Z90.81 Acquired absence of spleen

Name of the Condition

• Acquired absence of spleen

Summary

Acquired absence of spleen is a condition where the spleen is no longer present due to surgical removal or other medical interventions. This can result from procedures performed to treat underlying conditions or address complications related to the spleen.

Causes

The primary cause of acquired absence of spleen is surgical removal, often performed to treat conditions such as trauma, splenic rupture, malignancy, or severe infections. It may also result from organ donation or complications of diseases that necessitate splenectomy.

Risk Factors

• History of splenic trauma or injury.
• Underlying conditions requiring splenectomy, such as cancer or severe infections.
• Participation in organ donation programs.

Symptoms

Symptoms may include increased susceptibility to infections, particularly encapsulated bacteria, and potential complications related to the loss of splenic function. Some individuals may experience no direct symptoms, while others may have signs of immunological or hematological changes.

Diagnosis

Diagnosis involves reviewing the patient’s medical history, including prior surgeries or injuries. Imaging studies (e.g., CT scans, ultrasounds) or physical examinations may confirm the absence of the spleen. Laboratory tests can assess related functional impacts, such as changes in blood cell counts.

Treatment Options

Treatment focuses on managing symptoms and preventing complications, such as infections. This may include vaccinations, antibiotics, and monitoring for signs of infection or other related conditions.

Prognosis and Follow-Up

The prognosis varies depending on the underlying reason for splenectomy and the individual’s overall health. Regular follow-up is important to monitor for infections or other complications and to ensure appropriate preventive measures are in place.

Complications

Complications may include increased risk of severe infections, particularly from encapsulated bacteria, and potential issues with blood cell regulation. Long-term monitoring for these risks is often necessary.

Lifestyle & Prevention

Lifestyle adjustments may include adhering to vaccination schedules, practicing good hygiene, and avoiding activities that increase infection risk. Preventive measures, such as prophylactic antibiotics, may be recommended in some cases.

When to Seek Professional Help

Seek medical attention if experiencing signs of infection, such as fever, chills, or unexplained illness, especially if the spleen has been removed. Prompt evaluation is important to address potential complications.

Tips for Medical Coders

When coding for acquired absence of spleen, use ICD-10-CM code Z90.81. Ensure documentation supports the absence of the spleen due to acquired causes, such as surgery or trauma, and differentiate from congenital absence. Verify that the code is appropriately assigned based on the patient’s medical history and clinical findings.