Spleen Flashcards
Which arteries supply the spleen?
Splenic artery (a branch of the celiac trunk) and the short gastric arteries that arise for the gastroepiploic arteries
What is the venous drainage of the spleen?
Portal vein, via the splenic vein and the left gastroepiploic vein
What is said to tickle the spleen?
Tail of the pancreas
What percentage of people have an accessory spleen?
20%
What percentage of the total body platelets are stored in the spleen?
33%
What are the main functions of the spleen?
Filters abnormal RBCs, stores platelets, produces tuftsin and properdin (opsins), produces antibodies (especially IgM) and is site of phagocytosis
What is delayed splenic rupture?
Subcapsular hematoma or pseudoaneurysm may rupture some time after blunt trauma.
Rupture classically occurs about 2 weeks after the injury and presents with shock and abdominal pain.
What are the signs and symptoms of ruptured or injured spleen?
Hemoperitoneum and Kehr’s sign, LUQ abdominal pain, Ballance’s sign
What is Kehr’s sign?
Left shoulder pain seen with splenic rupture
What is Ballance’s sign?
LUQ dullness to percussion
What is Seagesser’s sign?
Phrenic nerve compression causing neck tenderness in splenic rupture
How is a spleen injury diagnosed?
If the patient is stable: abdominal CT.
If not, DPL or FAST exam.
What is the treatment for a spleen injury?
- Non-operative in a stable patient with an isolated splenic injury without hilar involvement or complete rupture.
- If patient is unstable, DPL/FAST laparotomy with splenorrhaphy or splenectomy.
- Embolization is an option in selected patients.
What is a splenorrhaphy?
Splenic salvage operation wrapping vicral mesh, aid of topical hemostatic agents or partial splenectomy, sutures (buttressed)
For which malignant diseases is a splenectomy indicated?
Hodgkin’s staging not conclusive by CT (rare); splenic tumors (primary/metastatic); hypersplenism caused by other leukemias/non-Hodgkin’s lymphomas
For which anemic conditions is a splenectomy indicated?
Medullary fibrosis with myeloid metaplasia; hereditary elliptocytosis; sickle cell anemia (rare, most autosplenectomize); pyruvate kinase deficiency; autoimmune hemolytic anemia; hereditary spherocytosis; thalassemias
For which thrombocytopenic conditions is a splenectomy indicated?
ITP, TTP
What are some miscellaneous conditions for which a splenectomy is indicated?
Variceal bleeding with splenic vein thrombosis, Gaucher’s disease, splenic abscess, refractory splenic cysts, hypersplenism, Felty’s syndrome
Is G6PD deficiency an indication for splenectomy?
No
What are the possible post-splenectomy complications?
Thrombocytosis, subphrenic abscess, atelectasis, pancreatitis gastric dilation, OPSS
What is OPSS?
Overwhelming Post-Splenectomy Sepsis
What causes OPSS?
Increased susceptibility to fulminant bacteremia, meningitis, or pneumonia because of loss of splenic function
What is the incidence of OPSS in adults?
< 1%
What is the incidence and overall mortality of OPSS in children?
1-2% with 50% mortality
What is the typical presentation of OPSS?
Fever, lethargy, common cold, sore throat, URI followed by confusion, shock, and coma with death ensuing within 24 hours in up to 50% of patients
What are the common organisms associated with OPSS?
Encapsulated (e.g. Strep pneumo, Neisseria meningitides, H. flu)
What is the most common bacteria in OPSS?
Streptococcus pneumoniae
What is the preventative treatment of OPSS?
Vaccinations for pneumococcus, H. flu, and meningococcus; prophylactic penicillin for all minor infections/illnesses and immediate medical care if febrile illness develops
What is the best time to give immunizations to splenectomy patients?
Preoperatively, if at all possible.
If emergent, then 2 weeks post-operatively.
What lab tests are abnormal after splenectomy?
WBC count increases by 50% over the baseline; marked thrombocytosis occurs; RBC smear is abnormal
What are the findings on post-splenectomy RBC smear?
Peripheral smear will show Pappenheimer bodies, Howell-Jolly bodies, and Heinz bodies
When and how should thrombocytosis be treated?
When platelet count is > 1 million, most surgeons will treat with aspirin
What is the most common cause of splenic vein thrombosis?
Pancreatitis
What opsonins does the spleen produce?
Properdin, tuftsin
Think: PROfessionally TUF spleen
What is the most common cause of isolated gastric varices?
Splenic vein thrombosis (usually from pancreatitis)
What is the treatment of gastric varices caused by splenic vein thrombosis?
Splenectomy
Which patients develop hyposplenism?
Patients with UC
What vaccinations should every patient with a splenectomy receive?
Pneumococcus; meningococcus; H. flu type B
What is hypersplenism?
Can include:
- Hyperfunctioning spleen
- Documented loss of blood elements (WBC, Hct, platelets)
- Large spleen (splenomegaly)
- Hyperactive bone marrow (trying to keep up with loss of blood elements)
What is splenomegaly?
Enlarged spleen
What is ITP?
Idiopathic Thrombocytopenic Purpura:
Autoimmune (IgG) platelet destruction leading to troublesome bleeding and purpura
What is the most common cause of failure to correct thrombocytopenia after splenectomy for ITP?
Missed accessory spleen
What are the “I’s” of ITP?
Immune etiology (IgG anti-platelet antibodies)
Immunosuppressive treatment (steroids)
Immune globulin
Improvement with splenectomy
What is TTP
Thrombotic Thrombocytopenic Purpura
What is the treatment for TTP?
Plasmapheresis (splenectomy is a last resort)
What is the most common physical finding of portal hypertension?
Splenomegaly
