History and Physical Examination
The clinical spectrum ranges from asymptomatic infarction (discovered incidentally on radiologic or postmortem studies or at laparoscopy or laparotomy for another indication) to hemorrhagic shock (secondary to massive subcapsular hemorrhage with free rupture into the peritoneal cavity). Approximately one third of splenic infarcts are clinically occult.
The most common presenting symptom is left-upper-quadrant abdominal pain (up to 70%). Additional symptoms include fever and chills, nausea and vomiting, pleuritic chest pain, and left shoulder pain (Kehr sign).
Septic thromboemboli may result in splenic abscesses, which present with sepsis and left upper abdominal pain.
In the series of Nores et al, most of the patients with thromboembolic infarction were symptomatic; 70% of patients with emboli were febrile, and 86% of individuals with thrombosis had abdominal pain. [12]
In a 10-year retrospective study, Antopolsky et al examined clinical presentations in 49 episodes of acute splenic infarction. The most common symptom was either abdominal or left flank pain (80% of episodes), while the most common sign was left-upper-quadrant tenderness (35% of episodes). In 16.6% of patients, splenic infarction was the presenting symptom of an underlying disease. No in-hospital mortality or serious complications occurred in the cohort. [18]
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Splenic infarct. Computed tomography scan of a 51-year-old man following a motor vehicle accident. American Association for the Surgery of Trauma (AAST) grade III splenic injury, with active extravasation of contrast from the splenic parenchyma (the white area along the medial aspect of the spleen).
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Splenic infarct. Selective splenic arteriogram showing extravasation of contrast from the splenic artery at the splenic hilum prior to angioembolization (same patient as in the above image).
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Computed tomography scan of the spleen 5 days after angioembolization of a bleeding splenic artery, showing partial splenic infarct (demonstrated by a lack of IV contrast enhancement of the lower pole of spleen). The patient experienced no adverse sequelae and fared well following his discharge to home 5 days after the embolization (same patient as in the above images).
