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Diagnosis and Treatment of Splenic Abscess (about 11 cases)

Bassem Nasr, Amine Chhaider, Mohamed Ben Mabrouk, Mehdi Ben Hadj Hamida, Waad Farhat, Mouna Ben Othmen, Jaafar Mazhoud, Fathia Harrabi, Mohamed Azzaza, Walid Naija, Fethi Derbel, Ali Ben Ali, Ridha Ben Hadj Hamida

Bassem Nasr, Amine Chhaider, Mohamed Ben Mabrouk, Mehdi Ben Hadj Hamida, Waad Farhat, Mouna Ben Othmen, Jaafar Mazhoud, Fathia Harrabi, Mohamed Azzaza, Walid Naija, Fethi Derbel, Ali Ben Ali, Ridha Ben Hadj Hamida, Department of surgery. University hospital sahloul. 4051. Sousse. Tunisia.

Correspondence to: Fethi Derbel, MD, Department of General Surgery,Sahloul Hospital, Sousse, Tunisia.
fethi.derbel@gmail.com
Telephone:+216 24130460
Received: June 9, 2013
Revised: July 4, 2013
Accepted: July 6, 2013
Published online: September 21, 2013

ABSTRACT

AIM: To describe the clinical features, etiology, imaging findings, bacteriologic profile, treatment and outcome in patients presenting splenic abscess in a Tunisian hospital.

METHODS: It is a retrospective study, where we reviewed 11 splenic abscess cases that were hospitalized between January, 1st 2000 and October, 31st 2009.

RESULTS: Eleven cases (5 males, 6 females) were found., the mean age was 59 years. Fever was found in 7 cases, the left-upper-quadrant guarding was found in 6 cases, splenomegaly was found in 2 cases were the main clinical signs. Laboratory tests revealed leukocytosis and elevated level of CRP in all cases. All patients were investigated by ultrasound and CT scan.The primary site of infection was found In 3 cases, (endocarditis and urinary infection). There was one case of epithelial cyst of the spleen that was secondarily infected and in the other 7 cases the etiology was not found; it was about primary spleen damage.Treatment was essentially surgical (total splenectomy) except for one case which was treated medically (antibiotics) and successfully. The outcome was generally favorable with the exception of two deaths from septic shock (originating from a urinary infection)

CONCLUSION: The abscess of the spleen is a rare condition. Its clinical expression is highly polymorphic. Its positive diagnosis is based on imaging; the diagnosis must be made in good time to ensure timely treatment, which may be medical, interventional or surgical. The outcome after treatment is usually favorable.

Key words: Spleen; Abscess; Splenectomy; percutaneous drainage, antibiotics

© 2013 The Authors. Published by ACT Publishing Group Ltd.

Nasr B, Hamida MBH, Farhat W, Othmen MB, Chhaider A, Mabrouk MB, Mazhoud J, Harrabi F, Azzaza M, Naija W, Derbel F, Ali AB, Hamida RBH. Diagnosis and Treatment of splenic Abscess (about 11 cases). Journal of Gastroenterology and Hepatology Research 2013; 2(9): 786-790 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/483

Introduction

The abscess of the spleen is rare but fatal in the absence of treatment. The incidence of this condition after large series of Western autopsy is estimated to be up to 0.7%[1].

It is defined by the presence of one or more intraparenchymal or subcapsular collections of pus in the spleen. Its polymorphic symptomatology explains the difficulties of clinical diagnosis.

The diagnosis and treatment had been known well in the last century, and gains a great advances in recent decades because of the development of medical imaging (such as CT, ultrasound etc.). Thus, the mortality and morbidity of Spleen Abscess has decreased greatly.

METHODS

This is a retrospective study covering the period from 1 January 2000 until 31 October 2009 conducted in the digestive and visceral surgery department at Sahloul university hospital of Sousse, TUNISIA.

We report a series of 11 cases over 9 years.

The diagnosis was made on clinical, biological and imaging data. The treatment was either medical (antibiotic) or surgical (splenectomy).

Clinical, biological, radiological, therapeutic and evolutive data were collected from the records of inpatients.

RESULTS

This study included 5 men and 6 women (sex ratio=0.8), the mean age was 59 years (range 21-80). Twenty seven percent of patients had diabetes (n=3), 45.45% (n=5) were holders of cardiovascular problems (hypertension, PAD, coronary artery disease, ischemic stroke ...) and one case was operated for a gastric cancer. Fever was found in 63.63% of cases (n=7), the left-upper-quadrant guarding was found in 54.54% of cases (n=6), splenomegaly was found in 18.18% of cases (n=2), and were the main clinical signs.

Laboratory tests revealed leukocytosis and elevated level of CRP in all cases.

All patients were investigated by ultrasound and CT scan, which showed a positive diagnosis in 100% of cases.

The primary site of infection was found in 3 cases, (endocarditis and urinary infection). There was one case of epithelial cyst of the spleen that was secondarily infected and in the other 7 cases the abcess; it was about primary spleen damage.

Treatment was essentially surgical (total splenectomy) except for one case which was treated medically (antibiotics) and successfully.

The outcome was generally favorable with the exception of two deaths from septic shock (originating from a urinary infection).

DISCUSSION

The rarity of abscess of the spleen appears in all studies: 10 cases in 10 years for CHULAY[2], 5 cases in 30 years for FALL[3] and 11 cases in 9 years in our study. This scarcity may be explained by the fact that the spleen would have a capacity to resist local infections[4].The actual frequency is probably higher because of the existence of deceptive forms or because it is decapitated by antibiotics[5].The abscess of the spleen in our study comes at a relatively advanced age (59 years) and predominantly amongst women (sex ratio=0.8). In the literature[2], the condition also occurs most often in adults in their but predominance in terms of sex distribution in most studies is discordant: some authors found a higher frequency in women[2,6,7] and others found it within men[3,8-10].

Generally the suppurative infection of spleen is secondary and its primary focus is obscure because of its symptoms appearing after weeks or months following the primary infection receding.

The pathophysiology of splenic abscesses is still poorly understood, it may be better defined by the progress of medical imaging, however, three hypotheses as to it origin are still discussed:

Hematogenous: comes from other infective focus through blood, artery or portal vein, mainly artery route, such as endocarditis and childbed fever, accounting for about 75%n to 90% of all Spleen abscess. In fact nearly all purulent infection of a human body can cause the abscess of spleen. Its common pathogen are Staphylococcus, Streptocuccus and Pneumococcus etc.

In our study, the Splenic damage during a severe sepsis was noted in cases 2 and 7, and a result of infective endocarditis in case 6.

Intrinsic origin: The damage or infarct of Spleen, accounting for about 10% to 25% of abscess of the spleen. Even a small trauma to spleen could cause a hematoma, hence a secondary infection ensues, and Spleen abscess occurs. Thromboses, embolism, pathological hemoglobinemia are also common causes.

A preexisting lesion at the spleen on which is grafted an infectious violation. Example: splenic infarction, post traumatic hematoma, epithelial cyst of the spleen (case 8), malignant tumor of the spleen.

Extrinsic origin: affected by contiguity due to a neighboring infection. Adjacent viscera infection such as perinephric abcess, subphrenic abscess, acute pancreatitis, and gastroentestinal tumor etc could also invade directly to spleen and cause abscess of spleen.But, such conditions is rare, accounting for less than 10% of all the Spleen abscesses.

Immune suppress or defect such as critical illness, long-term use of immuno- suppressive drugs, AIDS patients. Besides, Spleen Cyst could also be infected to form abscess.

In addition, the pathogen for Spleen abscess could change under the widely usage of broad spectrum antibiotics. For example fungus (Candida albicans), anaerobic bacteria are also seen routinely and ameba is rare.

In terms of bacteriology, staphylococci and streptococci both preveil[4] since it is highly related to infective endocarditis of which these germs are the most common causes[7]. Thyphic abscesses and amoeba[10] are rare. With our means of investigation we weren’t always able to identify the causative agent.

Splenic abscesses occur in immuno-compromised individuals willingly by the presence of one or more defects. Indeed an underlying pathology was noted in 50% of cases [5], diabetes, leukemia, sickle cell anemia, cancer, cirrhosis, immunosuppressive treatment. In our study three patients had diabetes, five patients had cardiovascular problems (hypertension, PAD, coronary artery disease, ischemic stroke ...) and one case was operated for a gastric cancer.

The clinical features have no specificity; the classic triad made of painful and febrile splenomegaly is not always present. Indeed, fever is present in 7 cases, and pain or guarding of the left upper-quadrant in 6 cases, splenomegaly in 2 cases and in one case it was during the balance of septic shock that the splenic abscess was diagnosed and in another case the splenic abscess was discovered during an acute obstructive intestinal syndrome. More rarely, acute generalized peritonitis is indicative of the abscess (one case).

Biological data are not contributory to the diagnosis of abscess of the spleen. It is a biological inflammatory syndrome associated with leukocytosis in 60 to 100% of cases[11]. In our series, the inflammatory syndrome was present in 100% of cases.

It is the progress of medical imaging that facilitated the diagnosis of abscess of the spleen. Indeed, ultrasound can contribute to an early diagnosis[3] showing a typically single or multiple hypo-echogenic image within the splenic parenchyma[12]. Its sensitivity ranges from 75 to 95% depending on the series[13,14] But a hydatid cyst can be discussed because of our context (endemic hydatid disease). Misleading aspects of ultrasound are possible: hyper-echogenic or heterogeneous well circumscribed wide image suggesting malignancy. With a sensitivity close to 100%, the CT scan is better than ultrasound in terms of diagnosing splenic abscesses[13,14]. In our series the couple CT scan / ultrasound showed a positive diagnosis in 100% of cases.

The invasive treatment of splenic abscess includes 3 options: percutaneous drainage, open or laparoscopic surgery (splenectomy), and open drainage.

Systematic splenectomy based therapy can be criticized because of high mortality and morbidity because there is a need to keep the spleen at the end to avoid overwhelming infections[15]. The spleen is important for proper immunologic function, and splenectomy carries an increased morbidity rate with the danger of postsplenectomic infections[15]. Current therapeutic strategies established spleen-preserving treatment in cases of trauma and benign lesions.

In our study, about 90% of patients were treated by splenectomy and has achieved good results, only two deaths occurred and that were not attributed to splenectomy but were related to the loaded past patient’s history. Only one patient received medical treatment (antibiotics) with success.

Currently puncture or percutaneous drainage both associated with antibiotic transformed the prognosis of splenic abscess[5], contributing to the shortening of hospitalization, avoiding the risk of opening the abscess into the peritoneal cavity and preserving the splenic parenchyma.

The different current indications for the treatment of splenic abscess are:

Antibiotics alone: small abscesses or poorly collected.

Percutaneous drainage: Percutaneous drainage is indicated for easily accessible uniloculated or biloculated abscesses with otherwise favorable features, and also for surgical patients at very high risk who cannot tolerate general anesthesia or surgery. It is the first option especially if a patient is in a poor condition[3,18].

Its indications according to GLEICH are: A unique non-partitioned collection with a thin wall.

The success rate is about 70%[12].

However Contraindications to percutaneous drainage include the following[18-19].

Multiloculated or debris-filled abscess

Multiple small abscesses

Uncontrollable coagulopathy

Poorly defined abscess on CT scan or ultrasonogram

Diffuse ascites

No safe route for drainage

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%

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[6].

No prospective, randomized study is available to determine the most effective treatment for splenic abscess. The diversity of the patient population suggests the importance of patient selection to improve outcome.

CT scanning is currently considered the criterion standard for helping to establish the diagnosis of splenic abscess. Percutaneous, CT-guided drainage is a safe, minimally invasive, and successful treatment option that should be used as a spleen-conserving alternative to surgery in suitable patients[18-20].

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Peer reviewers: Lian-An Ding, Department of General Surgery, Eastern Branch of Affiliated Hospital, Qingdao University Medical College, No.59 Haier Road, High Scientific and Technical Garden of Laoshan, Qingdao, 266000, China; Gianluca Pellino, MD, General Surgery Unit, Second University of Naples, Via Giotto, 60, 81031, Aversa (CE) , Italy.

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