Spleen

Question 1

The splenic vessels run in which ligament?

Answer 1

the splenorenal

Question 2

The short gastrics run in which ligament?

Answer 2

the gastrosplenic

Question 3

T-cells take what architecture in the spleen?

Answer 3

periarterial lymphatic sheaths (PALS)

Question 4

Howell-Jolly bodies are made of what?

Answer 4

nuclear remnants

Question 5

What are pappenheimer bodies?

Answer 5

iron deposits in RBCs found in post-splenectomy patients

Question 6

What are target cells?

Answer 6

immature RBCs

Question 7

What are Heinz bodies?

Answer 7

intracellular denatured hemoglobin seen on a post-splenectomy blood smear

Question 8

If you don’t find Howell-Jolly bodies after a splenectomy, what does this suggest?

Answer 8

the presence of an accessory spleen

Question 9

What is the most reliable finding post-splenectomy on a blood smear?

Answer 9

Howell-Jolly bodies made up of nuclear remnants

Question 10

Which hematologic disorders are indications for splenectomy?

Answer 10

ITP and spherocytosis

Question 11

Angiographic intervention for splenic trauma should be considered for which patients?

Answer 11

• those with greater than a grade 3 injury
• those with a contrast blush
• those with moderate hemoperitoneum

Question 12

Describe the etiology and management of ITP.

Answer 12

• thought to be secondary to glycoprotein IIb/IIIa auto-antibodies
• initially managed medically with steroids and IVIG
• can perform splenectomy for medically refractory patients, especially those with a good response to steroids

Question 13

When do you transfuse platelets in a patient with ITP undergoing splenectomy?

Answer 13

after ligating the splenic artery if you can wait to prevent consumption

Question 14

Describe the etiology, presentation, and treatment of hereditary spherocytosis.

Answer 14

• due to an AD defect in cell membrane proteins like spectrum which make them less deformable and more likely to be culled by the spleen
• presents with anemia and splenomegaly
• splenectomy is indicated for symptomatic patients older than 6
• often require cholecystectomy at the same time

Question 15

Describe the etiology and management of splenic abscesses.

Answer 15

• most due to IVDU, endocarditis, sickle cell disease, and infection of a traumatic pseudocyst
• perc drains are appropriate for unilocular and thick walled lesions in stable patients
• multi-locular and thin walled abscesses are suspicious for echinococal abscess and are indications for splenectomy

Question 16

What is a well-defined hypodense splenic lesion most likely to be?

Answer 16

a splenic cyst

Question 17

What are the two types of splenic cysts?

Answer 17

• pseudocysts (post-traumatic)
• true cysts (parasitic, congenital, or neoplastic)

Question 18

How are splenic cysts managed?

Answer 18

laparoscopic resection or fenestration is indicated for cysts >5cm and those that are symptomatic

Question 19

What is the most common splenic tumor?

Answer 19

a hemangioma

Question 20

How are splenic hemangiomas managed?

Answer 20

with splenectomy if they become symptomatic

Question 21

What is the most common malignant tumor of the spleen?

Answer 21

angiosarcoma

Question 22

Angiosarcomas of the spleen are associated with what exposures?

Answer 22

vinyl chloride and thorium dioxide

Question 23

What is the most common lymphoma of the spleen, how is it managed surgically?

Answer 23

• most common is CLL
• indications for splenectomy are anemia and thrombocytopenia

Question 24

How are splenic artery aneurysms managed?

Answer 24

• treated with >2cm and in all women of childbearing age given the high risk of rupture during pregnancy
• typically treated endovascularly with coil embolization or covered stent

Question 25

What is the optimal timing for post-splenectomy vaccines?

Answer 25

2 weeks prior to elective splenectomy and at discharge or 2 weeks post-op

Question 26

How is OPSI initially managed?

Answer 26

if suspicious for OPSI, start antibiotics early before getting cultures

Question 27

When should you consider antibiotic prophylaxis against OPSI?

Answer 27

considered for patients under 10 but definitely not for adults

Question 28

What is the most common site of an accessory spleen? How else can it be found?

Answer 28

• most commonly at the splenic hilum
• can be found with a tagged RBC scan

Question 29

What is the most common organism associated with OPSI?

Answer 29

Strep pneumoniae

Question 30

What is the diagnosis for a patient with abdominal pain and CT showing the spleen in the RLQ with no flow in the splenic vein?

Answer 30

• wandering spleen, caused by a lack of failure of the dorsal mesogastrium to fuse leading to a. lack of splenic ligaments
• concerning for torsion and infarction

Question 31

What is the most common source of post-splenectomy bleeding?

Answer 31

the short gastrics

Question 32

If a splenectomy patient has lots of abdominal pain and a fluid collection in the lesser sac, what should be the concern? How is this managed?

Answer 32

pancreatic leak, managed with a perc drain

Question 33

What are the features of TTP?

Answer 33

• fever
• hemolytic anemia
• renal failure
• purpura
• neurologic changes

Question 34

What is the etiology, presentation, and treatment for TTP?

Answer 34

• due to defective ADAMTS13 metalloproteinase (cleaves vWF) leading to platelet aggregation in microvasculature
• presents with fever, hemolytic anemia, renal failure, neurologic changes, and purpura
• treated with plasmapharesis