initial therapy). Two complementary strategies are commonly used: daily antibiotic prophylaxis and empiric antibiotic therapy for fever.
More on Splenic Abscess |
| Overview: Splenic Abscess |
| Workup: Splenic Abscess |
 Treatment: Splenic Abscess |
| Follow-up: Splenic Abscess |
| Multimedia: Splenic Abscess |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Reid SE, Lang SJ. Abscess of the spleen. American Journal of Surgery. 1954;88:912-917.
Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC, et al. Clinical characteristics and prognostic factors of splenic abscess: a review of 67 cases in a single medical center of Taiwan. World J Gastroenterol. Jan 21 2006;12(3):460-4. [Medline].
Westh H, Reines E, Skibsted L. Splenic abscesses: a review of 20 cases. Scand J Infect Dis. 1990;22(5):569-73. [Medline].
Al-Salem AH, Qaisaruddin S, Al Jam'a A, Al-Kalaf J, El-Bashier AM. Splenic abscess and sickle cell disease. Am J Hematol. Jun 1998;58(2):100-4. [Medline].
Smyrniotis V, Kehagias D, Voros D, et al. Splenic abscess. An old disease with new interest. Dig Surg. 2000;17(4):354-7. [Medline].
Schaberle W, Eisele R. [Percutaneous ultrasound controlled drainage of large splenic abscesses]. Chirurg. Jul 1997;68(7):744-8. [Medline].
Fotiadis C, Lavranos G, Patapis P, et al. Abscesses of the spleen: report of three cases. World J Gastroenterol. May 21 2008;14(19):3088-91. [Medline].
Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation. Dec 22-29 1998;98(25):2936-48. [Medline]. [Full Text].
Albanopoulos K, Archontovassilis F, Alexakis N, Pantelidaki A, Bramis C, Leandros E. Splenic abscess in a patient with Wegener's granulomatosis treated with laparoscopic splenectomy. Mt Sinai J Med. Nov 2006;73(7):1045-8. [Medline].
Lee CH, Leu HS, Hu TH, Liu JW. Splenic abscess in southern Taiwan. J Microbiol Immunol Infect. Feb 2004;37(1):39-44. [Medline]. [Full Text].
Tung CC, Chen FC, Lo CJ. Splenic abscess: an easily overlooked disease?. Am Surg. Apr 2006;72(4):322-5. [Medline].
Ulhaci N, Meteoglu I, Kacar F, Ozbas S. Abscess of the spleen. Pathol Oncol Res. 2004;10(4):234-6. [Medline].
Villamil-Cajoto I, Lado FL, Van den Eynde-Collado A, Díaz-Peromingo JA. [Splenic abscess: presentation of nine cases.]. Rev Chilena Infectol. Jun 2006;23(2):150-4. [Medline].
Iniguez A, Butte JM, Zuniga JM, et al. [Splenic abscesses. Report of seven cases]. Rev Med Chil. Jan 2008;136(1):38-43. [Medline].
Liang JT, Lee PH, Wang SM, Chang KJ. Splenic abscess: a diagnostic pitfall in the ED. Am J Emerg Med. May/1995;13:337-43. [Medline].
Alvi AR, Kulsoom S, Shamsi G. Splenic abscess: outcome and prognostic factors. J Coll Physicians Surg Pak. Dec 2008;18(12):740-3. [Medline].
Klimpel V. [Does Kehr's sign derive from Hans Kehr? A critical commentary on its documentation?]. Chirurg. Jan 2004;75(1):80-3. [Medline].
Moll R, Sailer M, Reith HB, Schindler G. CT-gesteuerte Drainagenbehandlung der Milz bei Abscessen und Hamatomen. Klinikarzt. June/2004;33:183-188.
Volk M, Strotzer M. [Diagnostic imaging of splenic disease]. Radiologe. Mar 2006;46(3):229-43; quiz 244. [Medline].
Legrand F, Lecuit M, Dupont B, et al. Adjuvant corticosteroid therapy for chronic disseminated candidiasis. Clin Infect Dis. Mar 1 2008;46(5):696-702. [Medline].
Zerem E, Bergsland J. Ultrasound guided percutaneous treatment for splenic abscesses: The significance in treatment of critically ill patients. World J Gastroenterol. Dec 7 2006;12(45):7341-5. [Medline].
Ferraioli G, Brunetti E, Gulizia R, et al. Management of splenic abscess: report on 16 cases from a single center. Int J Infect Dis. Dec 11 2008;[Medline].
Choudhury SR, Rajiv C, Pitamber S, et al. Management of splenic abscess in children by percutaneous drainage. J Pediatr Surg. Jan 2006;41(1):e53-6. [Medline].
Ooi LL, Leong SS. Splenic abscesses from 1987 to 1995. Am J Surg. Jul 1997;174(1):87-93. [Medline].
Carbonell AM, Kercher KW, Matthews BD, Joels CS, Sing RF, Heniford BT. Laparoscopic splenectomy for splenic abscess. Surg Laparosc Endosc Percutan Tech. Oct 2004;14(5):289-91. [Medline].
Further Reading
Related eMedicine topics:
Candidiasis
Infective Endocarditis
Spleen, Trauma
Splenic Infarct
Splenic Rupture
Splenomegaly [Hematology]
Splenomegaly [Pediatrics: General Medicine]
Clinical guidelines:
Surgical treatment of disease and injuries of the spleen. Society for Surgery of the Alimentary Tract, Inc - Medical Specialty Society. 2004 Feb 21. 3 pages. NGC:003836
Clinical trials:
Anticoagulation Post Laparoscopic Splenectomy
A Randomized Double Blinded Comparison of Ceftazidime and Meropenem in Severe Melioidosis (ATOM)
Keywords
splenic abscess, spleen, abscess, splenectomy, spleen symptoms, spleen problems, spleen removal, endocarditis, spleen anatomy, spleens, spleen infection, splenic infarct, splenomegaly, abscess surgery, post splenectomy, removal of spleen, bacteremia, splenotomy
