Assessment of Clinical Conditions Associated With Splenic Infarction in Adult Patients

Abstract

This case series examines the clinical conditions associated with splenic infarction of adult patients between 2010 and 2015 from computed tomographic imaging scans.

The classic splenic infarction presents with acute pain and tenderness in the left upper quadrant or flank area. However, given the increasingly low threshold for performing abdominal computed tomographic (CT) imaging, splenic infarction is now identified in patients with less specific clinical presentations, sometimes as an incidental finding.^1,2,3,4,5,6 In this study, to our knowledge the largest case series of patients with splenic infarction, we describe clinical conditions associated with this disorder.

Methods

This retrospective observational study was conducted at 2 hospitals in Columbia, South Carolina. We queried the radiology database for adults (age ≥18 years) with definite or possible splenic infarction noted on CT scan reports between January 1, 2010, and January 1, 2015, using search terms splenic or spleen and infarct or infarction. We reviewed electronic medical records corresponding to each case (n = 232) and entered clinical information on standard forms. Data were analyzed from January 2017 to December 2019. Through iterative discussion, 2 of us (N.A. and A.S.B.) identified 11 categories (and several subcategories) of conditions associated with splenic infarction and assigned 1 or more categories for each case. Fourteen outpatient cases with inadequate clinical information were excluded. A study radiologist (M.A.M.) reviewed all images and excluded 55 additional cases when imaging suggested nonacute (old) infarctions, alternative explanations for splenic abnormalities, or perfusion artifacts. The total after exclusions was 163 patients with splenic infarction. Because we have encountered patients in whom celiac or splenic artery atherosclerosis was the sole plausible predisposition to splenic infarction, the radiologist also recorded whether this abnormality was present. When clinical and radiologic case reviews were complete, deidentified data were entered on Excel spread sheets. Additional details of methods are available in eMethods in the Supplement. The study was approved by the Palmetto Health institutional review board (known as Prisma since 2019) with waiver of informed consent. This study followed the reporting guideline for case series.

Results

The 163 patients were aged a mean (SD) 57.0 (18.1) years and 91 (56%) were women. Patient demographic and clinical characteristics are presented in Table 1. Forty percent of patients with splenic infarction (65 of 163) had more than 1 plausible predisposing factor. A broad variety of combinations was represented; examples include combinations of atrial fibrillation plus splenic artery atherosclerosis, hepatocellular cancer plus sepsis, and ischemic bowel plus hypotension. Only 20% (33 of 163) presented with left upper abdominal pain; remaining patients presented with other areas of abdominal pain (47% [77 of 163]) or without abdominal pain (33% [54 of 163]). Table 2 shows specific conditions associated with splenic infarction. In addition to traditional conditions (eg, cardioembolic and hematologic disorders), we noted a high prevalence of inflammatory or infectious abdominal conditions (16% [26 of 163]), sepsis (17% [27 of 163]), malignant tumor (20% [32 of 163]), and atherosclerosis involving celiac or splenic arteries (21% [34 of 163]). In 6 of 34 patients with celiac or splenic artery atherosclerosis, no other predisposing factor was evident. In-hospital mortality was 20% (32 of 163).

Table 1. Characteristics of 163 Patients With Splenic Infarction.

Characteristic	No. (%)
Age, mean (SD), y	57.0 (18.1)
Age group, y
<20	2 (1)
20-29	14 (9)
30-39	11 (7)
40-49	22 (13)
50-59	43 (26)
60-69	34 (21)
70-79	17 (10)
80-89	17 (10)
90-99	3 (2)
Sex
Male	72 (44)
Female	91 (56)
Race/ethnicity
Black	82 (50)
White	75 (46)
Other	6 (4)
Abdominal atherosclerosis
None	67 (41)
Present, but not involving celiac or splenic arteries	62 (38)
Present, involving celiac or splenic arteries	34 (21)a
No. of conditions associated with splenic infarction assigned per caseb
1	98 (60)
2	51 (31)
3	11 (7)
4	2 (1)
5	1 (1)
Abdominal pain in initial clinical presentation
Left upper quadrant pain as primary presenting symptom	32 (20)
Abdominal pain not localized to left upper quadrant	77 (47)
No abdominal pain	54 (33)

^aCeliac or splenic artery atherosclerosis was the sole identified associated condition in 6 of these 34 cases.

^bThese values indicate the following: 98 patients (60%) had a single potential condition associated with infarction; 51 patients (31%) had 2 potential associated conditions, and so on.

Table 2. Associated Clinical Conditions in 163 Patients With Splenic Infarction.

Associated condition	Patients, No. (%)a	Specific diagnoses within category	Cases, No.	In-hospital mortality within diagnostic category, %
Cardioembolic				12
Atrial fibrillation	26 (16)	NA	NA
Cardioembolic other than atrial fibrillation	15 (9)	Infective endocarditis	9
		Left ventricular thrombus	3
		Severe congestive heart failure	3
Malignant tumor				29
Nonabdominal solid tumor	5 (3)	Lung	5
Abdominal solid tumor	18 (11)	Pancreatic	8
		Hepatocellular	2
		Cervical	1
		Ovarian	1
		Esophageal	1
		Kidney	1
		Colon	1
		Lung metastases	1
		Unknown primary	2
Lymphoma or leukemia	9 (6)	Lymphoma	6
		Leukemia	3
Hypercoagulable state (not associated with malignant tumor)	15 (9)	Simultaneous thrombosis in multiple vascular bedsb	7	27
		Autoimmune hemolytic anemia	2
		Antiphospholipid syndrome	1
		Thrombotic thrombocytopenic purpura	1
		Nephrotic syndrome	1
		Systemic lupus	1
		Polycythemia	1
		History of documented hypercoagulable state	1
Sickle cell disease and variants	10 (6)	Homozygous sickle cell disease in adults	5	0
		Sickle-β-thalassemia	2
		Sickle trait	2
		Sickle cell disease	1
Sepsis or septic shock	27 (17)	NA	NA	30
Hypotension not associated with sepsis	11 (7)	NA	NA	55
Nonmalignant abdominal conditions				22
Inflammatory or infectious	26 (16)	Pancreatitis	10
		Bowel perforation with peritonitis	4
		Abdominal abscess	4
		Ischemic colitis	3
		Peritonitis with peritoneal dialysis	2
		Nonischemic colitis	2
		Hepatic necrosis	1
Cirrhosis and its complications	5 (3)	NA	NA
Trauma	9 (6)	NA	NA
Postoperative	19 (12)	Bowel perforation	4
		Roux-en-Y gastric bypass	3
		Trauma	2
		Cesarian delivery	2
		Small bowel obstruction	2
		Paraesophageal hernia	1
		Appendectomy	1
		Sleeve gastrectomy	1
		Abscess	1
		Necrotizing pancreatitis	1
		Ovarian cancer	1
Celiac or splenic atherosclerosis	34 (21)	NA	NA	29
Arterial dissection or ruptured aneurysm	5 (3)	Aortic dissection	2	40
		Celiac dissection	2
		Ruptured splenic aneurysm	1
Miscellaneous	4 (2)	HIV infection without other obvious cause	3	0
		Infectious mononucleosis	1
Unknown cause	8 (5)	NA	NA	0

Abbreviation: NA, not applicable.

^aTotal exceeds 163 because some patients had more than 1 potential associated condition.

^bIncludes 4 patients with simultaneous splenic infarction and either pulmonary embolism or deep vein thrombosis, and 3 patients with simultaneous arterial thrombosis in multiple organs but no cardioembolic source to explain the findings.

Discussion

This study found splenic infarction to be associated with a more diverse array of clinical conditions than is typically recognized in case series.^1,2,3,4,5,6 We highlight 4 observations not emphasized in previous reports. First, in 40% of cases, more than 1 plausible predisposing condition was identified. Although decreased arterial perfusion or hypercoagulability are final common pathways for infarction in most patients, these 2 processes can coexist, and various clinical entities can predispose to each of them.

Second, concomitant abdominal conditions (inflammatory or malignant) and sepsis were common; hypercoagulability accompanying inflammation, infection, or malignant tumor (or invasion of the splenic artery by tumor) are possible mechanisms. In particular, an association between pancreatic disorders and splenic infarction may be expected, given the proximity of splenic artery and pancreas.

Third, atherosclerosis involving the splenic artery and the celiac artery (from which the splenic artery originates) has not been discussed in most previous reviews.^1,2,3,4,5,6 Twenty-one percent of patients had this finding, which could lower the threshold for splenic infarction when hypercoagulability or hypoperfusion coexist. In 6 patients, celiac or splenic atherosclerosis was the only identifiable factor; acute in situ arterial thromboembolism involving previously subocclusive plaque is a possible mechanism.

Fourth, few patients presented with left upper quadrant pain. Many patients had complex clinical presentations with multi-organ involvement; in such cases, altered level of consciousness or competing sources of pain (within or outside the abdomen) might blunt the patient’s perception of discrete left upper quadrant pain. In patients with abdominal pain not localized to the left upper quadrant, splenic infarction was typically found alongside other intra-abdominal inflammatory or malignant disorders. In patients without abdominal pain, splenic infarction was typically an incidental finding when CT scanning was performed in evaluating critically ill patients.

A limitation of this study is the lack of standard protocol for evaluating patients with splenic infarction. Therefore, we might have underestimated the prevalence of conditions that can require extensive testing during or after an acute hospitalization.

Traditionally, cardioembolism and identifiable hypercoagulable states have been considered to be the cause of most splenic infarctions. Our study found that splenic infarction is associated with a broader spectrum of systemic and abdominal disorders than previously reported, and that celiac or splenic artery atherosclerosis may be an additional predisposing factor.

Supplement.

eMethods