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CASE REPORT
Ahead of print publication  

Case report: Splenic infarct without splenic vessel thrombosis in a patient with portal hypertension and acute pancreatitis


1 Department of Radiodiagnosis, Military Hospital Saugor, Sagar, Madhya Pradesh, India
2 Department of Psychiatry, Command Hospital, Chandimandir, Haryana, India

Date of Submission11-Mar-2022
Date of Acceptance16-Mar-2022
Date of Web Publication05-Oct-2022

Correspondence Address:
Ranjit Singh Lahel,
Department of Radiodiagnosis, Military Hospital Saugor, Saugor Cantt, Sagar - 470 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_38_22

  Abstract 


Splenic infarction without splenic vessel thrombosis is an infrequent presentation in clinical practice. The case discussed here is a 45-year-old male with a history of alcohol abuse, who presented to the hospital with pain abdomen epicentered in the left upper quadrant. On evaluation, the patient was found to be having portal hypertension complicated with alcoholic hepatitis, acute necrotizing pancreatitis, gastric, and paraesophageal varices. The presence of splenic infarction without concomitant splenic vessel thrombosis in this patient merits a discussion of relevant investigations and their findings thereof.

Keywords: Acute pancreatitis, alcoholic hepatitis, portal hypertension, splenic infarct



How to cite this URL:
Lahel RS, Chail A. Case report: Splenic infarct without splenic vessel thrombosis in a patient with portal hypertension and acute pancreatitis. J Mar Med Soc [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=357921




  Introduction Top


Splenic infarction is a rare clinical entity.[1] Pancreas is a retroperitoneal organ in proximity to the spleen. The hypercoagulability that can occur during acute pancreatitis episodes and the pancreatic inflammatory process itself can affect neighboring vessels and produce vascular complications such as thrombosis or the formation of pseudoaneurysms. The thrombotic occlusion of splenic blood vessels may result in organ infarction.[2] However, there was no splenic artery or venous thrombosis in the imaging findings of this patient. The presence of splenic infarct without any evident vessel thrombosis in the patient, further complicated by alcoholic hepatitis, portal hypertension, gastric, and paraesophageal varices merits a discussion of the case.


  Case Report Top


A 45-year-old male presented to the emergency department of the hospital with epigastric pain radiating to the back. He had a history of chronic alcohol abuse with no associated comorbidities.

Laboratory investigations revealed hemoglobin 10 g%, white cell count 14,000 per mm3, with 86% neutrophils, serum amylase 733 U/L, serum bilirubin 2 mg/dL, serum glutamic-oxaloacetic transaminase 150 U/L, and serum glutamic-pyruvic transaminase 211 U/L.

Contrast-enhanced computed tomography (CT) abdomen was done which revealed enlarged distal body and tail of pancreas with an irregularly marginated nonenhancing pancreatic parenchyma in the tail region, consistent with pancreatic necrosis (<30%). There was blurring of pancreatic margins with peripancreatic fat stranding and peripancreatic collections in relation to splenic hilum. Inflammatory changes extended to the splenic flexure in the form of colonic wall thickening. Nonenhancing areas were seen in the spleen in the anterior polar region: consistent with splenic infarct. Spleen measured more than 13 cm in span. Multiple dilated varices were seen in the left upper quadrant in communication with splenic vein. Gastric varices and paraesophageal varices were also noted. The portal vein measured up to 18 mm in diameter. The portal vein, superior mesenteric vein, splenic vein, and splenic artery demonstrated normal contrast opacification with no filling defects. The liver showed normal size and contrast enhancement with normal outline. The Modified CT Severity Index score of the patient was calculated to be 8/10.

Following [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6] demonstrate the imaging findings from axial sections of CECT Abdomen relevant to the case.
Figure 1: Nonenhancing pancreatic parenchyma consistent with pancreatic necrosis

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Figure 2: Nonenhancing splenic parenchyma consistent with splenic infarcts

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Figure 3: Dilated paraesophageal varices

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Figure 4: Dilated gastric varices

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Figure 5: Colonic wall thickening with adjacent fat stranding secondary to pancreatitis

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Figure 6: Dilated Portal vein consistent with Portal hypertension

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The patient was managed conservatively in intensive care unit setting and gradually improved after 2 weeks. He was discharged to regular follow-up on outpatient department basis with strict instructions to abstain from alcohol.


  Discussion Top


Splenic infarction is the result of arterial and venous compromise in the splenic vessels, either intraluminal or extraluminal.[3]

Various mechanisms have been described for splenic infarction in the course of acute pancreatitis. The most common cause is splenic vein thrombosis by direct extension of local inflammatory process or by hypercoagulable state induced by pancreatitis.[1] It has been reported that vascular complications are significantly more common in alcohol-induced pancreatitis than in gallstone-induced pancreatitis.[2] Thrombosis of the splenic vein develops because intrinsic damage to the intima of the vein occurs after inflammatory disease.[4] However, in our patient, there was no luminal occlusion or identifiable narrowing/spasm of splenic vessels that would explain the etiology of spontaneous splenic infarct.

Further, congestive splenomegaly is a frequent finding in patients with portal hypertension.[5] However, spontaneous splenic infarction has been rarely reported as a complication of portal hypertension.[6] In a review of a large series of patients with splenic infarction, only 3 of 152 cases were the result of portal hypertension.[7]

In view of the lack of evidence regarding the involvement of splenic vessels, it can be postulated that splenic infarct in our patient was due to hemodynamic changes leading to anoxia, rather than organic occlusion of splenic vasculature. First, an increase in the intravascular coagulability of splenic vessels secondary to pancreatitis can be a factor responsible for the areas of splenic infarction.[3] Second, splenomegaly results from portal hypertension, and this is believed to increase splenic oxygen requirements disproportionate to the body's oxygen delivering capacity. Consequently, the spleen suffers anoxic injury and subsequent infarction.[8]

It is imperative that despite being a relatively infrequent complication, splenic infarct must be considered in the list of serious complications, arising out of multifactorial etiology in such complicated cases involving portal hypertension, acute pancreatitis, gastroesophageal varices, and alcoholic hepatitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ray S, Mridha AR, Ahammed M. Diffuse splenic infarction in a case of severe acute pancreatitis. Am J Surg 2011;201:e23-5.  Back to cited text no. 1
    
2.
Yu HM, Myung E, Kim SH, Myung DS, Cho SB, Lee WS, et al. Gastric and splenic infarctions in acute pancreatitis. J Dig Dis 2016;17:340-3.  Back to cited text no. 2
    
3.
Arenal Vera JJ, Said A, Guerro JA, Otero M, Gil I. Splenic infarction secondary to acute pancreatitis. Rev Esp Enferm Dig 2008;100:300-3.  Back to cited text no. 3
    
4.
Lankisch PG. The spleen in inflammatory pancreatic disease. Gastroenterology 1990;98:509-16.  Back to cited text no. 4
    
5.
Capron JP, Chivrac D, Dupas JL, Rémond A, Ossart JL, Lorriaux A. Massive splenic infarction in cirrhosis: Report of a case with spontaneous disappearance of hypersplenism. Gastroenterology 1976;71:308-10.  Back to cited text no. 5
    
6.
Nehme F, Rowe K, Haris A, Nassif I. Spontaneous splenic infarcts in a cirrhotic patient with primary biliary cirrhosis. Case Rep Gastroenterol 2017;11:54-8.  Back to cited text no. 6
    
7.
Matsui A, Shimada T, Sasaki N, Ishikawa T, Momoya T, Makino S. Splenic infarction in a child with portal hypertension secondary to biliary atresia. J Pediatr Surg 1997;32:648-9.  Back to cited text no. 7
    
8.
Aijazi M, Gill B, Kalaria A, Ahuja A. Splenic infarction in alcoholic hepatitis. Proc (Bayl Univ Med Cent) 2020;33:239-40.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

 
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