Spleen

Question 1

What are the four major ligaments of the spleen?

Answer 1

• gastrosplenic (contains short gastrics)
• splenorenal (contains splenic vessels and tail of panc)
• splenocolic
• splenophrenic

Question 2

What is the function of the spleen?

Answer 2

• store platelets
• filter senescent erythrocytes
• immune function/lymphoid tissue

Question 3

What is the difference between red and white pulp of the spleen?

Answer 3

• most of it is red pulp which filters RBCs

- white pulp is composed of B-cell containing lymphoid follicles and T-cell containing periarterial lymphatic sheaths

Question 4

What are Howell-Jolly bodies?

Answer 4

nuclear remnants within RBCs suggestive of splenic damage or absence

Question 5

If you don’t see Howell-Jolly bodies or other pathopneumonic findings on peripheral blood smear after splenectomy, what should you think about?

Answer 5

a missed accessory spleen

Question 6

What are the most common indications for splenectomy?

Answer 6

• unstable trauma patients
• hematologic disorders
• splenic abscess
• symptomatic cysts
• primary malignancies

Question 7

Which patients with traumatic splenic injuries can be managed non-operatively?

Answer 7

those that are stable following blunt traumatic splenic injury and that are without peritonitis

Question 8

Which patients with traumatic splenic injuries should be considered for angiographic intervention?

Answer 8

• those that are stable following blunt traumatic splenic injury and that are without peritonitis
• and that have grade III or greater injuries, the presence of contrast blush, moderate hemoperitoneum, or signs of ongoing bleeding

Question 9

What is ITP? How is it managed medically and surgically?

Answer 9

• a disease caused by autoantibodies to GP IIb/IIIa
• results in thrombocytopenia and platelet dysfunction
• initially managed medically with steroids and IVIG
• consider splenectomy for refractory cases or for recurrence as this avoids the need for longstanding steroids
• good response to steroids is predictive of favorable response after splenectomy
• during surgery, platelets are only transfused for uncontrolled bleeding and should be given after ligation of the splenic artery to avoid consumption

Question 10

When are platelets indicated for ITP?

Answer 10

for intra-operative bleeding after ligation of the splenic artery

Question 11

For patients with ITP, what predicts a favorable response to splenectomy?

Answer 11

a good response to steroids

Question 12

For patients with ITP, what are the indications for splenectomy?

Answer 12

patients with recurrence or that are refractory to medical therapy

Question 13

What is hereditary spherocytosis? How does it present? What is the pathophysiology? When is splenectomy indicated?

Answer 13

• it is a hematologic disorder presenting with anemia and splenomegaly
• it results from an autosomal dominant cell membrane protein defect (spectrin), which makes RBCs less resistant to deformation and more susceptible to splenic culling
• splenectomy is recommended for symptomatic patients older than age 6 because this gives them time to take advantage of the immune function of the spleen

Question 14

Which patients with splenic abscess can be managed with perc drainage and which require splenectomy?

Answer 14

• perc drainage is appropriate for those that are unilocular with a thick wall and in a stable patient
• splenectomy is otherwise indicated

Question 15

What bacteria should you think of for splenic abscesses that are multi-loculated and thin walled?

Answer 15

Echinoccocal

Question 16

What is the radiographic appearance of splenic cysts?

Answer 16

well-defined, hypodense lesions without rim enhancement

Question 17

What are the two types of splenic cysts?

Answer 17

• true cysts (congenital, parasitic, neoplastic)

- false cysts (post-traumatic pseudocyst)

Question 18

How are splenic cysts managed?

Answer 18

• can leave alone if asymptomatic and benign appearing on imaging
• cysts > 5 cm or that are symptomatic should be considered for laparoscopic excision or fenestration

Question 19

What is the most common splenic tumor?

Answer 19

hemangioma

Question 20

How are splenic hemangiomas managed?

Answer 20

splenectomy only if symptomatic

Question 21

Angiosarcoma of the Spleen

Answer 21

• a primary malignant tumor of the spleen
• associated with vinyl chloride and thorium dioxide exposure
• very aggressive but treated with splenectomy if caught in time

Question 22

Hemangioma of the Spleen

Answer 22

• the most common benign tumor of the spleen

- require splenectomy only if symptomatic

Question 23

What is the most common visceral artery aneurysm?

Answer 23

splenic artery aneurysms

Question 24

Which splenic artery aneuryms require treatment?

Answer 24

• greater than 2 cm

- all in pregnant women or women of childbearing age, regardless of size (70% risk of rupture during pregnancy)

Question 25

How are splenic artery aneurysm treated?

Answer 25

IR embolization or stenting are preferred; however, very distal aneurysms may require splenectomy

Question 26

Splenic Artery Aneurysms

Answer 26

• the most common visceral artery aneurysm
• require treatment if greater than 2cm and in all pregnant women or women of childbearing age given a 70% chance of rupture
• can be embolized or stented; however, very distal aneurysms may require splenectomy

Question 27

What should be the timing for splenectomy vaccines?

Answer 27

• two weeks prior to elective splenectomy

- prior to hospital discharge following emergent splenectomy or 2 weeks after if reliable for follow up

Question 28

What is the first step in treating OPSI?

Answer 28

broad spectrum antibiotics

Question 29

What is the most common location for an accessory spleen?

Answer 29

the splenic hilum

Question 30

How is an accessory spleen diagnosed?

Answer 30

with a radionuclide spleen scan

Question 31

What is the most common organism associated with OPSI?

Answer 31

Strep pneumo

Question 32

What is a wandering spleen?

Answer 32

• a condition caused by a failure of fusion of the dorsal mesogastrium, leading to a lack of splenic ligaments
• typically presents with abdominal pain and CT will find a spleen in the RLQ
• there is a high risk of torsion and infarction
• treated with splenectomy if infarcted or splenopexy if healthy

Question 33

What is the most common source of bleeding in patients that are post-splenectomy

Answer 33

the short gastrics

Question 34

If a patient presents with abdominal pain following splenectomy and CT shows a large, low attenuation, fluid collection in the lesser sac, what is the most likely diagnosis and appropriate management?

Answer 34

• most likely a pancreatic leak

- managed with percutaneous drainage