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Appendix > Spleen > Flashcards

Spleen Flashcards

1
Q

The most common anomaly of splenic embryology is?

A

the accessory spleen

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2
Q

Accessory spleen seen in what % of pts?

A

20%

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3
Q

80% of accessory spleens are found where?

A

splenic hilum and vascular pedicle

other areas; gastrocolic ligament, pancreatic tail, greater omentum, stomach greater curvature

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4
Q

What organs surround the spleen?

A

greater curvature of stomach
splenic flexture of colon
apex of left kidney
tail of pancreas

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5
Q

What ligaments tether the spleen in place?

A

spleno-colic ligament
gastro-splenic ligament
phreno-splenic ligament
spleno-renal ligament

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6
Q

Which ligament tethering the spleen contains vessels?

A

gastro-splenic ligament—> short gastrics
spleno-renal ligament–> splenic artery and vein and tail of pancreas

the remaining ligaments are avascular

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7
Q

Relationship between spleen and panrceas?

A

tail of pancreas lies within 1 cm of spleen 75% of time

known to abut the spleen in 30% of pts

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8
Q

What ribs protect spleen on left?

A

ribs 9, 10, 11

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9
Q

Spleen derives it’s blood supply from where?

A

splenic artery

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10
Q

Splenic artery can be characterized by the pattern of its terminal branches, which are?

A

magistral (30%)

distributed (70%)

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11
Q

What splenic artery branching type most common?

A

distributed–> short trunk with many long branches enter spleen

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12
Q

What is the magistral splenic artery pattern?

A

magistral–> long trunk, with few short branches entering spleen

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13
Q

Aside from the splenic artery the spleen also receives some its blood supply from?

A

short gastrics in the gastro-splenic ligament

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14
Q

What is the venous drainage of the spleen?

A

splenic vein–> joined by the SMV to enter into the portal vein

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15
Q

Parenchyma of spleen is made up of two parts:

A

red pulp (75% of splenic volume)

white pulp

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16
Q

In the spleen, the red pulp and white pulp interface where?

A

at the narrow marginal zone

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17
Q

Function of red pulp?

A

macrophages phagocytize aging RBCs as they try to pass

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18
Q

This component of the spleen serves as a filtration system, allowing macrophages to remove microorganisms, cellular debris and aging RBCs;

A

red pulp

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19
Q

What is the white pulp of the spleen?

A

at the end of splenic arterioles we have a peri-articular lymphatic sheath made of B cells and T cells

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20
Q

Between the white and red pulp we have the marginal zone, what cell types reside there?

A

macrophages

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21
Q

White pulp is involved in what type of immunity?

A

adaptive

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22
Q

Innate immune function of spleen occurs via?

A

marginal zone macrophages

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23
Q

The spleen acts as major site of clearance for what?

A

aging RBCs

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24
Q

Of a RBCs 120 days life cycle, how much of that time do they spend in the spleen?

A

2 days

spleen removes 20 cc of aging RBCs from circulation

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25
Q

What 3 things does the spleen produce?

A

opsonins
tuftins
properidin

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26
Q

What splenic product initiates alternate pathway of complement activation:

A

properidin

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27
Q

Splenomegaly vs hypersplenism:

A

splenomegaly–> abnormal enlargement of spleen

hypersplenism–> presence of one or more ctyopenias in context of normal functioning bone marrow

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28
Q

Half life of a neutrophil vs platelet?

A

neutrophil–> 6 hrs

platelet—> 10 days

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29
Q

OPSI is commonly caused by encapsulated organisms such as:

A

strep pneumo
h. flu
neissieria meningitidis

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30
Q

What causes hereditary spherocytosis?

A

deficiency/dysfunction in one of the erythrocyte membrane proteins; spectrin, ankyrin, band 3 protein

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31
Q

This is an inherited disorder where we have dysfunction of one of the erythrocyte membrane proteins like spectrin and ankyrin;

A

hereditary spherocytosis

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32
Q

WHat happens to RBCs in hereditary spherocytosis?

A

bilipid membrane layer is destabilized, get pathological release of membrane lipids

RBC becomes spherical, less deformable, gets trapped in spleen and destroyed

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33
Q

This is an AD dx affecting spectrin, a RBC cytoskeleton protein;

A

hereditary spherocytosis

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34
Q

Inheritance patterns of hereditary sphercytosis?

A

AD

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35
Q

What are some clinical findings and lab values we see with hereditary spherocytosis?

A

mild jaundice
splenomegaly on exam
varying degrees of anemia
spherocytes seen on blood smear

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36
Q

Why is cholecystectomy performed for hereditary spherocytosis?

A

pts have increased risk of pigmented stone formation due to destruction of RBCs

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37
Q

Most common hemolytic anemia for which splenectomy is indicated?

A

HS

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38
Q

When do we remove the spleen in someone with hereditary spherocytosis?

A

symptomatic hemolytic anemia
growth retardation
skeletal changes
extramedullary hematopoietic tumors in young pts

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39
Q

If gallstones co-exist with hereditary spherocytosis what do we do?

A

splenectomy + cholecystectomy

**prophylactic cholecystectomy is not indicated

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40
Q

When performing splenectomies in children affected by HS, at what age do we perform it?

A

by age 5

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41
Q

Why do we wait to perform splenectomies for HS in children until age 5?

A

preserve immune fx of spleen

reduce risk of OPSI

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42
Q

What are the two hereditary conditions assc with hemolytic anemias?

A

pyruvate kinase deficiency

G6P dehydrogenase deficiency

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43
Q

This d/o is is an AR disease that results in decreased RBC deformability and the formation of echinocytes:

A

PK deficiency

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44
Q

This is the most common RBC enzyme deficiency;

A

PK deficiency

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45
Q

FOr which inherited enzyme deficiency d/o is splenectomy indicated?

A

PK deficiency

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46
Q

Primary treatment for G6P deficiency?

A

NOT splenectomy

avoid foods, drugs that can precipitate a crisis

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47
Q

This is an X-linked inherited d/o affecting more people worldwide that PK deficiency;

A

G6P deficiency

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48
Q

Primary treatment of G6P deficiency?

A

void foods, chemicals, drugs that exacerbate hemolytic episodes

most pts have mild to mod sxs

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49
Q

THis is an autoimmune d/o characterized by low platelet count, mucocutaneous and petechiae bleeding;

A

ITP

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50
Q

What causes the low platelets seen in ITP:

A

premature removal of platelets opsonized by anti-platelet IGG made by the spleen

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51
Q

Typical presentation of ITP includes?

A 
purpura
epistaxis
gingival bleeding 
(less common; gi bleeding, hematuria)
(rare but fatal; intracranial bleeding)
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52
Q

Diagnosis of ITP involves what?

A

exclusion of other causes of thrombocytopenia

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53
Q

Incidence of major intracranial bleeding from ITP?

A

1%

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54
Q

Difference in presentation of ITP in children vs adults?

A

children; often present at young age, with sudden onset of petechiae, purpura days/weeks after an infectious process

adults; have a more chronic form of dx, with insidious onset

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55
Q

How common is splenomegaly with ITP?

A

uncommon

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56
Q

ITP predominantly affects men or women?

A

young women

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57
Q

First line therapy for ITP?

A

oral predinose 1.0 mg/kg/day

most responses occur with first 3 weeks

58
Q

When do we give IVIG for ITP?

A

usually for internal bleeding, in pregnant pts, pts being prepped pre-op

59
Q

Dose of IVIG for ITP?

A

1g/kg for 2-3 days

60
Q

When do we perform splenectomies for ITP?

A

pts with plts <10K for 6 weeks or longer
thrombocytopenia refractory to steroid therapy
pts who require toxic steroid doses for remission

61
Q

How is sickle cell disease inherited?

A

autosomal co-dominant

pts can be carriers who inherit one abnormal gene from one parent (heterozygous)

pts can have the disease if they inherit two abnormal genes (homozygous)

62
Q

What causes sickle cell dx?

A

mutated adenine to thymine in 6th codon of B-globin gene

valine substituted for glutamic acid

63
Q

Valine substituted for what in sickle cell dx?

A

glutamic acid

64
Q

Common reasons for splenectomy in pts with sickle cell dx?

A

recurrent sequestration crises
hypersplenism
splenic abscess

65
Q

What medication can we use in sickle cell dx?

A

hydroxyurea

66
Q

How does hydroxyurea work for sickle cell dx?

A

upregulates fetal Hgb

67
Q

What is a target cell?

A

RBC with nucleus in tact

68
Q

This d/o characterized by thrombocytopenia, microangiopathic hemolytic anemia and neurological disorders;

A

TTP

69
Q

What causes TTP?

A

large multimers of VW factor assc. with platelet clumping in pt’s blood

70
Q

What are the clinical features of TTP?

A 
petechiae
fevers
neuro sx
renal sx
cardiac sx
71
Q

The diagnosis of TTP is confirmed by blood smear, which shows what?

A

schistocytes
nucleated RBCs
basophilic stippling

72
Q

Tx for TTP?

A

plasma exchange is first line

splenectomy for pts who relapse or require multiple exchanges

73
Q

Where do we find accessory spleens commonly?

A

hilum 54%
pedicle 25%
greater omentum 12%
tail of pancreas 6%

74
Q

What is Hodkin’s dx?

A

malignant lymphoma affects adults in their 20’s 30s

75
Q

How do pts with Hodkin’s dx typically present?

A

cervical lymphadenopathy

rarely present with constitutional sxs

76
Q

What are the different types of Hodkin’s dx?

A

lymphocyte predominant
nodular sclerosing
mixed cellularity
lymphocyte depleted

77
Q

How do we classify Hodkin’s dx?

A

Ann Arbor classification system

78
Q

What’s the Ann Arbor classification system of Hodkin’s dx?

A

Stage 1 –> single lymphatic site

Stage 2–> 2 or more lymphatic sites on same side of diaphragm

Stage 3–> disease on both sides of the diaphragm w/splenic involvement

Stage 4–> disease disseminated into extralymphatic sites like liver, lung, bone marrow

79
Q

Most common primary splenic neoplasm?

A

NHL

80
Q

Hairy cell leukemia is a rare disorder, characterized by what?

A

splenomegaly
pancytopenia
neoplastic mononuclear cells in the peripheral blood

81
Q

What chromosomal marker associated with CML?

A

philadelphia chromosome; 9;22

82
Q

Chromosome 9 and 22 fuse, causing expression of a bcr/abl gene product, a tyrosine kinase which accelarates cell division and impairs DNA repair, this is seen in what?

A

CML

83
Q

Chromosome seen in CML, coding for bcr/abl tyrosine kinase?

A

9;22

84
Q

Solid tumors that most frequently spread to the spleen?

A

breast
lung
melanoma

85
Q

Angiosarcomas of the spleen have been linked to what environment exposures?

A

vinyl chloride

thorium dioxide

86
Q

How do we classify splenic cysts?

A

true cysts (can be parasitic vs non-parasitic)

pseudocysts

87
Q

True cysts of spleen are lined with a squamoues epithelium and stain for what 2 markers?

A

CEA

CA 19-9

88
Q

Primary true cysts of spleen make up what %?

A

10% of all non-parasitic splenic cysts

89
Q

Most non-parasitic splenic cysts are?

A

pseudocysts due to trauma

90
Q

Are true splenic cysts malignant?

A

benign

91
Q

Operative intervention for splenic cysts?

A

indicated for pts with symptoms and those w/large cysts

92
Q

When performing partial splenectomies for symptomatic or large cysts, what % of spleen remnant needed to protect against pneumococcal pneumonia?

A

25%

93
Q

Most true splenic parasitic cysts and occur in endemic areas such as:

A

Echinococcus species

94
Q

What do we see on imaging of splenic cysts suspected to be echinococcal?

A

cyst wall calcificatons

daughter cysts

95
Q

What do we worry about with parasitic splenic cysts?

A

rupture into abdomen

spillage of cyst contents and an anaphylactic rxn

96
Q

Tx of choice for parasitic cysts?

A

splenectomy

97
Q

Other tx for parasitic cysts beside splenectomy?

A

inject cyst with 3% NS
alcohol or silver nitrate

avoid rupture intra-op

98
Q

What makes a pseudocyst of the spleen a pseudocyst?

A

not lined by epithelium

99
Q

These makes up 70-80% of non-parasitic splenic cysts:

A

pseudocysts due to trauma

100
Q

What is the size cutoff for pseudocysts treatment?

A

asymptomatic <4 cm cysts involve with time

101
Q

Mortality rates of splenic abscesses?

A

15-20% in healthy pts

80% in immunocompromised pts

102
Q

70% of splenic abscesses are due to hematogenous spread from?

A

endocarditis
osteomyelitis
IV drug use

103
Q

How do we diagnose splenic abscesses?

A

CT

104
Q

Tx of splenic abscess depends on what?

A

whether it’s unilocular or multilocular

105
Q

1/3 of adult pts, splenic abscess tend to be what?

A

multilocular

106
Q

1/3 of children pts, splenic abscces tend to be what?

A

unilocular

107
Q

What is the tx for unilocular vs multilocular splenic abscesses?

A

unilocular—> percutaneous drainage + abx

multilocular–> splenectomy, drainage of LUQ, abx

108
Q

How common are splenic abscesses?

A

uncommon

0.14–0.7%

109
Q

Infectious mononucleosis due to EBV or CMV imparts a small risk of?

A

splenic rupture

splenic parenchyma infiltrated by inflammatory cells–> thins the capsule

rupture can occur after minor trauma

110
Q

Common organisms isolated from splenic abscesses?

A

streptococci and e.coli **MC

others; mycobacteria tb, salmonella

111
Q

MCC of splenic cysts worlwide?

A

parasites like echinococcus

112
Q

SPlenic cysts resulting from trauma are called?

A

pseudocysts

113
Q

What Ca most commonly spreads to spleen?

A

lung

114
Q

In terms of splenic artery aneurysm who is more affected men or women?

A

women 4;1

115
Q

In what part of splenic artery do we commonly seen splenic artery anuerysm?

A

mid to distal

116
Q

When do we treat splenic artery aneurysms?

A

presence of sxs
pregnancy
intent to get pregnant

117
Q

Tx for splenic artery aneurysms?

A

aneurysms in mid portion–>resection or ligation

distal portion–> need splenectomy

118
Q

Rheumatoid arthritis, neutropenia, splenomegaly make up what ?

A

Felty syndrome

119
Q

Preferred method of splenectomy?

A

laparoscopic

barring trauma and massive splenomegaly

120
Q

Disadvantage of laparoscopic splenectomy?

A

longer op times

difficult removing large organs

121
Q

When do we give vaccines prior to elective splenectomies?

A

2 weeks prior

122
Q

Most common fatal late complication of splenectomy?

A

OPSI

123
Q

After splenectomies when do we see OPSI?

A

most occurred after 2 yrs

42% occurred after 5 yrs

124
Q

OPSI as a result of dog bites due to what bacteria?

A

capnocytophaga canimorsus

125
Q

OPSI is greatest in pts who have had splenectomies for what?

A

hematologic disorders rather than trauma

126
Q

For post-splenectomy pts when do we give vaccines?

A

within 2 weeks of splenectomy if pt did not receive before surgery

127
Q

What vaccines do we give in splenectomized pts?

A

PPV23 (polyvalent pneumococcal vaccine)
h flu type B conjugate
meningococcal polysaccharide vaccine

128
Q

OPSI is more common children or adults?

A

adults

risk greatest within first 2 yrs

129
Q

What bacteria responsible for >50% of OPSI?

A

s. pneumo

130
Q

For emergent splenectomy cases why do we wait 2 weeks to vaccinate pts post-op?

A

transient immunosuppressions assc w/surgery

131
Q

What is the overall incidence of OPSI?

A

<1 %

132
Q

Most common method of intra-op splenic injuries?

A

improper splenic traction against its peritoneal attachments

causes capsular tears

lower pole more commonly injured to greater peritoneal attachments in lower pole

133
Q

What causes OPSI in splenectomized pts?

A

loss of splenic macrophages

diminished tuftsin production

loss of spleens reticuloendothelial system

*** in normal pts, these three things work together to opsonize bacteria from bloodstream

134
Q

Most common complication after open splenectomy?

A

left lower lobe atelectasis

135
Q

Most common indication for open splenectomy?

A

trauma

136
Q

Incision for open splenectomy?

A

left subcostal incision along left costal margin
2 fingerbreadths below

midline incision preferred when spleen ruptured or massive

137
Q

In splenectomies how do we gain access to lesser sac?

A

free up the gastro-splenic ligament

138
Q

WHere do we find the splenic artery?

A

superior border of pancreas

139
Q

When doing splenectomies for enlarged spleen why ligate splenic artery first?

A

easier to mobilize spleen
easier to dissect hilum
allows spleen to shrink a bit
allows for transfusion of RBCs and platelets

140
Q

After open splenectomy do we leave a splenic drain in place?

A

not routinely done

**risk of subphrenic abscess

141
Q

How do we mobilize the spleen in open splenectomies?

A

mobilize the spleno-colic ligament first
mobilize spleno-phrenic ligament
mobilize and ligate short gastrics
dissect hilum, ligate artery then vein

142
Q

Gold standard approach to splenectomy in pts with normal sized spleens?

A

laparoscopic

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