Etiology and Management of Splenic Infarction and Splenic Vein Thrombosis: Unusual Causes of Abdominal Pain in Sickle Cell Trait Patient

Abstract 4775

Abdominal pain is a common complaint among all ages of patients. Splenic infarction and splenic vein thrombosis are rare causes of abdominal pain, usually presenting as left-sided abdominal pain associated with fever, nausea or vomiting, and elevated white blood cell count. CT scan is currently the preferred diagnostic test. Once the diagnosis is identified, the etiology of splenic infarction and/or splenic vein thrombosis should be elicited.

Retrospective chart review was conducted in all the patients admitted to our hospital from 2000 till now. Four cases of splenic infarction and/or splenic vein thrombosis were identified (4 males, average age of 45 years, range from 38 to 52 years). Case 1, a 45-year-old male with sickle cell trait (HbS of 38.7%), presented with left upper quadrant pain after 5-hour flight and alcohol binge prior to flight. CT showed splenic infarct and splenic vein thrombosis. Patient received aggressive hydration, abdominal pain resolved and was discharged home. Case 2, a 52-year-old male with renal cell carcinoma, presented with generalized abdominal pain. CT showed splenic infarct. Patient was treated with Coumadin, and routinely followed-up at Oncology clinic. Case 3, a 38-year old male with alcohol abuse and chronic pancreatitis, presented with recurrent abdominal pain and hypersplenism. CT showed splenic vein thrombosis, and the patient underwent splenectomy. Case 4, a 45-year-old male with acute pancreatitis, presented with epigastric pain. CT showed splenic vein thrombosis, and the patient was treated with Coumadin.

It is important to reveal the underlying causes for splenic infarction and/or splenic vein thrombosis. Splenic infarction can occur in a variety of settings, including hemoglobinopathy (especially sickle cell disease), hypercoagulable state, embolic disease, malignancy and myeloproliferative disorders. Pancreatitis and pancreatic cancer are the most common causes of splenic vein thrombosis. In general, splenic infarction and/or splenic vein thrombosis can be managed safely with medical treatment, including hydration, oxygenation and pain management. Coumadin can be considered in cancer patients with splenic infarction and in patients with splenic vein thrombosis. Splenectomy is indicated in patients with hypersplenism, splenic sequestration crisis, splenic abscess, splenic rupture, and massive splenic infarction.

Splenic infarction in sickle cell disease is usually small and repetitive, leading ultimately to autosplenectomy. Splenic infarction in sickle cell trait is rare. High altitude, vigorous exercise, airplane flight, coexistence with thalassemia or hereditary spherocytosis or severe pyruvate kinase deficiency, can precipitate infarction. Interestingly in our first case, the patient with sickle cell trait developed splenic infarction and non-occlusive thrombus in the distal splenic vein after 5-hour flight. It is possible that the hypoxia associated with the commercial flight caused conformational changes in sickle cells, leading to red blood cells sluggish in the splenic red pulp, and eventually leading to splenic infarction. The alcohol binge resulted in dehydration and hemostasis, leading to splenic vein thrombosis, further perpetuating the vicious cycle. Therefore, we recommend adequate hydration and in-flight oxygen supplementation for sickle cell trait patients taking airplane flight. Further studies need to be done to confirm our hypothesis.