SIR 2024
Gastrointestinal Interventions
Lisa Ho, MD
Associate Professor
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Paul Suhocki, MD
Associate Professor of Radiology
Duke University Medical Center
Disclosure information not submitted.
Danielle Kruse, MD
Assistant Professor
Duke University Medical Center
Disclosure information not submitted.
Benjamin Wildman-Tobriner, MD
Assistant Professor
Duke University Medical Center
Disclosure information not submitted.
1. Understand appropriate indications for splenic biopsies and aspirations/drainages.
2. Understand risks associated with splenic interventions and how to mitigate them.
3. Describe appropriate technique and best practices.
Background:
Most splenic findings are incidental and benign with PET/CT and MRI often able to confirm benign diagnoses. Indeterminate lesions may require image-guided biopsy and strategies to minimize procedural risk are useful. Additionally, the spleen may harbor infection necessitating image-guided treatment. This presentation discusses appropriate indications for proceeding with splenic intervention, what techniques maximize chances of success, and how to minimize complications.
Clinical Findings/Procedure Details:
Cystic lesions are almost always benign and no biopsy needed {1}. Solid benign lesions have well-defined borders, progressive enhancement, lack of uptake on PET/CT, and distinctive MRI features that characterize hemangiomas (high T2 signal), hamartomas ("stealthy"), and sclerosing angiomatoid nodular transformation (low T2 due to hemosiderin). Solid malignant lesions, most commonly lymphoma and metastases, are often FDG avid {1,2}. Image-guided biopsy can be safely performed with ≤ 18-gauge needles, peripheral approaches, and avoidance of normal parenchyma. Complications: 1-2% risk of hemorrhage and rarely pneumothorax {3}. Needle track plugging with Gelfoam reduces bleeding risk {4,5}.
Image-guided aspiration/drainage of pyogenic and amebic abscesses of the spleen is optimized by peripheral approaches, avoidance of normal parenchyma, ≤ 18-gauge needle, and ≤ 10 Fr drain. Rare complications: hemorrhage, pneumothorax, empyema {6,7}. Fungal infections often form microabscesses which respond to medical therapy {8}. Echinococcal infections may be treated with image-guided aspiration and injection with scolicidal agents, with risks of recurrent infection, peritoneal dissemination, and anaphylaxis {9}.
Conclusion and/or Teaching Points:
Cystic lesions are almost always benign and can be left alone.
MRI and PET/CT can be diagnostic and may obviate the need to biopsy some solid masses.
Safety for splenic biopsy is optimized by using ≤ 18-gauge needles, a peripheral approach, and avoiding normal parenchyma.
Pyogenic or amebic abscesses can be aspirated and drained safely using ≤ 18-gauge needles or ≤ 10 Fr drains with a peripheral approach and avoid traversing normal parenchyma.
Image-guided treatment of echinococcal abscess: high risk of recurrence, peritoneal seeding, anaphylaxis.