Splenic Infarct
A splenic infarct is an area of tissue death within the spleen caused by interruption of its blood supply. Causes include emboli from the heart or aorta, blood clots in the splenic artery or vein, sickle cell disease, certain blood disorders, infections, vasculitis, and trauma. Many splenic infarcts are discovered when patients present with sudden upper left abdominal pain, while others are detected incidentally on imaging done for other reasons. Most uncomplicated infarcts heal with supportive care, but identifying the underlying cause is essential. Imaging—particularly CT and MRI—is central to diagnosis.
What is it?
The spleen receives most of its blood supply through the splenic artery, a major branch of the celiac trunk that arises from the abdominal aorta. The artery divides into smaller branches that supply different segments of the spleen. A splenic infarct is an area of tissue death within the spleen caused by sudden or significant interruption of this blood supply. The affected segment of the spleen loses its normal function, and over time the dead tissue is either reabsorbed by the body, replaced by scar tissue, or, less commonly, becomes complicated by bleeding, infection, or other problems.
Splenic infarcts can result from many different conditions, and identifying the underlying cause is an important part of evaluation. Embolic causes are among the most common, in which a small blood clot or other material travels from elsewhere in the body and lodges in the splenic artery or its branches. Common sources include atrial fibrillation, left-sided heart valve disease, infective endocarditis, ventricular thrombi (such as after a heart attack), atherosclerotic plaque in the aorta, and—less commonly—paradoxical emboli through cardiac shunts. Local blood clots within the splenic artery or vein (thrombosis) are another important cause and may develop in the setting of myeloproliferative neoplasms, inherited or acquired clotting disorders, pancreatitis, abdominal cancers, and other conditions.
Hematologic conditions are well-recognized contributors. Sickle cell disease can lead to recurrent splenic infarcts—particularly in childhood—and ultimately to functional asplenia. Other hemoglobinopathies, myeloproliferative neoplasms (especially with JAK2 mutations), and severe splenomegaly from various causes can also lead to infarction. Infections—including infective endocarditis, malaria, mononucleosis, sepsis, tuberculosis, and others—can produce splenic infarcts. Vasculitis (such as polyarteritis nodosa), connective tissue diseases, prior surgery or interventional procedures (including splenic artery embolization, which is sometimes performed intentionally for trauma or other reasons), and abdominal trauma can also cause splenic infarcts. In some patients, despite thorough evaluation, no specific cause is identified.
Many patients with splenic infarcts present with sudden upper left abdominal pain that may radiate to the left shoulder (a phenomenon called Kehr sign, related to diaphragmatic irritation). Other possible features include nausea, vomiting, low-grade fever, fatigue, and symptoms related to the underlying cause—such as palpitations in atrial fibrillation, fevers and chills in endocarditis, or systemic symptoms in vasculitis. Some splenic infarcts cause minimal symptoms and are discovered incidentally on imaging done for other reasons, while others are found during evaluation of unexplained pain, fever, or signs of widespread embolic disease. Less commonly, complications such as splenic rupture, hemorrhage, abscess formation, or pseudocyst formation can occur, particularly with very large or complicated infarcts.
Diagnosis combines clinical assessment, blood tests, and imaging. Blood tests often include a complete blood count, inflammatory markers, blood cultures (when infection or endocarditis is suspected), liver and kidney function, and assessment for clotting disorders. CT of the abdomen with intravenous contrast is the primary imaging test and typically shows characteristic findings, including a well-defined wedge-shaped or rounded area of reduced enhancement in the spleen that often points toward the splenic hilum. MRI with contrast can be useful in select cases, particularly when avoiding radiation or iodinated contrast is preferred. Ultrasound may identify infarcts but is generally less sensitive than CT. Echocardiography is often performed when an embolic source is suspected. Additional studies—such as Holter monitoring for arrhythmias, evaluation for thrombophilia, and tests for infection or vasculitis—are guided by the clinical picture.
Important to Know
Management of a splenic infarct involves both supportive care of the infarct itself and identification and treatment of the underlying cause. For most uncomplicated infarcts, the spleen tends to heal with conservative management, and the focus shifts to preventing future events.
Supportive care typically includes pain control, hydration, monitoring of vital signs and blood counts, and—in many cases—a period of hospitalization. Patients with mild symptoms and small, uncomplicated infarcts may be managed as outpatients in selected situations, while those with severe pain, large infarcts, signs of complications, or significant underlying conditions usually require inpatient care.
Identification and treatment of the underlying cause is essential. Embolic causes related to atrial fibrillation, heart valve disease, or other cardiovascular conditions are managed with anticoagulation, treatment of the underlying arrhythmia or valve disease, and consideration of additional procedures or surgery when appropriate. Infective endocarditis is managed with prolonged antibiotic therapy and—in selected patients—surgical valve replacement. Clotting disorders are managed with anticoagulation and evaluation for inherited or acquired thrombophilias, with longer-term decisions individualized based on the underlying condition. Hematologic conditions such as sickle cell disease, myeloproliferative neoplasms, and hemoglobinopathies are managed under specialized care, often with disease-specific therapies. Vasculitis, infections, and other underlying causes are treated according to standard principles for those conditions.
Complications of splenic infarct can include hemorrhage within or around the infarct, infection of the infarcted tissue (splenic abscess), pseudocyst formation, and—rarely—splenic rupture. These complications often require additional treatment, ranging from antibiotics and percutaneous drainage to interventional radiology procedures or splenectomy. Splenectomy is reserved for severe complications or specific scenarios in which spleen-preserving approaches are not feasible.
Patients who undergo total splenectomy require specific attention to infection prevention, including vaccinations against encapsulated bacteria (such as pneumococcal, meningococcal, and Haemophilus influenzae type b vaccines), antibiotic prophylaxis in selected patients, education about prompt evaluation of fevers, and consideration of travel-related risks. Patients with functional asplenia from chronic conditions such as sickle cell disease require similar preventive measures.
Follow-up imaging may be appropriate in selected patients to confirm healing and rule out complications. The frequency and type of follow-up are individualized based on the specific findings and overall clinical context.
Care is typically coordinated by primary care clinicians, hospitalists (during acute management), hematologists, cardiologists, infectious disease specialists, hepatobiliary or general surgeons, interventional radiologists, and other relevant providers. Imaging and laboratory findings are interpreted alongside the patient’s symptoms, examination, and broader clinical context rather than in isolation.
Patient education plays an important role. Understanding the underlying cause, adhering to anticoagulation or other long-term treatments, recognizing warning signs of complications or recurrent embolic events, and following up as recommended all contribute to better outcomes.
Red flag symptoms include sudden severe upper left abdominal pain (especially after trauma), lightheadedness or fainting, rapid heart rate, cool clammy skin or signs of shock, high fever with chills (which may suggest infection or abscess), severe shortness of breath, signs of stroke or other embolic events, severe weakness or bleeding, or sudden change in known abdominal symptoms. These warrant prompt or urgent medical evaluation, as they may indicate splenic rupture, abscess, recurrent embolic events, or other serious complications.