Spleen Flashcards
What are the results of splenectomy/hyposplenism?
Transient increase in platelet, RBC, and WBC; persistent increase in lymphocytes and monocytes.
What is the minimum age for splenectomy?
5 years old.
What causes ITP?
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
What is the spleen’s condition in ITP?
The spleen is normal, with no splenomegaly.
How is ITP diagnosed?
Diagnosis of exclusion; requires peripheral smear and bone marrow biopsy, both of which will be normal.
How do children typically present in ITP?
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
What is the treatment for ITP?
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
When is splenectomy indicated for ITP?
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
What should be checked if persistent thrombocytopenia occurs after splenectomy?
Look for Howell-Jolly bodies, Heinz bodies, etc. If not present, consider an accessory spleen.
What is TTP and its treatment?
-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
What is hereditary spherocytosis?
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
What should be searched for during splenectomy in hemolytic anemias?
Accessory spleen.
What is pyruvate kinase deficiency?
A congenital hemolytic anemia with altered glucose metabolism; RBC survival is enhanced by splenectomy.
What is warm antibody type acquired immune hemolytic anemia?
IgG against RBCs; splenectomy if refractory to steroids. Will have a positive direct Coombs test.
What is beta thalassemia?
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)
What conditions almost always require splenectomy?
Hereditary spherocytosis, elliptocytosis, echinococcal cyst, dermoid cyst, and multiloculated splenic abscess.
What conditions usually require splenectomy?
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)
What should be done for asymptomatic splenic cysts < 4 cm?
Leave them alone; they can secrete CA 19-9 and CEA but are still benign.
What should be done if an echinococcal cyst is suspected?
Get serologic testing; splenectomy may be needed, and alcohol can be injected before splenectomy.
What is the diagnosis process for Hodgkin’s disease?
Never do FNA; use core needle or excisional biopsy only, along with bone marrow biopsy.
What imaging is used for Hodgkin’s disease?
PET or gallium MRI of spleen and liver; CT does not detect spleen or liver involvement.
What are the stages of Hodgkin’s disease?
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
What is the prognosis for lymphocyte predominant and lymphocyte depleted Hodgkin’s disease?
Lymphocyte predominant has the best prognosis; lymphocyte depleted has the worst prognosis.
What is the most common type of Hodgkin’s disease?
Nodular sclerosing.
What are the risks associated with treatment for lymphoma?
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
What is the survival rate for Hodgkin’s and Non-Hodgkin’s lymphoma?
5-year survival for Hodgkin’s is 85%, Non-Hodgkin’s is 65%.
Non-hodgkin’s lymphoma: 90% B-cell lymphomas
What is the treatment for Hodgkin’s disease?
Chemo-XRT (ABVD - Adriamycin, bleomycin, vinblastine, dacarbazine).
What is OPSI?
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
What is the highest risk factor for OPSI?
Wiskott-Aldrich syndrome
hemolytic disorders, malignancy
What is the recommendation regarding splenectomy in children?
Try to delay any splenectomy until 5 years old.
What is needed for prophylaxis after splenectomy?
Antibiotic prophylaxis with every dental procedure for a lifetime; booster immunization every 5-7 years for pneumococcal vaccine.
What is the treatment for children < 5 years old after splenectomy?
Daily penicillin/amoxicillin for 2 years if splenectomy is performed.
What is Felty’s syndrome?
Rheumatoid arthritis, splenomegaly, and neutropenia.
What is the initial treatment for Felty’s syndrome?
Steroids to improve PMN count. Methotrexate.
When is splenectomy indicated in Felty’s syndrome?
If refractory to treatment, recurrent infections, anemia, or severe thrombocytopenia.
What is a wandering spleen?
A spleen that lacks normal peritoneal attachments and has a long splenic pedicle.
Can twist around splenic artery= torsion -> infarction
What is the treatment for a symptomatic wandering spleen?
Splenopexy in the LUQ.
What is the most common cause of spontaneous splenic rupture in the US?
Mononucleosis; worldwide, it is malaria.
What is the most common cause of splenic abscess?
Hematogenous spread, primarily from endocarditis, with strep pneumonia as the most common pathogen.
What is the treatment for a unilocular splenic abscess?
Drainage; splenectomy if multilocular.
What are the main ligaments associated with the spleen?
Gastrosplenic (contains short gastrics), splenorenal (contains splenic vessels and tail of pancreas), splenocolic, and splenophrenic.
What is the red pulp of the spleen responsible for?
Filtering RBCs; it comprises most of the spleen and contains thin-walled sinusoids separated by cords with red cells.
What is the white pulp of the spleen responsible for?
Immune functions; contains lymphoid follicles (B-cells) and periarterial lymphatic sheath (T-cells).
Spleen is largest producer of IgM
What peripheral blood smear findings suggest an absent or damaged spleen?
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
What is the management for penetrating trauma to the spleen?
Splenectomy.
What is the management for blunt injury to the spleen?
Selective non-operative management if the patient is hemodynamically stable without peritonitis.
When is angiographic intervention considered for splenic injuries?
-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
When should platelets be transfused in ITP?
Only for intraoperative bleeding, ideally after ligating the splenic artery.
What are the characteristics of splenic cysts?
Well-defined hypodense lesions without an enhancing rim; true cysts can be congenital, parasitic, or neoplastic.
What should be done for asymptomatic splenic cysts?
Leave them alone; large cysts (>5cm) or symptomatic ones may require laparoscopic cyst excision or fenestration.
What is the most common splenic tumor?
Hemangioma; splenectomy if symptomatic.
What is angiosarcoma?
A primary malignant tumor of the spleen associated with vinyl chloride and thorium dioxide exposure; treatment is splenectomy if caught in time.
What is the management for splenic artery aneurysm?
Endovascular coil embolization or placement of a covered stent if >2cm, pregnant women, or women of childbearing age.
What is the most common source of post-splenectomy bleeding?
Short gastrics.
What is the diagnosis for abdominal pain following splenectomy with a CT showing large fluid collection?
Pancreatic leak; treatment is percutaneous drainage.
When should vaccinations be given in relation to splenectomy?
2 weeks prior to elective splenectomy or prior to hospital discharge after emergent splenectomy.
What is the immediate treatment if OPSI is suspected?
Immediate IV antibiotics with vancomycin + ceftriaxone.
What prophylactic measures should be considered for children <10 years old after splenectomy?
Prophylactic antibiotics.
What is the diagnosis for gastric varices from splenic vein thrombosis?
Treatment is splenectomy.
Pancreatitis is most common cause of splenic artery and vein thrombosis.
Sickle cell anemia
HgbA replaced with HgbS
Spleen usually autoinfarcts and splenectomy not required
