Once the diagnosis of a splenic abscess has been made, the patient must be admitted to the hospital and treated. Treatment depends on the patient’s overall condition, comorbidities, and primary disorder (if any), as well as the size and topography of the abscess. [22]
Empiric broad-spectrum antibiotic therapy has a primary role in the initial management of splenic abscesses. The success of antibiotic therapy is not affected by the presence of multiple abscesses or by a polymicrobial flora. The choice of antibiotics is tailored to the culture results.
Percutaneous drainage has gained acceptance as an effective and less invasive treatment method than surgical intervention in selected patients. The reported success rate of percutaneous drainage ranges from 67% to 100%. Such drainage preserves the spleen and avoids the risk of overwhelming postsplenectomy sepsis (OPSS). Percutaneous drainage can also be used as a bridge to elective surgery in patients who are clinically unstable or in patients who have multiple comorbidities.
Early diagnosis and percutaneous drainage can increase the chance to preserve the spleen and, hence, its immunologic function
Percutaneous drainage is likely to be useful in patients who have unilocular or bilocular collections and if the character of the abscess content permits a minimally invasive drainage. Multilocular abscesses, ill-defined cavities, septations, and necrotic debris typically do not respond to percutaneous drainage.
Surgery is reserved for patients who are stable and not amenable to percutaneous drainage. Depending on available expertise, laparoscopic or open procedures can be considered.
- Multiloculated or debris-filled abscess
- Multiple small abscesses
- Uncontrollable coagulopathy
- Poorly defined abscess on computed tomography (CT) or ultrasonography
- Diffuse ascites
- No safe route for drainage
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 in this group has been reported to be approximately 50%.[14
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
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. 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
Surgical options
Invasive treatment of splenic abscess includes the following three options:
- Percutaneous drainage
- Open or laparoscopic splenectomy
- 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. [30, 31] The procedure includes a risk of iatrogenic injury of the spleen, colon (splenic flexure), stomach, left kidney, and diaphragm.
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. [7] 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.
Splenectomy
Splenectomy has long been considered the standard treatment of splenic abscess. Depending on the patient population, open splenectomy has a mortality of 0-17% and a morbidity of 28-43%. [33] The procedure 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.
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