epiploic appendagitis of the fat adjacent the colon
splenomegaly (not usually painful but can cause discomfort and tenderness)
splenic rupture - this may be rapidly fatal
usually post-trauma
higher risk in those with splenomegaly
splenic infarct
rare cause of abdominal pain and may be the result of arterial or venous occlusion
often is the presenting complaint of an underlying condition
usually in a person with an underlying hematologic disorder (eg. sickle cell disease (SCD)), hypercoagulable state, blood-borne malignancy causing splenomegaly, blunt abdominal trauma, pancreatitis, compressive pancreatic masses, or embolic illness.
1/3rd have splenomegaly; 1/3rd have a fever; over half have a raised WCC; over 2/3rds have raised LDH;
splenic artery aneurysm with distended thin wall and impending rupture
rare, but a condition to consider in 2nd or 3rd TM of pregnancy, portal hypertension, liver transplant, pancreatitis, hypertension, atherosclerosis, Marfans, trauma, large vessel vasculitis, etc
prevalence of splenic artery aneurysm is 0.04% to 0.10% at arteriography and autopsy
50% of those that occur in pregnant women will rupture during pregnancy! Two-thirds of SAA rupture in the third trimester and typically in the last two weeks of pregnancy. 2)
accounts for about 60% of visceral arterial aneurysms (remainder are mainly renal artery aneurysms)
may present with episodic LUQ pains often lasting 24hrs +/- radiation to L shoulder
may be detected as a cystic mass near the pancreas on US if not obese, or CTKUB
early diagnosis with contrast CT is critical to manage prior to rupture
risk of rupture is 2% to 10% (much higher in pregnant patients)
intervention prior to rupture is usually recommended if either:
aneurysm size larger than 2 or 2.5 cm
growth of the aneurysm by 3 to 5 mm or more during surveillance regardless of initial size
symptomatic
women of childbearing age
portal hypertension
planned liver transplant
mortality of intervention options is said to be ~1% 3)
complications of intervention include postembolization syndrome, splenic infarction or abscess, and pancreatitis
ruptured splenic artery aneurysm - this may be rapidly fatal mortality is over 25% (maternal mortality due to SAA rupture increases up to 75%, and fetal mortality increases as high as 95%)
usually present in hypovolaemic shock with abdominal or chest pain and positive FAST US (DDx ruptured ectopic or spleen), but may also have haematuria
patients in shock needing massive blood transfusion to keep alive should probably go straight to theatre for surgical intervention rather than radiologic intervention
these are rare (0.1% of the population in autopsy studies), usually present in hypovolaemic shock with abdominal pain, but may also have haematuria or urinary obstruction
rupture occurs in 3-5% with these aneurysms and has a 10% mortality, thus rupture prevalence and mortality rates are much lower than with splenic artery aneurysms
mainly in those over 60yrs, 90% have hypertension
most younger patients are women and two-thirds have fibromuscular dysplasia 4)
indications for intervention for non-ruptured renal artery aneurysm:
size > 2cm
symptoms
refractory hypertension with significant renal artery stenosis or thromboembolism