Dalak kitleleri

Görüntüleme : CT or MRI can be used to evaluate splenic involvement by a systemic process or a focal lesion .

•*In suspected abscess or infarct, CT with contrast or MRI is appropriate; MRI can be performed without contrast if the patient has a contrast allergy or lacks venous access. On ultrasound, an abscess appears as a poorly defined hypoechoic or cystic lesion . On CT, abscesses are ill-defined and have low attenuation. Central, higher attenuation and/or ring enhancement can also be seen. Multiple lesions may represent microabscesses or disseminated fungal disease, especially in immunocompromised individuals or individuals with endocarditis . Infarction can cause areas of low attenuation with ring enhancement .

•*Solid masses include benign and malignant tumors and inflammatory lesions such as sarcoidosis . PET with 18F-fluorodeoxyglucose combined with CT (PET-CT) may be used to determine the likelihood of malignancy; PET-avid lesions are most likely to be malignant or to contain granulomas . In most types of lymphoma, PET-CT is typically used for staging and monitoring of disease response.

•*Cystic lesions include simple congenital cysts or post-traumatic pseudocysts, hemangiomas and other vascular lesions, and abscess or hydatid disease from echinococcus larva . Suspected hematomas in individuals with trauma or acute pain can be imaged using contrast-enhanced CT or MRI. By CT, they appear as high-density, non-enhancing collections of fluid and can be classified according to one of several grading scales

Simple cysts and hemangiomas appear as well-defined, hypoechoic lesions . Pseudocysts, which typically occur after trauma, may have calcified walls. For complex cysts, hemangiomas, or lymphangiomas, MRI may provide greater resolution and/or give greater confidence in the likely diagnosis. Hydatid disease from echinococcus larva can produce homogenous cysts or cysts with internal debris, calcifications, or inflammatory features; in some cases, small peripheral cysts can be seen .

 Biopsy of the spleen is not frequently performed due to its extensive vascularity and associated risk of bleeding. Splenic biopsy may be used in cases of isolated splenic lesions of unknown cause for which there is no other tissue more amenable to biopsy or if biopsies from other sites have been unrevealing [31]. It is generally done using ultrasound or CT guidance under controlled circumstances, with surgical support available in case emergency splenectomy due to bleeding is required.

 Tümör hücreleri ve metastazlar:

in a retrospective study of individuals who underwent diagnostic splenectomy for splenomegaly, approximately half had malignancy as a cause, with lymphoma as the most common diagnosis.

In some individuals with solid tumors who have known intraabdominal metastasis affecting other organs, it may not be necessary to establish a definite pathologic diagnosis of a splenic lesion. However, an isolated splenic lesion in an individual who otherwise has limited disease may warrant biopsy or diagnostic splenectomy.

Angiosarcoma is a rare, aggressive, highly metastatic malignancy that arises from the endothelial lining of splenic blood vessels . Resection may be possible for isolated lesions; metastatic disease is treated with chemotherapy.

Kistik lezyonlar : 

Non-parasitic splenic cysts are rare, and there is no evidence-based information regarding their optimal surgical management . In most cases, the cyst(s) can be monitored with periodic imaging to determine whether they are stable or enlarging. Some splenic cysts may remain unchanged for many years, while others may enlarge slowly, enlarge to massive proportions, rupture, bleed, or become secondarily infected.

For those with symptomatic cysts or cysts that are enlarging over time, a number of radiologic and surgical procedures are available for diagnosis . Available treatment options for those with non-parasitic cysts include percutaneous procedures (eg, biopsy, aspiration, drainage) or more direct surgical interventions such as decapsulation/cyst wall unroofing or partial or total splenectomy. Only splenectomy provides diagnostic certainty, but this is rarely clinically justified.

Kalsifikasyon and granulomas — Calcification may be noted in the splenic parenchyma or vasculature. A number of conditions may cause calcification, including phleboliths, splenic artery aneurysm, sickle cell disease (SCD), tumors (eg, hemangioma, hemangiosarcoma, lymphoma), and infections (eg, histoplasmosis, brucellosis, echinococcosis, candidiasis, tuberculosis)

Splenic artery calcification can occur in the setting of aging, systemic disorders (eg, diabetes mellitus), or splenic artery aneurysms  

Splenic granulomas can be caused by infection  or infiltrative diseases such as sarcoidosis; evaluation is similar to granulomas of the liver.

Splenic artery aneurysm: SAAs can present with abdominal pain or discomfort, left shoulder pain, nausea, or they may be detected incidentally on plain radiographs or abdominal imaging performed for another reason. 

SAAs are clinically important because of the possibility of rupture, which is associated with a high mortality rate, especially during pregnancy and/or in patients with portal hypertension

Optimal management has not been established. Options for unruptured SAAs include serial monitoring, surgical resection with vascular reconstruction, stenting of the vessel, or endovascular coil/glue ablation techniques . Treatment is generally recommended to reduce the risk of rupture, especially for individuals with symptomatic disease, individuals who are pregnant, those with an SAA larger than 2 cm in diameter, or those with an expanding aneurysm.  

Abscess and infarction :  Splenic abscess is an uncommon infection that typically results from endocarditis or another source of hematogenous seeding such as pneumonia, gastrointestinal perforation, or arteriovenous malformation

Apse için Risk faktörleri:  endocarditis ,diabetes mellitus, hematologic malignancy, pancreatic disease , prolonged febrile neutropenia , HIV infection and a history of pulmonary tuberculosis 

Risk factors for infarction : 

•Splenomegaly, especially due to hematologic conditions. 

•Septic emboli (eg, in endocarditis)

•Thromboemboli associated with atrial fibrillation, valvular heart disease, or an atrial septal defect 

•Sickle cell disease (SCD) or sickle cell trait 

•Prothrombotic states such as antiphospholipid syndrome (APS), heparin-induced thrombocytopenia (HIT), infections, or cancer . Rarely, Epstein Barr virus (EBV) infection has been associated with splenic infarct, and there are multiple reports of splenic infarct in association with COVID-19 

Anticoagulation – Treatment of splenic infarction depends upon the underlying cause and usually involves anticoagulation.

Anticoagulation is generally appropriate if the underlying cause is a hypercoagulable state such as antiphospholipid syndrome (APS), heparin-induced thrombocytopenia (HIT), a cardioembolic source, malignancy, or an inherited thrombophilia. It is appropriate to consider these conditions and perform appropriate evaluations in an individual with otherwise unexplained splenic infarction.

•If an underlying cause cannot be identified (ie, truly cryptogenic infarction), anticoagulation is likely to be prudent.(tedbirli,ihtiyatlı)

Anticoagulation is generally well tolerated; however, a case of splenic rupture following anticoagulant has been described . ( Atrumatic rupture )

•Anticoagulation generally is not used in splenic infarction due to vaso-occlusion in SCD. Therapies directed at vaso-occlusion may be indicated, such as oxygenation and/or transfusion.