Splenic Abscess in a German Sheperd

             Inga, a six year old intact female German Shepherd was presented three times in four weeks for gastric dilatation without volvulus, abdominal pain, lethargy, anorexia and frequent vomiting. The condition was relieved on one occasion by puncturing the stomach by a locum Vet and on the other two occasions by passing an orogastric tube and evacuating the gas. Abdominal palpation of the abdomen revealed splenomegaly and spleen of hard consistency. An ultrasonographical exam of the abdomen on the second visit revealed a hypoechoic pocket in the splenic parenchyma with minimal color flow on doppler. Hematology revealed regenerative anemia (RBC- 4.3 millions/microlitre; PCV -25.8 %; HGB - 8.5g/dL; % Reticulocytes - 2.7% ) pronounced leukocytosis (WBC - 35.04 thousands/ microlitre) with neutrophilia and band cells and thrombocytopenia (PLT - 70 thousand / microlitre). No significant changes were observed in any biochemical parameters except a high SDMA value (22µg/dL).

 

             

 Sonographic images showing the hypoechoic/anechoic pockets in the splenic parenchyma, spleenomegaly (extending till the Urinary bladder) and the distended stomach. 

        A splenic / gastric pathology was suspected from the above diagnostics and response to primary conservative medical management for 2 weeks. We decided to operate on Inga to perform a Splenectomy and Gastropexy if necessary. 

Anesthesia - 0.7 mg/kg Xylazine + 0.3 mg/kg Butorphanol for sedation. Induction using Propofol to effect and maintenance with Isoflurane . 

Surgery - An obvious midventral approach with a linear mid ventral incision from the xiphoid to umbilicus and later extended till the pubis to exteriorise the mass. The enlarged spleen was easily exteriorised but the tail of the spleen which had the mass had abundant adhesions arising from the omentum which made it laborious to exteriorise it. The splenic artery and vein, gastroepiploic artery     and vein were ligated and sealed with a bipolar vessel sealer and the healthy spleen transected at        the level of gastrosplenic ligament. The Omental adhesions were later scrapped off the splenic            mass with a surgical mop and gentle traction and exteriorised. The ventral branches of the left            gastroepiploic artery and the short gastric arteries are sealed nearer to the splenic mass and the        entire spleen was transected. 

Intraoperative Image showing the exteriorisation of spleen and the omental adhesions surrounding the splenic abscess.

Intraoperative image of the Pancreas showing the engorged Pancreatic artery post ligation of the splenic and gastroepiploic artery

Intraoperative videos depicting the omental adhesions around the abscess making it difficult to exteriorize the entire spleen

Postoperative video showing the lancing of splenic abscess 

Exploration of the abdominal viscera revealed no gross abnormalities in stomach, liver, intestines, kidneys. The pancreatic artery was found to be engorged which could be attributed to ligation of the gastroepiploic artery. Ovariohysterectomy was also performed as per owner’s request. The laparotomy was closed in a routine manner. 

The systolic blood pressure dropped to 90 mmHg post surgery and to 55 mmHg two hours post surgery despite administering colloidal drip. The mucus membranes turned paler on every subsequent examination over a period of one hour. The anesthetic recovery was also delayed. We decided to go ahead for blood transfusion the same day transfused one unit of blood. Inga found a spark of life with the blood and walked back to the car post transfusion! 

The recovery was uneventful despite the large incision and a long operative time. Ceftriaxone + Sulbactam was administered intravenously for 2 days post-op and later shifted on to oral Cefuroxime axetil for a week. Oral Carprofen and a combination of Trypsin, Bromelain and Rutoside was used for analgesia.

 

Discussion and Takeaways 

                Repeated bloating of the stomach hints at a possible splenic pathology.       

 

                A backup blood donor must preferably be present while performing a splenectomy. In this case, the capillary breeding from the omental adhesions and the huge volume of blood in the excised spleen ( weighing 1.9 Kilos along with the abscess) was the reason for acute blood loss and hypovolemic shock.     

                The etiology of this splenic abscess remains unclear. Splenic abscess are often sequelae of untreated splenitis and splenitis can either be due to Bacterial, Fungal or a protozoal origin. It is reported that the prognosis with bacterial or protozoal splenitis is generally better compared to that with fungal splenitis. Pus culture and sensitivity was not performed in this case but is advisable.     

                

                This goes unsaid, but blood pressure monitoring during and after anesthesia is vital and remains an underestimated aspect of anesthetic monitoring especially in surgeries expected to have high blood loss. 

Sequential Hematology Reports prior to and after Surgery. 

	15 Days prior to Surgery	7 days prior to Surgery	Pre-Surgery	15 Days Post Surgery
RBC (M/µL)	6.77	5.96	4.26	5.48
HGB (G/dL)	13.9	12.2	8.9	11.4
WBC (T/µL)	22.51	24.80	35.04	21.83
PLT (T/µL)	135	237	69	1124
Reticulocyte %	0.8	1.1	2.7	0.3%

                Complete splenectomy causes decrease in red blood cell values, even below physiological values. Total splenectomy leads to an increased number of circulating old red blood cells, this combined with severe reticulocytosis, leads to a high mean corpuscular volume values.

                Platelets count showed significant increase in completely splenectomized small and large dogs soon after operation. As about one third of total platelets are sequestered in spleen, also spleen is the site of platelet destruction, so after removal of spleen, thrombocytosis will develop. 

                It has been stated that splenectomy causes changes in the number of white blood cells with later leukocytosis. Decrease in apoptotic cell death rate following splenectomy is the most probable reason for this change.

                The spleen normally contains a reservoir of red blood cells (RBCs), has hematopoietic capabilities, has important phagocytic functions, and is helpful in maintaining immunocompetence; total splenectomy eliminates these beneficial actions. Partial splenectomy is preferred over total splenectomy when possible because it preserves splenic function but is technically and practically more challenging and time consuming.