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Snowboard mishap with a twist: an uncommon injury that keeps you on your toes! [FEBRUARY 2025]
June 3, 2025
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Splenic Infarction: An Ultrasonographic Diagnosis
Authors:
Anca Voron, Tudor Moga, Alina Popescu
1Clinical History
A 72-year-old female patient with a known diagnosis of autoimmune liver cirrhosis (Child-Pugh class C), currently receiving treatment with Azathioprine, presented to the emergency department with complaints of generalized weakness and fatigue. These symptoms were accompanied by pain, edema, and ecchymosis of the right lower limb, following an accidental fall from standing height. An orthopedic evaluation was performed to exclude fractures or joint dislocations. Laboratory investigations revealed moderate anemia and thrombocytopenia. The patient underwent further imaging studies, including ultrasound and computed tomography, to enable a comprehensive diagnostic assessment.
2Image Findings
Abdominal Ultrasonography
An ultrasonographic examination revealed splenomegaly, with the spleen measuring 15 cm in length and an echo-poor, well delineated lesions measuring 7 × 2 cm reaching the capsule was depicted (Fig.1). The liver exhibited a heterogeneous parenchymal echotexture and an irregular surface contour. Additionally, small volumes of perihepatic ascites and pelvic ascites in the pouch of Douglas were identified. Doppler imaging demonstrated absent flow in a branch of the splenic vein, consistent with splenic vein thrombosis (Fig.2).
Contrast-Enhanced Ultrasound of the Spleen (CEUS)
At the level of the spleen, the echo-poor, well delineated lesions on B-mode, was unenhancing during all vascular phases, suggesting a well defined, avascular area (Fig.3).
Contrast-Enhanced CT of the Abdomen and Pelvis (CECT)
CECT revealed a hypodense area in the lower pole of the splenic parenchyma, which exhibited a post-contrast pyramidal configuration with the apex directed toward the splenic hilum, consistent with splenic infarction (Fig.4) . Additionally, extensive portal vein thrombosis was identified, involving the spleno-mesenteric confluence and the splenic vein.
An ultrasonographic examination revealed splenomegaly, with the spleen measuring 15 cm in length and an echo-poor, well delineated lesions measuring 7 × 2 cm reaching the capsule was depicted (Fig.1). The liver exhibited a heterogeneous parenchymal echotexture and an irregular surface contour. Additionally, small volumes of perihepatic ascites and pelvic ascites in the pouch of Douglas were identified. Doppler imaging demonstrated absent flow in a branch of the splenic vein, consistent with splenic vein thrombosis (Fig.2).
Contrast-Enhanced Ultrasound of the Spleen (CEUS)
At the level of the spleen, the echo-poor, well delineated lesions on B-mode, was unenhancing during all vascular phases, suggesting a well defined, avascular area (Fig.3).
Contrast-Enhanced CT of the Abdomen and Pelvis (CECT)
CECT revealed a hypodense area in the lower pole of the splenic parenchyma, which exhibited a post-contrast pyramidal configuration with the apex directed toward the splenic hilum, consistent with splenic infarction (Fig.4) . Additionally, extensive portal vein thrombosis was identified, involving the spleno-mesenteric confluence and the splenic vein.
3Diagnosis
A splenic infarct was identified in the context of extensive portal vein thrombosis involving the spleno-mesenteric confluence, associated with underlying autoimmune liver cirrhosis.
4Discussion
BACKGROUND:
Splenic infarctions are common in vascular disease, typically resulting from embolic or thrombotic occlusion of splenic arteries. Hemostatic alterations are commonly observed in cirrhotic individuals and likely contribute to the heightened risk of portal vein thrombosis [1].
Sonographically, infarctions initially appear as hypoechoic, wedge-shaped lesions that become hyperechoic and scarred over time. Contrast-enhanced ultrasound (CEUS) greatly enhances detection, revealing avascular regions and disrupted arterial flow, which are often missed or underestimated with standard B-mode imaging. CEUS also aids in identifying regional perfusion deficits in splenomegaly related to systemic disease and improves accuracy in diagnosing splenic vein thrombosis, exceeding the reliability of conventional ultrasound and Doppler. Overall, CEUS is a valuable tool for precise assessment of splenic vascular pathology [2, 3].
CLINICAL PERSPECTIVE:
Splenic infarction typically presents with left upper quadrant abdominal pain and nausea. Physical examination may reveal jaundice, with the abdomen being soft and mobile; palpation often elicits tenderness in the left hypochondrium and flank regions. Laboratory findings commonly demonstrate moderate thrombocytopenia, mild anemia, and hyperbilirubinemia. In patients diagnosed with splanchnic vein thrombosis, the development of portal hypertension is frequent. Accordingly, gastroscopy is performed, revealing grade II esophageal varices and hypertensive portal gastropathy [4].
THERAPEUTIC APPROACH:
The treatment of splenic infarction is multifaceted, emphasizing conservative management for uncomplicated cases and reserving surgical interventions for those with complications. A thorough evaluation to determine the underlying cause is essential to guide therapy and improve outcomes [5]. Anticoagulation is recommended for patients with cirrhosis who present with recent (<6 months) complete or partial (>50%) occlusion of the portal vein trunk, with or without extension into the superior mesenteric vein, as well as for those with symptomatic portal vein thrombosis (PVT), regardless of the extent of thrombosis [6, 7]
In the present case, anticoagulant therapy with enoxaparin sodium was initiated at a daily subcutaneous dose of 0.6 mL, alongside management of the underlying liver disease. In this patient, the infarcted spleen was managed conservatively with close observation.
OUTCOME & PROGNOSIS:
Splenic infarction generally follows a benign clinical course; however, the overall prognosis is primarily determined by the underlying etiological factors.
Splenic infarctions are common in vascular disease, typically resulting from embolic or thrombotic occlusion of splenic arteries. Hemostatic alterations are commonly observed in cirrhotic individuals and likely contribute to the heightened risk of portal vein thrombosis [1].
Sonographically, infarctions initially appear as hypoechoic, wedge-shaped lesions that become hyperechoic and scarred over time. Contrast-enhanced ultrasound (CEUS) greatly enhances detection, revealing avascular regions and disrupted arterial flow, which are often missed or underestimated with standard B-mode imaging. CEUS also aids in identifying regional perfusion deficits in splenomegaly related to systemic disease and improves accuracy in diagnosing splenic vein thrombosis, exceeding the reliability of conventional ultrasound and Doppler. Overall, CEUS is a valuable tool for precise assessment of splenic vascular pathology [2, 3].
CLINICAL PERSPECTIVE:
Splenic infarction typically presents with left upper quadrant abdominal pain and nausea. Physical examination may reveal jaundice, with the abdomen being soft and mobile; palpation often elicits tenderness in the left hypochondrium and flank regions. Laboratory findings commonly demonstrate moderate thrombocytopenia, mild anemia, and hyperbilirubinemia. In patients diagnosed with splanchnic vein thrombosis, the development of portal hypertension is frequent. Accordingly, gastroscopy is performed, revealing grade II esophageal varices and hypertensive portal gastropathy [4].
THERAPEUTIC APPROACH:
The treatment of splenic infarction is multifaceted, emphasizing conservative management for uncomplicated cases and reserving surgical interventions for those with complications. A thorough evaluation to determine the underlying cause is essential to guide therapy and improve outcomes [5]. Anticoagulation is recommended for patients with cirrhosis who present with recent (<6 months) complete or partial (>50%) occlusion of the portal vein trunk, with or without extension into the superior mesenteric vein, as well as for those with symptomatic portal vein thrombosis (PVT), regardless of the extent of thrombosis [6, 7]
In the present case, anticoagulant therapy with enoxaparin sodium was initiated at a daily subcutaneous dose of 0.6 mL, alongside management of the underlying liver disease. In this patient, the infarcted spleen was managed conservatively with close observation.
OUTCOME & PROGNOSIS:
Splenic infarction generally follows a benign clinical course; however, the overall prognosis is primarily determined by the underlying etiological factors.
5Teaching Points
Splenic infarction is often overlooked in acute clinical settings due to its wide spectrum of nonspecific clinical manifestations. Consequently, it is frequently underdiagnosed. Abdominal ultrasonography remains the rapid, noninvasive, and preferred imaging modality for the initial evaluation and detection of splenic infarction [8].
6References
1. Prakash S, Bies J, Hassan M, Mares A, Didia SC. Portal vein thrombosis in cirrhosis: A literature review. Front Med (Lausanne). 2023;10:1134801.
2. Ioanițescu ES, Weskott HP. Ultrasound of the spleen. In: Dietrich CF, editor. EFSUMB Course Book. 2nd ed. 2020.
3. Ioanițescu ES, Copaci I, Mîndruț E, et al. Various aspects of contrast-enhanced ultrasonography in splenic lesions -Med Ultrason. 2020;22(3):356–363.
4. Schattner A, Meital A, Kitroser E, Klepfish A. Acute splenic infarction at an academic general hospital over 10 years: Presentation, etiology, and outcome. Medicine (Baltimore). 2015;94(36):e1363.
5.Cleveland Clinic. Splenic infarction: Symptoms, causes & treatment [Internet]. Cleveland Clinic; 2025 [cited 2025 May 21
6.European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines on the management of bleeding and thrombosis in patients with cirrhosis. J Hepatol. 2022;76(5):1151–1184.
7.Carlin S, Cuker A, Gatt A, Gendron N, Hernández-Gea V, Meijer K, et al. Anticoagulation for stroke prevention in atrial fibrillation and treatment of venous thromboembolism and portal vein thrombosis in cirrhosis: guidance from the SSC of the ISTH. J Thromb Haemost. 2024;22(9):2653–2669.
8. Trenker C, Görg C, Freeman S, Jenssen C, Dong Y, Caraiani C, Ioanițescu ES, Dietrich CF WFUMB Position Paper-Incidental Findings, How to Manage: Spleen;.Ultrasound Med Biol. 2021;47(8):2017-2032.
2. Ioanițescu ES, Weskott HP. Ultrasound of the spleen. In: Dietrich CF, editor. EFSUMB Course Book. 2nd ed. 2020.
3. Ioanițescu ES, Copaci I, Mîndruț E, et al. Various aspects of contrast-enhanced ultrasonography in splenic lesions -Med Ultrason. 2020;22(3):356–363.
4. Schattner A, Meital A, Kitroser E, Klepfish A. Acute splenic infarction at an academic general hospital over 10 years: Presentation, etiology, and outcome. Medicine (Baltimore). 2015;94(36):e1363.
5.Cleveland Clinic. Splenic infarction: Symptoms, causes & treatment [Internet]. Cleveland Clinic; 2025 [cited 2025 May 21
6.European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines on the management of bleeding and thrombosis in patients with cirrhosis. J Hepatol. 2022;76(5):1151–1184.
7.Carlin S, Cuker A, Gatt A, Gendron N, Hernández-Gea V, Meijer K, et al. Anticoagulation for stroke prevention in atrial fibrillation and treatment of venous thromboembolism and portal vein thrombosis in cirrhosis: guidance from the SSC of the ISTH. J Thromb Haemost. 2024;22(9):2653–2669.
8. Trenker C, Görg C, Freeman S, Jenssen C, Dong Y, Caraiani C, Ioanițescu ES, Dietrich CF WFUMB Position Paper-Incidental Findings, How to Manage: Spleen;.Ultrasound Med Biol. 2021;47(8):2017-2032.
