E2- Spleen and pancreas Flashcards
What attaches the spleen to the stomach?
gastrosplenic ligament
Blood flow into the spleen?
celiac a. to splenic a.
Blood flow out of spleen?
splenic v. to gastrosplenic v. to portal v.
Splenic white pulp Vs red pulp
white pulp- nodular lymphoreticular tissue: site of immune response
red pulp- venous sinuses: stores RBCs/traps antigens
Should we worry about siderotic plaques?
NO- non pathologic
pale yellow/rust color- Ca/iron deposits
Should we worry about ectopic splenic tissue?
NO- non pathogenic
splenosis- usually from seeding of cells after sx/trauma, tiny nodules sitting in omentum near spleen
accessory spleen- incidental congenital issue, bigger than a nodule
T/F: we need our spleen to survive
FALSE- we do not need it
What is stored in the spleen?
10-20% of RBCs and 30% platelets
What cells mature in the spleen?
RBCs
Senescent/sick RBC removal
become non pliable and cant squeeze through pores of splenic sinuses = rupture or they are phagocytized
filters
T/F: Hematopoeisis in the spleen is active during fetal development
TRUE
How does the spleen help in immune function?
removal of poorly opsonized bacteria (better than liver)
Causes of splenomegaly
(symmetric enlargement)
drug induced: thiopental and acepromazine- 5-40% of blood can be sequestered in spleen during anesthesia, propofol=minimal effects
congestion (torsion)
infiltrative diseases
immune mediated dz
Causes of splenic mass
(asymmetrical enlargement)
neoplasia
hematoma
nodular hyperplasia/EMH
trauma ► splenosis
abscess
Splenic torsion is most common with ____
GDV
Splenic torsion from stretching of ____ during previous GDV or trauma
gastrosplenic ligament
What dog breeds are predisposed to splenic torsion?
large/giant breed dogs
great dane
greater swiss mountain dog
german shepherd
english bulldog
Clinical signs of acute splenic torsion
acute abdomen- similar to GDV or BECAUSE OF GDV
acute abdominal pain/shock
abd distension
cardiovascular collapse
dysrhythmias
DIC
Clinical signs of chronic splenic torsion
vague/intermittent signs for up to 2 weeks
vomiting/diarrhea
weakness/depression
anemia
hematuria/hemoglobinuria
PU/PD
How do we diagnose splenic torsion? what is the best dx method?
rads
- mid-abdominal mass
- abdominal effusion
- gas bubbles in spleem
- C-shaped spleen
Ultrasound*** best method
- mottled/diffuse hypoechoic areas
- intralumunal echogenic densitites in veins
- no flow in splenic vessels
CT scan
How do we stabilize P pre-op for splenic torsion?
fluids- end point resuscitation
transfusion
antibiotics
What is the treatment for splenic torsion?
Exploratory Laparotomy***** splenectomy
How can we prevent a splenic torsion?
gastropexy- at risk breed for GDV or to address GDV
What is VERY important to remember when you are removing the spleen?
DO NOT DEROTATE IT
Why cant we derotate the spleen prior to splenectomy?
spleen will release free radicals and could lead to DIC
Ideally we submit the spleen for ____ assessment to ensure no underlying pathology
histopathologic
T/F: neoplasia is a cause of splenic torsion
FALSE- neoplasia is NOT a cause of splenic torsion = not found in any case
T/F: splenic infarction is common
FALSE- RARE- can often see infarcted areas on abdominal US
T/F: splenic infarction requires surgery
FALSE: No, dont race to sx bc usually something systemic needs to be sorted out
renal disease, hyperadrenocorticism- cushings, neoplasia, DIC, heart disease
Splenic torsion can look like what on a ultrasound?
mass effect- devascularized area may turn into hematoma
Nodular splenic hyperplasia = sites of _____
extramedullary hematopoiesis
single or multiple SUBSCAPLULAR nodules
Very common***
Diagnosis of nodular hyperplasia of the spleen?
dx dilemma- can look like cancer
***FNA/Cytology = poor sensitivity***
Splenic nodular hyperplasia is typically asymptomatic but what may happen?
could rupture causing hemoabdomen
Are splenic nodules usually benign or neoplastic?
- 5% patients had benign splenic lesions = most commonly benign
- 5% had malignant neoplasia
How is splenic nodular hyperplasia usually found?
incidentally- non ruptured splenic masses or nodules w/o associated hemoperitoneum = most commonly benign!
What can cause splenic trauma?
blunt force (HBC/falls/dog attack)- ruptures capsule and parenchyma
What type of management is preferred and successful for splenic trauma?
conservative management
compression bandage= controversial but this is the time to use it (belly band)
supportive care and transfusion PRN
In splenic trauma can we just do a partial splenectomy?
can be considered if possible but in at risk breeds (labs/golden/GSD) please remove ALL spleen- dont leave any behind
T/F: autotransplantation doesn’t really work consistently
TRUE
Splenic neoplasia Ddx in dogs
Hemangiosarcoma (HSA)
Sarcomas
hemangioma
lymphosarcoma
Splenic neoplasia Ddx in cats
Mast Cell Tumor = Most Common
hemangiosarcoma
lymphoma
Splenic neoplasia Rule of 2/3rds
2/3rds of dogs w/ a splenic mass will have malignancy
2/3rds of those malignancies will be hemangiosarcoma (HSA)
66.6%
Risk factors of hemangiosarcoma in spleen
age- older
>/= 21kg
breeds: GSD, labs, Goldens, poodles
presence of hemoperitoneum
presence of hemoperitoneum with splenic tumor means ___% chance of malignancy
>80%
Chances of splenic neoplasia in small breed dogs?
50:50 split benign vs malignant
wheaten terriers predisposed
hemoperitoneum NOT associated w/ malignancy
What is the benign splenic mass to mass size ratio?
bigger the mass, (the better) more likely benign
Splenic hemangiosarcoma prognosis
Poor :(
***in nearly ALL cases microscopic metastasis is present at the time of diagnosis***
What does Cav recommend with splenic hemangiosarcoma?
careful staging pre-op
client communication- must know survival stats!
sx not recommended when: visible metastasis, very sick dogs, owner not informed
Splenic hemangiosarcoma prognosis with alternative therapies
C versicolor mushroom (turkey tail)- significantly delayed metastasis
eBAT- bispecific urokinase angiotoxin designed to target EGFR
Two techniques to consider for splenectomy
ligation of individual hilar vessels- preferred
ligation of the splenic and short gastric a.
Splenectomy: Ligation of individual hilar vessels
preferred
preserves branches to pancreas and stomach
time consuming to do by hand
less risk of PO hemorrhage
Splenectomy: ligation of the splenic and short gastric a.
w/out compromising blood flow to greater curvature of stomach
decreased surgical time
more challenging if large mass or omental adhesions distort anatomy
increased risk of major hemorrhage w/ technique failure
What does complete splenectomy with hilar dissection preserve?
preserves branches to pancreas and stomach
What does complete splenectomy with splenic artery ligation preserve?
preserves branch to left limb of pancreas (primary blood supply)
Advantages using hemostatic clips with splenectomy
faster and easier than hand sewn
Disadvantages of a splenectomy using hemostatic clips
clip instability, use limited to vessels <4mm diameter and implantation of non absorbable material
most medium to large breeds will have hilar vessels >4mm especially in the center of hilus where splenic a./v. are directly feeding- DO NOT USE CLIPS here
What is stapler is good for rapidly ligating and cuts for splenectomy?
LDS- ligate divide stapler
Electrothermal bipolar system- ***Ligasure***
handle vessels up to 7mm w/ minimal thermal damage to surrounding tissue
local hemostasis, fast, no foreign material left behind
$$$- good investment
Monocaudary Vs bipolar caudary
biopolar caudary is good for delicate tissues
mono-caudary has a lot of electro thermal spread- a lot of heat transfer
Partial splenectomy
PLEASE remove whole spleen in at risk breeds for splenic dz, Cav is not a fan of this procedure
indication: trauma, focal abscess, partial infarction
What is the most common complication of splenectomy?
hemorrhage- if ligations arent sound
What complication causes 2x risk of death?
Arrhythmias****
Whats the deal with arrhythmias and splenectomy?
typically ventricular, similar to GDV
MOA: compromised venous return to the heart caused by intra-abdominal hemorrhage and compression of the caudal vena cava
How should we monitor rhythms with splenectomy?
holter monitoring (continuous EKG)- 70% would have been missed if not wearing monitor
arrhythmias are especially in Ps w/ splenic rupture- only 6% of dogs w/o rupture had arrhythmias
How do we visualize the left limb of pancreas?
looking in deep leaf of greater omentum
Blood supplyof pancreas for left limb? right limb?
left limb- branch of splenic a.
body/right limb- caudal pancreaticoduodenal a. → branch of cranial mesenteric
What does the pancreatic duct drain? What does the accessory pancreatic duct drain?
pancreatic duct: drains Right lobe
accessory pancreatic duct: drains left lobe
The pancreatic duct enters the duodenum at _______ with _____
major duodenal papilla with bilde duct
(primary and ONLY duct in cats)
The accessory pancreatic duct drains into _____ in DOGs
duodenum at minor duodenal papilla in DOGs
T/F: cats dont have an accessory pancreatic duct
TRUE- CAT=Cant Accessorize That
2 Functions of the _exo_crine system via pancreas
digestive secretions via duct system
major and minor duodenal papilla
4 Cell types of the endocrine system via pancreas
4 cell types:
A- make glucaogn
B- insulin (60-70% of islet cells)
D- somatostatin
F (or P)- pancreatic polypeptide
T/F: pancreatitis is a very common surgical disease
FALSE- NOT a surgical dz
cross over in clinical signs that may prompt exploratory laprotomy but could EXACERBATE the condition due to manipulation and hypoperfusion/tension during anesthesia
What is the most common type of endocrine pancreatic neoplasia?
insulinoma- insulin based
Laparoscopic biopsy of the pancreas
obtain from edge of organ (careful of deep vessels)
cats may not have grossly abnormal tissue = procure multiple samples
Surgical biopsy of the pancreas
Guillotine technique
focal lesions in body = shave biopsy or trucut
do partial panceatectomy if lesion near caudal aspect of limbs
Why is it important to handle the pancreas with care?
it will secrete digestibe enzymes and cause pancreatitis if overhandled
Suture Fracture/ Guillotine Technique for surgical biopsy of pancreas
- if diffuse dz is present
- sample distal aspect of right limb = easiest access
- get multiple bx’s
- individual lobule dissection for small central body lesion
- Halstead’s principles = handle with care
Partial pacreatectomy: indications for procedure? What works best for ligation?
- indications: tumor removal
- incise omentum and capsule
- dissect b/t lobules to isolate vessels and ducts in portion of gland to be removed
- hemoclips or biopolar cautery work BEST for ligations
If remaining ducts in the pancreas are patent, we can remove ___% of the pancreas
80%
What very common issue must we warn owners about because it is very unpredictable who gets it?
Pancreatitis
What causes Exocrin pancreatic insufficiency (EPI)? Tx?
if pancreatic drainage is completely obstructed
tx: pancreatic enzyme supplementation and low-high fat/highly digestible food
Give an example of Endocrine pancreatic insufficiency. When does it occur?
diabetes mellitus
if > 80-90% of the pancreatic tissue is removed
tx w/ insulin
What rare but relevant issue do we worry about with partial pancreatectomy?
Devitalization of duodenum
if pancreaticoduodenal a. which arises from cranial mesenteric a. gets damaged, then duodenm can be compromised
Ligasure for pancreatic surgery has shown what?
faster sx and short hospitalization
***No pancreatitis*****
Cav’s preferred dissection/resection tool***
Indications for a total pancreatectomy
RARE- be careful
acute trauma, severe, chronic fibrosis, extensive neoplasia
only do this if you MUST- Cav doesn’t like this procedure
Pacreatic pseudocysts is not a true cyst because? How are they usually found?
lacks epithelial wall (fibrous sac of granulation tissue)
fluid is not secreted from lining rather is thought to leak from damaged pancreatic ducts and vessels
usually an incidental finding*** may be associated w/ recurrent bouts of pancreatitis or trauma
Signalment and history of pancreatic pseudocysts
middle to older aged -mostly dogs
asymptomatic, vague signs of abdominal discomfort, anroexia, +/- vomit
Diagnosis of pancreatic pseudocysts
diagnostic imaging: US= test of choice and most senstive
cant differentiate from abscess on US
Pancreatic pseudocyst treatment
percutaneous aspiration- 1st line treatment esp if aclinical
if clinically ill from dz: resection, debride and drain (cures), >75% successful treated and survive
Pancreatic abscess is usually secondary to?
acute bouts of pancreatitis
most are sterile, no bacteria on culture
Pancreatic abscess diagnosis
rads- increased soft tissue density in right cranial or central cranial abdomen= ascites/peritonitis
US- mass lesions, guided FNA
Lab data- hyperbilirubinemia/elevated LES due to EHBO- inflam of pancreas causing duodenal papilla of CBD to swell shut
Treatment for pancreatic abscess
resect- often challenging bc dz is NOT localized
debride and drain- omentalize****, active drainage
PO enteral nutrition plan- HAVE ONE= need post-gastric feeding!! can give pancreatitis after
Prognosis of pancreatic abscess
guarded in dogs
high perioperatve mortality
potential recurrence if non-resectable
Pancreatic neoplasia exocrine pancreatic adenocarcinoma
Malignant and invades locally- mets 50-78%
very aggressive, deadly- poor px
vomit, abd pain, weight loss, signs of EHBO
surgical resection if possible
Pancreatic insulinoma
B cells of the islets of Langerhans= secreete insulin despite hypoglycemia
uncommon in dogs, rare in cats
90% malignant
weakness, szs
Dx- Whipples triad
Whipples Triad
Medical management of pancreatic insulinoma
small frequent meals, high protein, complex carbs
glucocorticoid therapy- increases hepatic glucose and decreases cellular glucose
oral hyperglycemic agents- Diazoxide=inhibits pancreatic insulin secretion and glucose uptake
If severe= ICU and dextrose supplement in fluids BUT dont overdo it→ remember these dogs are used to living hypoglycemic
What is the gold standard of surgical management for pancreatic insulinoma?
partial pancreatectomy
Insulinoma: recurrence of hypoglycemia after sx is common due to what?
metastasis
Pancreatic insulinoma prognosis
**stage of dz important**
I confined to pancreas = MST 785days
II w/ reginal LN involvement= MST 547days
III systemic mets= MST 217days
Gastrinoma are ____ tumors in dogs and cats. Are they usually malignant?
rare- highly malignant
_______ syndrome describes syndrome of gastric acid hypersecretion, gastrointestinal ulceration and non-B cell pancreatic tumors
Zollinger-Ellison
