appendicitis & spleen

Question 1

rate of postop abscess formation after complicated/perforated appy?

Answer 1

10-20%

Question 2

appendiceal mass 3 cm on appendectomy for presumed appendicitis

Answer 2

> 2cm should be treated as ca; do hemicolectomy with nodal resection (onc resection)

Question 3

asx simple splenic cyst mgmt

Answer 3

no size cute off; leave alone if sx
BTK “consider 5 cm”

Question 4

sx simple splenic cyst mgmt

Answer 4

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

Question 5

US and splenic anatomy

Answer 5

not great… need a CT scan (I.e. for abscess)

Question 6

Sequestration crisis

Answer 6

in sickle cell disease - lethargy, LUQ pain, lightheaded, tachy, hypotensive.
anemic.

tx: supportive care and transfusions as needed, with decision regarding splenectomy.

Question 7

splenic aa aneurysm surgical indication

Answer 7

pregnancy or > 2cm
(endovascular coil or surgery if too close to hilum)

Question 8

splenic aa aneurysm CT scan finding

Answer 8

double rupture!

Question 9

G6PD triggers

Answer 9

Recent infection»> sulfonamides, fava beans, antimalarials, and nitrofurantoin

Question 10

hereditary spherocytosis surgical indication

Answer 10

splenectomy at 6 YO
brings up Hgb by 3 g/dL

Question 11

why cholecystectomy with splenectomy in 6YO spherocytosis

Answer 11

bilirubin stones usually formed

Question 12

elliptocytosis

Answer 12

similar to spherocytosis, but less common

spectrin & protein 4.1 deficit

Question 13

\splenic opsonization proteins

Answer 13

Tuftsin (phagocytosis function) and Properdin (complement pathway) peptides

Question 14

post splenectomy smear

Answer 14

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)

Question 15

how to identify accessory spleen

Answer 15

tagged RBC study = Tech-99 nanocolloid scintigraphy

Question 16

MC location for accessory spleen

Answer 16

hilum

Question 17

splenorenal and gastrosplenic ligament contents

Answer 17

splenorenal: pancreatic tail and splenic vessels
gastrosplenic: short gastrics (MC bleeding after splenectomy) and gastroepiploics

Question 18

where do splenic aa and vein run compared to pancreas

Answer 18

Splenic artery is found SUPERIOR to the pancreas; vein runs POSTERIOR to pancreas and INFERIOR to artery

Question 19

hereditary spherocytosis defect, inheritance

Answer 19

AD, spectrin protein

Question 20

TTP HUS defect

Answer 20

ADAMTS13 defect

metalloproteinase vWF cleaving protein… HUGE clots lead to tpenia which leads to bleeding !!! fs

needs plasmapharesis wa

Question 21

ITP defect

Answer 21

2b3a and 1a2a glycoprotein Ab’s made in the spleen

Question 22

ITP mgmt

Answer 22

IVIG and steroids
splenectomy If recurs. – good response to steroids = good response to splenectomy

Question 23

MC indication for splenectomy

Answer 23

1. TRAUMA
2. ITP

far down: TTP

Question 24

when to transfuse in ITP?

Answer 24

after artery is clamped (splenectomy)

Question 25

PK deficiency and anemia/thrombocytopenia

Answer 25

congenital hemolytic anemia from glucose metabolism issue Tx: splenectomy reduces transfusion requirements

Question 26

MC splenic tumor benign and overall

Answer 26

hemangioma (resect if sx only)

Question 27

MC splenic non-blood tumor malignant

Answer 27

angiosarcoma (vinyl chloride and thorium dioxide) high mortality... resect if able

Question 28

MC OVERALL malignant splenic tumor

Answer 28

Nonhodgkins lymphoma = MC CLL splenectomy if huge spleen; needs chemotherapy after staging

Question 29

wandering spleen dx and tx

Answer 29

presents as torsion RLQ CT/US failure fusion of dorsal mesogastrium lack of splenic ligaments splenopexy if no infarct otherwise splenectomy

Question 30

postop LUQ fluid collection after splenectomy?

Answer 30

panc leak; perc drainage and send for amylase

Question 31

AAST splenic injury grades

Answer 31

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

Question 32

mgmt of splenic injury based off of grading

Answer 32

IV and V = angioembolization

Question 33

opsi (overwhelming post splenectomy infection) bugs

Answer 33

S. pneumo > N. meningitidis, H. flu

Question 34

OPSI ppx in kids < 10 YO after splenectomy

Answer 34

wait for at least 6YO to get vaccinated but still need to give 6 mo of Augmentin as ppx

Question 35

appendicitis first sx

Answer 35

anorexia

Question 36

appendicitis WBC

Answer 36

can be normal

Question 37

appendicitis CT scan findings

Answer 37

diameter > 7 cm, wall > 2mm, fat stranding, no rectal contrast in lumen

Question 38

appendicitis presentation in pregnancy

Answer 38

MC cause of pain in 1st trimester MC occurence in 2nd trimester most likley to perf to 3rd trimester

Question 39

what improves intraabdominal abscess formation rates after perf appy

Answer 39

converting to OPEN (not drain placement) 2018 Cochrane review

Question 40

lap positioning preg appy

Answer 40

side bump Veress Palmars point 5 mm trocar RUQ Target and triangulate once ID'd appy

Question 41

contraindication to CRS/HIPEC?

Answer 41

extraabdominal mets.

Question 42

what will a coombs test distinguish between?

Answer 42

TTP and Evans (ITP+IAHA)

Question 43

post splenectomy sepsis aabx

Answer 43

IV vanc/Rocephin or IV Vanc/cefotaxime

Question 44

MC variant of for splenic vasculature?

Answer 44

short splenic trunk with 6-12 long branches into the spleen

Question 45

what veins dilate (varices) after splenic vein thrombus?

Answer 45

short gastrics, gastroepiploics, and coronary vein (feeds directly from cardia to the PV).... PV, SMV, IMV are all patent/not an issue

Question 46

red pulp vs white pulp

Answer 46

red: filter RBC; thin walled sinusoids separated by cords of Red cells white: immune... B cell follicles and periarterial lymphatic sheath PALS T cells

Question 47

functions of spleen

Answer 47

1. store plt 2. filter out senescent rBC 3. PIT RBC by removing intracellular products 4. immune 5. opsonization tuftsin/properdin

Question 48

howell jolly body

Answer 48

nuclear remnants that aren't filtered out... =damaged spleen

Question 49

pappenheimer body

Answer 49

iron deposits left in RBCs, flecks

Question 50

target cell

Answer 50

immature RBC released by spleen

Question 51

heinz body

Answer 51

intracellular denatured Hgb in RBC

Question 52

spur cell

Answer 52

deformed membrane of RBC

Question 53

only absolute contraindication to splenectomy

Answer 53

cirrhosis with portal HTN

Question 54

ttp hus sx

Answer 54

fat rn fever anemia thrombocytopenia renal failure neurologic ams

Question 55

IgM production in spleen

Answer 55

LARGEST Produced of IgM in the body

Question 56

largest concentration of lymphoid tissue in the body

Answer 56

SPLEEN

Question 57

B-thalassemia

Answer 57

MC ... major: both chains, minor: 1 chain (asx)

Question 58

B-thal tx

Answer 58

splenectomy if splenomegaly (may decrease hemolysis and transfusion requirement)

Question 59

B-thal MC reason for death

Answer 59

hemosiderosis ... in teens

Question 60

feltys syndrome

Answer 60

RA hepatomegaly splenomegaly pancytopenia tx: methotrexate (control RA) >>> splenectomy if splneomegaly is symptomatmic

Question 61

MC bug in splenic abscess

Answer 61

Strep