appendicitis & spleen Flashcards
rate of postop abscess formation after complicated/perforated appy?
10-20%
appendiceal mass 3 cm on appendectomy for presumed appendicitis
> 2cm should be treated as ca; do hemicolectomy with nodal resection (onc resection)
asx simple splenic cyst mgmt
no size cute off; leave alone if sx
BTK “consider 5 cm”
sx simple splenic cyst mgmt
fenestrate if very close to capsule
partial splenectomy if >1/3 spleen exists
full splenectomy if <1/3 spleen exists (functional loss)
unroof and aspirate is too high recurrence
US and splenic anatomy
not great… need a CT scan (I.e. for abscess)
Sequestration crisis
in sickle cell disease - lethargy, LUQ pain, lightheaded, tachy, hypotensive.
anemic.
tx: supportive care and transfusions as needed, with decision regarding splenectomy.
splenic aa aneurysm surgical indication
pregnancy or > 2cm
(endovascular coil or surgery if too close to hilum)
splenic aa aneurysm CT scan finding
double rupture!
G6PD triggers
Recent infection»> sulfonamides, fava beans, antimalarials, and nitrofurantoin
hereditary spherocytosis surgical indication
splenectomy at 6 YO
brings up Hgb by 3 g/dL
why cholecystectomy with splenectomy in 6YO spherocytosis
bilirubin stones usually formed
elliptocytosis
similar to spherocytosis, but less common
spectrin & protein 4.1 deficit
\splenic opsonization proteins
Tuftsin (phagocytosis function) and Properdin (complement pathway) peptides
post splenectomy smear
Howell Jolly bodies (basophilic nuclear remnants of the cells that don’t get filtered out by the spleen), Pappenheimer bodies (Fe), target cells (immature RBC), heinz body (denatured Hgb), Spur cell (deformed membrane)
how to identify accessory spleen
tagged RBC study = Tech-99 nanocolloid scintigraphy
MC location for accessory spleen
hilum
splenorenal and gastrosplenic ligament contents
splenorenal: pancreatic tail and splenic vessels
gastrosplenic: short gastrics (MC bleeding after splenectomy) and gastroepiploics
where do splenic aa and vein run compared to pancreas
Splenic artery is found SUPERIOR to the pancreas; vein runs POSTERIOR to pancreas and INFERIOR to artery
hereditary spherocytosis defect, inheritance
AD, spectrin protein
TTP HUS defect
ADAMTS13 defect
metalloproteinase vWF cleaving protein… HUGE clots lead to tpenia which leads to bleeding !!! fs
needs plasmapharesis wa
ITP defect
2b3a and 1a2a glycoprotein Ab’s made in the spleen
ITP mgmt
IVIG and steroids
splenectomy If recurs. – good response to steroids = good response to splenectomy
MC indication for splenectomy
- TRAUMA
- ITP
far down: TTP
when to transfuse in ITP?
after artery is clamped (splenectomy)
PK deficiency and anemia/thrombocytopenia
congenital hemolytic anemia from glucose metabolism issue
Tx: splenectomy reduces transfusion requirements
MC splenic tumor benign and overall
hemangioma (resect if sx only)
MC splenic non-blood tumor malignant
angiosarcoma (vinyl chloride and thorium dioxide)
high mortality… resect if able
MC OVERALL malignant splenic tumor
Nonhodgkins lymphoma = MC CLL
splenectomy if huge spleen; needs chemotherapy after staging
wandering spleen dx and tx
presents as torsion
RLQ CT/US failure fusion of dorsal mesogastrium
lack of splenic ligaments
splenopexy if no infarct
otherwise splenectomy
postop LUQ fluid collection after splenectomy?
panc leak; perc drainage and send for amylase
AAST splenic injury grades
I: Lac of capsule, < 1cm parenchymal depth
II: lac with 1-3 cm parenchyma, hematoma 10-50% of surface area
III: laceration > 3 cm parenchyma or involves trabecular vessels
Hematoma > 50% surface area or expanding, or any ruptured hematoma
IV: Lac involving segmental or hilar vessels producing major devascularization > 25% spleen
V: Lac causing completely shattered spleen
Hilar vascular injury which devascularized spleen
mgmt of splenic injury based off of grading
IV and V = angioembolization
opsi (overwhelming post splenectomy infection) bugs
S. pneumo > N. meningitidis, H. flu
OPSI ppx in kids < 10 YO after splenectomy
wait for at least 6YO to get vaccinated but still need to give 6 mo of Augmentin as ppx
appendicitis first sx
anorexia
appendicitis WBC
can be normal
appendicitis CT scan findings
diameter > 7 cm, wall > 2mm, fat stranding, no rectal contrast in lumen
appendicitis presentation in pregnancy
MC cause of pain in 1st trimester
MC occurence in 2nd trimester
most likley to perf to 3rd trimester
what improves intraabdominal abscess formation rates after perf appy
converting to OPEN (not drain placement) 2018 Cochrane review
lap positioning preg appy
side bump
Veress Palmars point
5 mm trocar RUQ
Target and triangulate once ID’d appy
contraindication to CRS/HIPEC?
extraabdominal mets.
what will a coombs test distinguish between?
TTP and Evans (ITP+IAHA)
post splenectomy sepsis aabx
IV vanc/Rocephin or
IV Vanc/cefotaxime
MC variant of for splenic vasculature?
short splenic trunk with 6-12 long branches into the spleen
what veins dilate (varices) after splenic vein thrombus?
short gastrics, gastroepiploics, and coronary vein (feeds directly from cardia to the PV)….
PV, SMV, IMV are all patent/not an issue
red pulp vs white pulp
red: filter RBC; thin walled sinusoids separated by cords of Red cells
white: immune… B cell follicles and periarterial lymphatic sheath PALS T cells
functions of spleen
- store plt
- filter out senescent rBC
- PIT RBC by removing intracellular products
- immune
- opsonization tuftsin/properdin
howell jolly body
nuclear remnants that aren’t filtered out… =damaged spleen
pappenheimer body
iron deposits left in RBCs, flecks
target cell
immature RBC released by spleen
heinz body
intracellular denatured Hgb in RBC
spur cell
deformed membrane of RBC
only absolute contraindication to splenectomy
cirrhosis with portal HTN
ttp hus sx
fat rn
fever
anemia
thrombocytopenia
renal failure
neurologic ams
IgM production in spleen
LARGEST Produced of IgM in the body
largest concentration of lymphoid tissue in the body
SPLEEN
B-thalassemia
MC … major: both chains, minor: 1 chain (asx)
B-thal tx
splenectomy if splenomegaly (may decrease hemolysis and transfusion requirement)
B-thal MC reason for death
hemosiderosis … in teens
feltys syndrome
RA
hepatomegaly
splenomegaly
pancytopenia
tx: methotrexate (control RA) »_space;> splenectomy if splneomegaly is symptomatmic
MC bug in splenic abscess
Strep
