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Spleen Flashcards

1
Q

What are the results of splenectomy/hyposplenism?

A

Transient increase in platelet, RBC, and WBC; persistent increase in lymphocytes and monocytes.

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2
Q

What is the minimum age for splenectomy?

A

5 years old.

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3
Q

What causes ITP?

A

IgG antibody to platelet glycoprotein, specifically fibrinogen receptor GpIIb/IIIa and Gp Ia/iia. Results in decrease platelets.

Zdx: petechiae, gingival bleeding, bruising, soft tissue ecchymosis

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4
Q

What is the spleen’s condition in ITP?

A

The spleen is normal, with no splenomegaly.

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5
Q

How is ITP diagnosed?

A

Diagnosis of exclusion; requires peripheral smear and bone marrow biopsy, both of which will be normal.

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6
Q

How do children typically present in ITP?

A

Usually with a preceding viral illness, and most are managed with medical treatment.

In children < 10, usually resolves on its own. Try to avoid splenectomy

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7
Q

What is the treatment for ITP?

A

Only need to treat if actively bleeding or platelets < 30k

  • 1st start with steroids and +/- IVIG/immunoglobulin (Platelets only given if actively bleeding)
  • Only 20% will achieve a durable result from above
  • 2nd line:
  • romiplostim, eltrombopag = thrombopoetin receptor agonist
  • Splenectomy
  • Rituximab, only tested after splenectomy failure
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8
Q

When is splenectomy indicated for ITP?

A

Indicating for splenectomy: medical failure (4-6 weeks), prolonged use of steroids (3 months) and platelets < 30k, cases of first relapse, severe life-threatening bleeding

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9
Q

What should be checked if persistent thrombocytopenia occurs after splenectomy?

A

Look for Howell-Jolly bodies, Heinz bodies, etc. If not present, consider an accessory spleen.

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10
Q

What is TTP and its treatment?

A

-Thrombotic thrombocytopenic purpura (TTP)
-FAT-RN mnemonic (Fever, Anemia, Thrombocytopenia, Renal, Neurological)
-Caused by defective ADAMTS13 metalloproteinase (vWF cleaving protein) -> Platelet aggregation in microvasculature
-Tx = Plasmapheresis

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11
Q

What is hereditary spherocytosis?

A

Autosomal dominant
-MC congenital hemolytic anemia requiring splenectomy
-Spectrin membrane protein deficit -> less deformable RBCs & splenic sequestration

Hemolytic anemia
Leg ulcers
Hypersplenism, Pigmented stones, splenomegaly

Tx: splenectomy and cholecystectomy (if has stones) is curative

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12
Q

What should be searched for during splenectomy in hemolytic anemias?

A

Accessory spleen.

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13
Q

What is pyruvate kinase deficiency?

A

A congenital hemolytic anemia with altered glucose metabolism; RBC survival is enhanced by splenectomy.

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14
Q

What is warm antibody type acquired immune hemolytic anemia?

A

IgG against RBCs; splenectomy if refractory to steroids. Will have a positive direct Coombs test.

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15
Q

What is beta thalassemia?

A

A condition due to persistent HgbF, causing pallor, retarded body growth, and head enlargement; splenectomy if splenomegaly is present.

Most die teens 2/2 hemosiderosis.
Medical tx: blood transfusions, iron chelators (deferoxamine, deferiprone)

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16
Q

What conditions almost always require splenectomy?

A

Hereditary spherocytosis, elliptocytosis, echinococcal cyst, dermoid cyst, and multiloculated splenic abscess.

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17
Q

What conditions usually require splenectomy?

A

Refractory warm antibody hemolytic anemia, refractory ITP, isolated splenic lymphoma (with splenomegaly), and myelofibrosis with splenic myeloid metaplasia (spleen acts as bone marrow, Tx: splenectomy if transfusion dependent or severe thrombocytopenia)

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18
Q

What should be done for asymptomatic splenic cysts < 4 cm?

A

Leave them alone; they can secrete CA 19-9 and CEA but are still benign.

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19
Q

What should be done if an echinococcal cyst is suspected?

A

Get serologic testing; splenectomy may be needed, and alcohol can be injected before splenectomy.

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20
Q

What is the diagnosis process for Hodgkin’s disease?

A

Never do FNA; use core needle or excisional biopsy only, along with bone marrow biopsy.

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21
Q

What imaging is used for Hodgkin’s disease?

A

PET or gallium MRI of spleen and liver; CT does not detect spleen or liver involvement.

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22
Q

What are the stages of Hodgkin’s disease?

A

Stage I: 1 LN region contiguous;

Stage II: > 2 non-contiguous LN regions on the same side of the diaphragm

Stage III: involved on each side of the diaphragm

Stage IV: Mets to non-lymphoid organs. (liver, bone, lung; not spleen)

Reed-Sternberg cells

A: asymptomatic
B: symptomatic (night sweats, fever, weight loss)

MCC of chylous ascites: lymphoma

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23
Q

What is the prognosis for lymphocyte predominant and lymphocyte depleted Hodgkin’s disease?

A

Lymphocyte predominant has the best prognosis; lymphocyte depleted has the worst prognosis.

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24
Q

What is the most common type of Hodgkin’s disease?

A

Nodular sclerosing.

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25
Q

What are the risks associated with treatment for lymphoma?

A

High risk of second cancers

  • MC from XRT and chemo: lung CA and leukemia
  • MC from XRT only: breast CA
  • Also, at increased risk of CAD 2/2 to XRT
26
Q

What is the survival rate for Hodgkin’s and Non-Hodgkin’s lymphoma?

A

5-year survival for Hodgkin’s is 85%, Non-Hodgkin’s is 65%.

Non-hodgkin’s lymphoma: 90% B-cell lymphomas

27
Q

What is the treatment for Hodgkin’s disease?

A

Chemo-XRT (ABVD - Adriamycin, bleomycin, vinblastine, dacarbazine).

28
Q

What is OPSI?

A

Overwhelming post-splenectomy infection

MC in children < 5. The younger the patient the higher the risk
High risk if splenectomy done for malignancy especially hematologic malignancies
Splenectomy due to trauma has the least incidence

Organisms: S. pneumoniae (#1), H influenzae, N. meningitides

Tx: third generation cephalosporin

29
Q

What is the highest risk factor for OPSI?

A

Wiskott-Aldrich syndrome

hemolytic disorders, malignancy

30
Q

What is the recommendation regarding splenectomy in children?

A

Try to delay any splenectomy until 5 years old.

31
Q

What is needed for prophylaxis after splenectomy?

A

Antibiotic prophylaxis with every dental procedure for a lifetime; booster immunization every 5-7 years for pneumococcal vaccine.

32
Q

What is the treatment for children < 5 years old after splenectomy?

A

Daily penicillin/amoxicillin for 2 years if splenectomy is performed.

33
Q

What is Felty’s syndrome?

A

Rheumatoid arthritis, splenomegaly, and neutropenia.

34
Q

What is the initial treatment for Felty’s syndrome?

A

Steroids to improve PMN count. Methotrexate.

35
Q

When is splenectomy indicated in Felty’s syndrome?

A

If refractory to treatment, recurrent infections, anemia, or severe thrombocytopenia.

36
Q

What is a wandering spleen?

A

A spleen that lacks normal peritoneal attachments and has a long splenic pedicle.

Can twist around splenic artery= torsion -> infarction

37
Q

What is the treatment for a symptomatic wandering spleen?

A

Splenopexy in the LUQ.

38
Q

What is the most common cause of spontaneous splenic rupture in the US?

A

Mononucleosis; worldwide, it is malaria.

39
Q

What is the most common cause of splenic abscess?

A

Hematogenous spread, primarily from endocarditis, with strep pneumonia as the most common pathogen.

40
Q

What is the treatment for a unilocular splenic abscess?

A

Drainage; splenectomy if multilocular.

41
Q

What are the main ligaments associated with the spleen?

A

Gastrosplenic (contains short gastrics), splenorenal (contains splenic vessels and tail of pancreas), splenocolic, and splenophrenic.

42
Q

What is the red pulp of the spleen responsible for?

A

Filtering RBCs; it comprises most of the spleen and contains thin-walled sinusoids separated by cords with red cells.

43
Q

What is the white pulp of the spleen responsible for?

A

Immune functions; contains lymphoid follicles (B-cells) and periarterial lymphatic sheath (T-cells).

Spleen is largest producer of IgM

44
Q

What peripheral blood smear findings suggest an absent or damaged spleen?

A

Howell-Jolly bodies (nuclear remnants), Pappenheimer bodies (iron deposits), target cells (immature RBCs), Heinz bodies (intracellular denatured hemoglobin), spur cells (deformed membrane).

Platelets: transient leukocytosis

Leukocytes: transient leukocytosis, persistent lymphocytosis, persistent monocytosis

45
Q

What is the management for penetrating trauma to the spleen?

A

Splenectomy.

46
Q

What is the management for blunt injury to the spleen?

A

Selective non-operative management if the patient is hemodynamically stable without peritonitis.

47
Q

When is angiographic intervention considered for splenic injuries?

A

-AAST grade >III injuries (subcapsular hematoma >50% or expanding; ruptured subcapsular hematoma; laceration >3cm or involving trabecular vessels)
-Presence of contrast blush
-Moderate hemoperitoneum
-Any signs of ongoing splenic bleeding

48
Q

When should platelets be transfused in ITP?

A

Only for intraoperative bleeding, ideally after ligating the splenic artery.

49
Q

What are the characteristics of splenic cysts?

A

Well-defined hypodense lesions without an enhancing rim; true cysts can be congenital, parasitic, or neoplastic.

50
Q

What should be done for asymptomatic splenic cysts?

A

Leave them alone; large cysts (>5cm) or symptomatic ones may require laparoscopic cyst excision or fenestration.

51
Q

What is the most common splenic tumor?

A

Hemangioma; splenectomy if symptomatic.

52
Q

What is angiosarcoma?

A

A primary malignant tumor of the spleen associated with vinyl chloride and thorium dioxide exposure; treatment is splenectomy if caught in time.

53
Q

What is the management for splenic artery aneurysm?

A

Endovascular coil embolization or placement of a covered stent if >2cm, pregnant women, or women of childbearing age.

54
Q

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

A

Short gastrics.

55
Q

What is the diagnosis for abdominal pain following splenectomy with a CT showing large fluid collection?

A

Pancreatic leak; treatment is percutaneous drainage.

56
Q

When should vaccinations be given in relation to splenectomy?

A

2 weeks prior to elective splenectomy or prior to hospital discharge after emergent splenectomy.

57
Q

What is the immediate treatment if OPSI is suspected?

A

Immediate IV antibiotics with vancomycin + ceftriaxone.

58
Q

What prophylactic measures should be considered for children <10 years old after splenectomy?

A

Prophylactic antibiotics.

59
Q

What is the diagnosis for gastric varices from splenic vein thrombosis?

A

Treatment is splenectomy.

Pancreatitis is most common cause of splenic artery and vein thrombosis.

60
Q

Sickle cell anemia

A

HgbA replaced with HgbS
Spleen usually autoinfarcts and splenectomy not required

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