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CASE SCENARIO

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Scenario 1

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A 56-year-old man with a past medical history significant for paroxysmal atrial fibrillation presents to the emergency department complaining of 2 days of left upper quadrant pain that occasionally radiates to his left shoulder. He cannot recall any recent trauma, illness, or other inciting factors. On review of systems, he has had a recent history of fatigue. He is afebrile with normal vital signs. On examination, he is tender to palpation in the left upper quadrant with no appreciable splenomegaly. His white blood cell count (WBC) is 14.2 and lactate dehydrogenase (LDH) is 300 U/L.

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Scenario 2

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A 65-year-old woman with a past medical history significant for type 2 diabetes mellitus and chronic obstructive pulmonary disease, for which she takes prednisone, presents to her local urgent care with a 3-day history of subjective fevers, chills, fatigue, and abdominal pain. She has had nausea but no emesis or diarrhea. Her vital signs are notable for a temperature of 101.6°F. Physical examination reveals a diffusely tender abdomen that is soft and non-distended. Her WBC is 16.4 and blood glucose level is 320.

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Scenario 3

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A 19-year-old man with no past medical history is brought in by ambulance following a highway-speed motor vehicle collision in which he was a restrained front seat passenger. He is alert, oriented, and hemodynamically stable. Primary survey is unremarkable on arrival, and secondary survey reveals significant tenderness to palpation of the left upper quadrant. A focused assessment with sonography for trauma (FAST) examination in the trauma bay is negative for intra-peritoneal fluid, and initial laboratory evaluation is within normal limits.

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INTRODUCTION

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The above scenarios all describe splenic diseases encountered in acute care surgery: splenic infarction, splenic abscess, and splenic laceration. Although all three entities present with abdominal pain, the history and patient risk factors for these diagnoses differ. The following discussion aims to describe these differences and to assist in differentiating acute splenic lesions on imaging.

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EPIDEMIOLOGY

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Splenic Infarction

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Splenic infarction rarely occurs in a previously healthy patient. The most common etiology is atrial fibrillation, with its associated thromboemboli. Other frequent comorbid conditions include hypertension, diabetes, and malignancy, as well as any hypercoagulable state.1 Patients less than 40 years of age are more likely to have an associated hematologic disorder, whereas those over 41 years of age are more likely to suffer an embolic event.2

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Splenic Abscess

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Splenic abscess is a rare condition with a reported incidence of 0.1% to 0.7%, most commonly affecting patients in the fifth to seventh decades of life.3,4 The condition confers high fatality, with a reported mortality rate ranging from 40% to100%.3,4 Unlike splenic infarction, for which hypercoagulability and atrial fibrillation ...

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