脾脓肿

目的　介绍脾脓肿的病因 ,发病机理 ,临床表现及诊治方法。方法　根据作者收治的 9例脾脓肿的临床资料 ,结合文献复习。结果　脾脓肿可分为尸检型和临床型。尸检发现率为 0 4%～0 7%。临床型以单发巨大脾脓肿多见。脾脓肿主要为血源性感染所致。早期临床表现无特殊性。血培养阳性率为 1 5 %～ 70 % ,影像学检查对诊断有帮助。本病误诊率高达 2 2 2 %～ 50 %。脾脓肿手术治疗效果好。结论　脾脓肿临床少见 ,术前诊断率低 ,易误诊漏诊。一经确诊 ,应及时手术治疗。     

Splenic hematoma

An extremely rare yet potentially fatal complication of colonoscopy is reported. A 52-year-old female developed a splenic subcapsular hematoma following routine colonoscopy. Conservative treatment was successful. In the English literature, only 14 similar cases have been reported. Treatment of a splenic flexure lesion, previous surgery with splenocolic adhesions, and inflammatory bowel disease increase the risk of such a complication. Increased awareness by surgeons and gastroenterologists should lead to prompt treatment and favorable outcome. Received: 27 December 1996/Accepted: 12 February 1997     

Splenic abscess

Abscess of the spleen is a rare entity. It may develop after generalized infection, hematologic disorders and trauma. The authors report the case of a 7-year-old boy who presented with a 2-month history of spiking fever, anorexia, fatigue and weight loss. He had left subcostal tenderness and a palpable spleen. He had a history of trauma to the left flank 5 months before admission but a splenic scan obtained at that time appeared normal. A splenic abscess was diagnosed by gallium scanning, computerized tomography and ultrasonography. Although splenectomy has been advocated as the treatment of choice for splenic abscess, this patient was treated successfully with appropriate antibiotics and simple drainage, preserving the spleen. Cultures grew Staphylococcus aureus. Of all the diagnostic methods available, ultrasonography is the least invasive study that will make the diagnosis and is less expensive than some methods.     

Proximal Splenic Artery Embolization In Blunt Splenic Trauma

Abstract Background:   Proximal embolization of the splenic artery (PSAE) has recently been reported for traumatic splenic injury. The suggested mechanism of action entails a decrease in the splenic blood pressure without ischemia due to collateral blood supply. The main complications of selective embolization are continuous bleeding, splenic infarcts and splenic abscesses. The main complications of observation alone are continuous bleeding and formation of splenic pseudoaneurysms. Our aim was to assess the efficacy of PSAE in the cessation of bleeding without formation of pseudoaneurysms, and the outcome of the spleen after such intervention. Methods:   A prospective observational study of all patients undergoing PSAE for traumatic splenic injury in our institution over a 33-month period. Clinical and Doppler sonographic examinations were performed to assess cessation of bleeding, splenic blood flow, and formation of splenic pseudoaneurysms, infarcts or abscesses. Results:   During 33 months, 11 patients with blunt abdominal trauma and tomographic evidence of either high grade or actively bleeding splenic injuries were treated by PSAE. During follow-up, no patient underwent surgery or repeated embolization. Preserved blood flow was found on Doppler sonography in 82% of the patients and no pseudoaneurysms were demonstrated. A perisplenic collection was found in one patient and responded well to percutaneous drainage. Conclusions:   Proximal embolization of the splenic artery for severe splenic injury is highly successful in cessation of bleeding while preserving splenic architecture. There were minimal complications in this series demonstrated by clinical and Doppler examinations.     

Splenic preservation

The current principle of splenic preservation in both adults and children is now well accepted, and the reason for this is outlined. The surgical anatomy is briefly discussed and a method of handling the patient with splenic trauma is described. Splenic preservation is vital as regards protection of the child against infection, both in cases involving trauma and for other conditions previously treated by splenectomy.     

Splenic abscess

We present 7 cases of splenic abscess collected in our hospital from 1980 to 1988 as well as a review of 227 cases of the world literature. The signs and symptoms are nonspecific in all of them, fever being the most constant. Computed tomography scan followed by sonography were demonstrated to be the best methods of diagnosis. The treatment carried out on all of our patients was splenectomy followed by antibiotic coverage. Two of them died 15 days after the operation due to persistence of the septic state. In our review of the literature, we observe a rise in the population at risk for splenic abscess due to an increase in the use of immunosuppressive agents, to the higher survival of leukemic patients, and to the great incidence of drug abuse among others. Nevertheless, the advances in the use of sonography and computed tomography scan have made possible a more accurate diagnosis, therefore making possible an earlier treatment and a better prognosis. We believe that the treatment of choice is splenectomy with conservative treatment used only in specific cases where surgery represents a high risk for the patient.

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Resumen Presentamos 7 casos de absceso esplénico recolectados en nuestro hospital entre 1980 y 1988 y la revisión de 227 casos de la literatura mundial. Los signos y síntomas aparecieron como no específicos, siendo la fiebre el más constante. La tomografía computadorizada, seguida de la sonografía, demostraron ser los mejores métodos de diagnóstico. El tratamiento empleado en la totalidad de nuestros pacientes fue la esplenectomía seguida de cubrimiento antibiótico. Dos pacientes murieron después de la operación debido a persistencia del estado séptico. En nuestra revisión de la literatura observamos un incremento de la población en riesgo de desarrollar absceso esplénico por el aumento en el uso de agentes inmunosupresores, por la mayor tasa de sobrevida de pacientes con leucemia y por la alta incidencia de drogadicción. Sin embargo, los avances en el uso de la sonografía y de la tomografía computadorizada han hecho posible un diagnóstico más certero, y, por lo tanto, un tratamiento más temprano con mejor pronóstico. Creemos que el tratamiento de elección es la esplenectomía y que el tratamiento conservador sólo debe ser usado en casos específicos en los cuales la cirugía represente un elevado riesgo para el paciente.

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Résumé Nous présentons 7 cas d'abscès splénique colligés dans notre hôpital de 1980 à 1988 et la revue de 227 cas de la littérature mondiale. Les signes et symptômes ne sont jamais spécifiques, la fièvre étant le plus constant. La tomodensitométrie et la sonographie, dans cet ordre, se sont avérées les meilleures méthodes de diagnostic. Le traitement appliqué à tous nos patients a été la splénectomie suivie d'une couverture antibiotique. Deux d'entre eux sont morts 15 jours après l'opération à cause de la persistance de l'état septique. Dans la revue de la littérature, nous observons une hausse de la population à risque d'abscès splénique à cause de l'augmentation de l'emploi d'agents immunodépresseurs, du taux de survie plus grand des patients leucémiques et du rôle important des excès de drogue chez les autres. Néanmoins, les progrès de la sonographie et de la tomodensitométrie ont rendu possible un diagnostic plus sûr, amenant de ce fait à un traitement précoce et un pronostic meilleur. Nous pensons que le traitement de choix est la splénectomie. Le traitement conservateur doit être réservé uniquement aux cas où la chirurgie présente de gros risques pour le patient.

     

Splenic cysts

The treatment of splenic cysts is a difficult challenge to surgeons and physicians. This paper reviews the literature on splenic cysts, with special attention to the pathogenesis, diagnosis, and various options of surgical treatment. Splenic cysts are classified as primary or secondary cysts, according to the presence of an epithelial lining. The primary cysts are further subdivided as parasitic or non-parasitic. Secondary cysts are in most cases posttraumatic. Symptoms are usually correlated to the size of the cyst. Prior to surgery, imaging with ultrasound and computer tomography or magnetic resonance should be performed. A cyst puncture should be conducted for diagnostic purposes (amylase and bacteria) as well as to reduce the size of the cyst. Furthermore, the titer of Echinococcus and other biomarkers can be measured. Surgeons should make every possible effort to preserve splenic tissue and spleen-saving techniques with laparoscopic techniques are recommended.     

Splenic abscess

Splenic abscess is an unusual disease and may be present either as a localized area of infection in the spleen or as a part of generalized sepsis. There are no specific clinical findings for a splenic abscess; the symptoms and signs of sepsis should arouse a suspicion of splenic abscess. Computerized axial tomography (CAT) scan probably offers the most direct way of evaluating the spleen and making an early diagnosis. Although gram-positive cocci are most frequently reported in splenic abscesses, there is enough variation of organisms that specific combination of antibiotics cannot be recommended. Antibiotic selection should be based on positive blood cultures and intraoperative cultures. The preferred treatment is splenectomy, although occasionally external drainage may be required. A successful outcome is dependent on an early diagnosis and prompt treatment by splenectomy. When splenic abscess is part of an overall septic process, the prognosis is generally very poor.

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Resumen bsceso esplénico es una entidad rara y puede estar presente bien como un área localizada de infección en el bazo o como parte de una sepsis generalizada. No existen manifestaciones clínicas específicas en el absceso esplénico; los síntomas y signos de sepsis deben provocar la sospecha de un absceso esplénico. El examen con el escáner (TAC) probablemente provee la manera más directa de evaluar el bazo y de lograr un diagnóstico temprano. Aunque los cocos Gram positivos son informados con máxima frecuencia en los abscesos esplénicos, existe suficiente variedad de organismos en tal forma que no es posible recomendar una combination específica de antibióticos. La selection del antibiótico debe fundamentarse en hemocultivos positivos y en el resultado de los cultivos intraoperatorios. El tratamiento de electión es la esplenectomía, aunque ocasionalmente el drenaje externo puede ser requerido. El resultado exitoso del manejo depende del diagnóstico precoz y de pronto tratamiento mediante esplenectomía. Cuando el absceso esplénico hace parte de un proceso séptico general, el pronóstico generalmente es muy pobre.

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Résumé Les abcès de la rate représentent une affection rare; ils peuvent être isolés ou accompagnés d'une infection générale. L'abcès de la rate ne présente pas de symptômes ou de signes particuliers. On doit simplement l'envisager en présence de toute infection dont l'étiologie n'est pas reconnue. La tomodensitométrie représente la meilleure méthode d'exploration de la rate. Elle permet un diagnostic précoce. Bien que les cocci gram + soit le plus souvent à l'origine des abcès spléniques, le grand nombre de bactéries en cause ne permet pas l'emploi d'une combinaison d'antibiotiques spécifiques. L'antibiothérapie doit être sélective en se basant sur les germes découverts dans le sang ou au niveau de l'abcès.Le meilleur traitement est la splénectomie bien que parfois on doive se contenter d'un drainage externe. L'évolution de l'affection dépend de la précocité du diagnostic et de la promptitude de la splénectomie. Lorsque l'abcès splénique est constaté au cours d'une infection généralée, le pronostic est généralement très grave.

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Supported in part by the Veterans Administration.