E2- Spleen and pancreas Flashcards
1
Q
What attaches the spleen to the stomach?
A
gastrosplenic ligament
2
Q
Blood flow into the spleen?
A
celiac a. to splenic a.
3
Q
Blood flow out of spleen?
A
splenic v. to gastrosplenic v. to portal v.
4
Q
Splenic white pulp Vs red pulp
A
white pulp- nodular lymphoreticular tissue: site of immune response
red pulp- venous sinuses: stores RBCs/traps antigens
5
Q
Should we worry about siderotic plaques?
A
NO- non pathologic
pale yellow/rust color- Ca/iron deposits
6
Q
Should we worry about ectopic splenic tissue?
A
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
7
Q
T/F: we need our spleen to survive
A
FALSE- we do not need it
8
Q
What is stored in the spleen?
A
10-20% of RBCs and 30% platelets
9
Q
What cells mature in the spleen?
A
RBCs
10
Q
Senescent/sick RBC removal
A
become non pliable and cant squeeze through pores of splenic sinuses = rupture or they are phagocytized
filters
11
Q
T/F: Hematopoeisis in the spleen is active during fetal development
A
TRUE
12
Q
How does the spleen help in immune function?
A
removal of poorly opsonized bacteria (better than liver)
13
Q
Causes of splenomegaly
A
(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
14
Q
Causes of splenic mass
A
(asymmetrical enlargement)
neoplasia
hematoma
nodular hyperplasia/EMH
trauma ► splenosis
abscess
15
Q
Splenic torsion is most common with ____
A
GDV
16
Q
Splenic torsion from stretching of ____ during previous GDV or trauma
A
gastrosplenic ligament
17
Q
What dog breeds are predisposed to splenic torsion?
A
large/giant breed dogs
great dane
greater swiss mountain dog
german shepherd
english bulldog
18
Q
Clinical signs of acute splenic torsion
A
acute abdomen- similar to GDV or BECAUSE OF GDV
acute abdominal pain/shock
abd distension
cardiovascular collapse
dysrhythmias
DIC
19
Q
Clinical signs of chronic splenic torsion
A
vague/intermittent signs for up to 2 weeks
vomiting/diarrhea
weakness/depression
anemia
hematuria/hemoglobinuria
PU/PD
20
Q
How do we diagnose splenic torsion? what is the best dx method?
A
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
21
Q
How do we stabilize P pre-op for splenic torsion?
A
fluids- end point resuscitation
transfusion
antibiotics
22
Q
What is the treatment for splenic torsion?
A
Exploratory Laparotomy***** splenectomy
23
Q
How can we prevent a splenic torsion?
A
gastropexy- at risk breed for GDV or to address GDV
24
Q
What is VERY important to remember when you are removing the spleen?
A
DO NOT DEROTATE IT
25
**Why cant we derotate the spleen prior to splenectomy?**
spleen will release free radicals and could lead to DIC
26
Ideally we submit the spleen for ____ assessment to ensure no underlying pathology
histopathologic
27
T/F: **neoplasia is a cause of splenic torsion**
FALSE- **neoplasia is NOT a cause of splenic torsion = not found in any case**
28
T/F: splenic infarction is common
FALSE- RARE- can often see infarcted areas on abdominal US
29
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
30
Splenic torsion can look like what on a ultrasound?
mass effect- devascularized area may turn into hematoma
31
**Nodular splenic hyperplasia = sites of \_\_\_\_\_**
**extramedullary hematopoiesis**
single or multiple SUBSCAPLULAR nodules
Very common\*\*\*
32
Diagnosis of nodular hyperplasia of the spleen?
dx dilemma- can look like cancer
## Footnote
**\*\*\*FNA/Cytology = poor sensitivity\*\*\***
33
Splenic nodular hyperplasia is typically asymptomatic but what may happen?
could rupture causing hemoabdomen
34
Are splenic nodules usually benign or neoplastic?
70. 5% patients had benign splenic lesions = most commonly benign
29. 5% had malignant neoplasia
35
How is splenic nodular hyperplasia usually found?
**_incidentally_**- non ruptured splenic masses or nodules w/o associated hemoperitoneum = most commonly benign!
36
What can cause splenic trauma?
blunt force (HBC/falls/dog attack)- ruptures capsule and parenchyma
37
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
38
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
39
T/F: autotransplantation doesn't really work consistently
TRUE
40
Splenic neoplasia Ddx in dogs
**_Hemangiosarcoma (HSA)_**
**Sarcomas**
hemangioma
lymphosarcoma
41
Splenic neoplasia Ddx in cats
**_Mast Cell Tumor = Most Common_**
hemangiosarcoma
lymphoma
42
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%
43
Risk factors of hemangiosarcoma in spleen
age- older
\>/= 21kg
breeds: GSD, labs, Goldens, poodles
**presence of hemoperitoneum**
44
**presence of hemoperitoneum with splenic tumor means \_\_\_% chance of malignancy**
**_\>80%_**
45
Chances of splenic neoplasia in small breed dogs?
50:50 split benign vs malignant
wheaten terriers predisposed
hemoperitoneum **_NOT_** associated w/ malignancy
46
What is the benign splenic mass to mass size ratio?
bigger the mass, (the better) more likely benign
47
Splenic hemangiosarcoma prognosis
Poor :(
## Footnote
**\*\*\*in nearly ALL cases microscopic metastasis is present at the time of diagnosis\*\*\***
48
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
49
Splenic hemangiosarcoma prognosis with alternative therapies
C versicolor mushroom (turkey tail)- significantly delayed metastasis
eBAT- bispecific urokinase angiotoxin designed to target EGFR
50
Two techniques to consider for splenectomy
**ligation of individual hilar vessels-** preferred
## Footnote
**ligation of the splenic and short gastric a.**
51
Splenectomy: Ligation of individual hilar vessels
preferred
preserves branches to pancreas and stomach
time consuming to do by hand
less risk of PO hemorrhage
52
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
53
What does complete splenectomy with hilar dissection preserve?
preserves branches to pancreas and stomach
54
What does complete splenectomy with splenic artery ligation preserve?
**_preserves branch to left limb of pancreas (primary blood supply)_**
55
Advantages using hemostatic clips with splenectomy
faster and easier than hand sewn
56
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
57
What is stapler is good for rapidly ligating and cuts for splenectomy?
LDS- ligate divide stapler
58
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
59
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
60
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
61
What is the most common complication of splenectomy?
_hemorrhage_- if ligations arent sound
62
What complication causes 2x risk of death?
**Arrhythmias\*\*\*\***
63
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
64
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**
65
How do we visualize the left limb of pancreas?
looking in deep leaf of greater omentum
66
Blood supplyof pancreas for left limb? right limb?
left limb- branch of splenic a.
body/right limb- caudal pancreaticoduodenal a. → branch of cranial mesenteric
67
What does the pancreatic duct drain? What does the accessory pancreatic duct drain?
pancreatic duct: drains Right lobe
accessory pancreatic duct: drains left lobe
68
The pancreatic duct enters the duodenum at _______ with \_\_\_\_\_
**major duodenal papilla with bilde duct**
| (primary and ONLY duct in cats)
69
The accessory pancreatic duct drains into _____ in DOGs
duodenum at minor duodenal papilla in DOGs
70
T/F: cats dont have an accessory pancreatic duct
**_TRUE- CAT=Cant Accessorize That_**
71
2 Functions of the _exo_crine system via pancreas
digestive secretions via duct system
major and minor duodenal papilla
72
4 Cell types of the **_endo_**crine system via pancreas
4 cell types:
**A**- make glucaogn
**B**- insulin (60-70% of islet cells)
**D**- somatostatin
**F** (or P)- pancreatic polypeptide
73
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
74
What is the most common type of endocrine pancreatic neoplasia?
insulinoma- insulin based
75
Laparoscopic biopsy of the pancreas
obtain from edge of organ (careful of deep vessels)
cats may not have grossly abnormal tissue = procure multiple samples
76
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
77
Why is it important to handle the pancreas with care?
it will secrete digestibe enzymes and cause pancreatitis if overhandled
78
**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
79
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**
80
If remaining ducts in the pancreas are patent, we can remove \_\_\_% of the pancreas
80%
81
What very **common** issue must we warn owners about because it is very **unpredictable** who gets it?
**Pancreatitis**
82
What causes Exocrin pancreatic insufficiency (EPI)? Tx?
if pancreatic drainage is completely obstructed
tx: pancreatic enzyme supplementation and low-high fat/highly digestible food
83
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
84
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_
85
**_Ligasure_** for pancreatic surgery has shown what?
faster sx and short hospitalization
## Footnote
**\*\*\*No pancreatitis\*\*\*\*\***
**Cav's preferred dissection/resection tool\*\*\***
86
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
87
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
88
Signalment and history of pancreatic pseudocysts
middle to older aged -mostly dogs
asymptomatic, vague signs of abdominal discomfort, anroexia, +/- vomit
89
Diagnosis of pancreatic pseudocysts
diagnostic imaging: **US= test of choice and most senstive**
cant differentiate from abscess on US
90
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
91
Pancreatic abscess is usually secondary to?
acute bouts of pancreatitis
most are sterile, no bacteria on culture
92
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
93
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
94
Prognosis of pancreatic abscess
guarded in dogs
high perioperatve mortality
potential recurrence if non-resectable
95
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
96
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
97
Whipples Triad
98
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
99
What is the gold standard of surgical management for pancreatic insulinoma?
partial pancreatectomy
100
Insulinoma: recurrence of hypoglycemia after sx is common due to what?
metastasis
101
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
102
Gastrinoma are ____ tumors in dogs and cats. Are they usually malignant?
rare- highly malignant
103
\_\_\_\_\_\_\_ syndrome describes syndrome of gastric acid hypersecretion, gastrointestinal ulceration and non-B cell pancreatic tumors
**Zollinger-Ellison**
