SPLEEN Flashcards
Vascular vs. avascular ligaments of spleen
vascular: splenorenal (hilar vessels + panc tail), gastrosplenic (short gastrics)
avascular: splenocolic, splenophrenic
What are: Howell-Jolley bodies
nuclear remnant; most reliable to detect asplenic smear
What are: target cells
immature RBC (target is nucleus)
What are: Pappenheimer bodies
iron granules
What are: Heinz bodies
intracellular denatured Hgb
What are: Spur cells
deformed RBC membranes
For splenectomy, what do you ligate first: splenic vein vs. artery?
artery
Patho: idiopathic thrombocytopenic purpura
Ab to glycoproteins GP2b3A and GP1A2A
Patho: hereditary spherocytosis
autosomal defect in cell membrane (spectrin)
Prophylactic mgmt children w/ hereditary spherocystosis
splenectomy for symptomatic children >6yo (time to develop immunity) + 2-wk pre-op vaccinations
Anemia + splenomegaly in child, suspect…?
hereditary spherocytosis
MCC hereditary reason for splenectomy that is not structure-related
pyruvate kinase def: hemolytic anemia 2/2 defect in glucose metabolism
Mgmt for splenic cysts
if symptomatic or >5cm -> laparoscopic cyst excision or fenestration
Mgmt: splenic artery aneurysm
> 2cm -> repair
female of child-bearing age of ANY size -> repair (coil embolize, covered stent)
Mgmt splenic artery aneurysm at distal hilum of spleen
splenectomy
Sxs splenic artery aneurysm rupture
“double rupture sign” = acute abdominal pain, but stabilize (bc tamponade by lesser sac) -> lesser sac ruptures -> intraperitoneal blood
Splenectomy population most at risk of OPSI
children, particularly if splenectomy 2/2 beta-thalassemia
MC location accessory spleen
hilum
MC organism responsible for OPSI
strep pneumo
Hypotensive + tender abdominal exam post-splenectomy, suspect…?
short gastric bleed
Fluid collection s/p splenectomy, concern for…?
pancreatic leak from tail
Patho: TTP (thrombotic thrombocytopenic purpura)
ADAMTS13 metalloproteinase defect -> cannot break down wWF -> platelet aggregation in microvasculature
Sxs TTP
MC primary splenic neoplasm
non-Hodgkin’s lymphoma
When give platelets intra-op splenectomy for ITP?
after ligating splenic artery, unless bleeding and need to give for hemostasis
What else do you need to check for in pts with hereditary spherocytosis that you would have to intervene for?
gallstones from hemolysis; may do cholecystectomy at time of splenectomy
MC visceral artery aneurysm
splenic artery
Mgmt splenic hemangioma
if symptomatic -> splenectomy
Splenic hemangiosarcoma associated with … exposure?
vinyl chloride and thorium dioxide
First step in child w/ fever + hx splenectomy
immediate broad spectrum Abx (high mortality)
Mgmt TTP
emergency plasmaphoresis
s/p sleeve gastrectomy + CT w/ infarcted superior pole of spleen
normal after takedown of short gastrics - non-op mgmt, pain mgmt, will resolve spontaneously
Spleen in RLQ + abd US shows no flow in splenic vein… suspect?
wandering spleen 2/2 failure of fusion of dorsal mesogastrium -> lack of splenic ligaments
Mgmt wandering spleen
increased risk splenic torsion/infarction -> splenopexy (unless infarcted, then need splenectomy)
If isolated gastric varices, suspect…?
splenic vein thrombosis
Isolated gastric varices 2/2 retrograde flow through…?
short gastric and posterior gastric veins
Dx splenic vein thrombosis
abdominal ultrasound
Mgmt nonparasitic splenic cysts
obs, most asymptomatic. if symptomatic, relief with aspiration (often recur) suggests benefit of operative mgmt
Mgmt splenic abscess
perQ drain + IV Abx (high mortality rate)
The most consistent predictor of response to splenectomy from ITP is…?
young age
DVT prophylaxis during non-op mgmt spleen lac
early use of LWMH (<3d) does NOT increase failure rate for non-op mgmt of spleen lac - must have trauma pts on DVT ppx
After non-op spleen lac, child should be kept on bed rest until what criteria is fulfilled?
- Hct stabilizes
- abdominal pain resolves
After non-op spleen lac, how long before can return to full activity?
Grade of splenic injury + 2 weeks
Etiology of popliteal artery entrapment syndrome
MC 2/2 congenital anomaly where medial/lateral gastrocnemius head shifted to artery -> compression during knee flexion
Popliteal entrapment causes ?? pathology of popliteal artery that -> parasthesia and complete occlusion or thrombosis of artery
popliteal artery fibrosis
Mgmt splenic injury by grade + unstable, or requiring continued transfusions
Grade 1 = topical hemostatic agents, cautery
2/3 = splenorrhaphy with suture or absorbable mesh repair (or omentum
4/5 = splenectomy required
How to mobilize spleen?
Must medialize spleen.
- ligate splenorenal ligament (contains splenic vessels)
- ligate splenocolic ligament
- divide splenophrenic ligament (avascular)
Should drain be placed after splenectomy?
Not routinely (associated with devel of abscess) - only if coexisting injury to pancreatic tail or renal collecting duct
Mgmt splenic injury by grade + unstable, or requiring continued transfusions
Grade 1 = topical hemostatic agents, cautery
2/3 = splenorrhaphy with suture or absorbable mesh repair (or omentum
4/5 = splenectomy required
How to mobilize spleen?
Must medialize spleen.
- ligate splenorenal ligament (contains splenic vessels)
- ligate splenocolic ligament
- divide splenophrenic ligament (avascular)
Should drain be placed after splenectomy?
Not routinely (associated with devel of abscess) - only if coexisting injury to pancreatic tail or renal collecting duct
