Spleen Disorders Flashcards
Diaphragmatic surface of the spleen ?
It is convex directed laterally and
related to diaphragm which separates it from lower part of left pleura, left lung , ribs & intercostal muscles.
Visceral surface of the spleen ?
It is directed medially and shows the hilum &
4 impressions:
Colic impression: anterior to the hilum , near lateral end &related to left colic flexure.
Pancreatic impression: just below the lateral end of the hilum , related to the tail of pancreas.
Renal impression: below hilum, related to front of left kidney.
Gastric impression: above the hilum & related to the fundus of the stomach.
Superior and inferior border of the spleen
Surface anatomy
It lies opposite left 9, 10, 11 ribs, its medial end
lies 1.5 inch from midline posterior & its lateral end in the left mid-axillary line.
Arterial supply
Splenic artery (arises from the coeliac trunk,
tortuous, runs on the upper border of pancreas) .
Venous drainage?
Splenic vein (runs behind the body of pancreas &
joins the superior mesenteric vein to form the portal vein ).
Peritoneum
nearly completely covered with. peritoneum & related to:
Gastro-splenic ligament: contains short gastric & left
gastroepiploic vessels , splenic lymph nodes , autonomic plexus and extraperitoneal fat.
Spleno-renal (Lieno-renal) ligament: contains tail of
pancreas & splenic vessels ,lymph nodes , autonomic plexus and extraperitoneal fat.
Phreno-colic ligament : between left colic flexure and
diaphragm , support the spleen from below. This ligament direct the enlarged spleen towards the right iliac fossa.
Hypersplenisim
This is a syndrome of splenomegaly combined with destruction of formed blood elements leading to one or more of the following:
• Anaemia;
• Leukopenia < 4-5 x 109/L;
• Thrombocytopenia < l00 X 109/L.
Hyposplenism
Hyposplenism is confirmed by the appearance of defective red cells in the peripheral circulation.
• The most frequent cause is surgical splenectomy.
Causes of splenomegaly
Infection
• Bacterial: Typhoid fever, endocarditis, septicemia, abscess
• Viral:E-B virus, CMV, and others
• Protozoal: Malaria, toxoplasmosis • Hematologic processes
• Hemolytic anemia: Congenital, acquired
• Extramedullary hematopoiesis: thalassemia, osteopetrosis, myelofibrosis
• Neoplasms
• Malignant: Leukemia, lymphoma, histiocytoses, metastatic tumors
• Benign: Hemagioma, hamartoma • Metabolic diseases
• Lipidosis: Niemann-Pick, Gaucher disease
• Mucopolysaccharidosis infiltration: Histiocytosis
• Cirrhosis
• Cysts
Causes of hyposplenism
• Splenectomy
• Splenic agenesis
• Coeliac disease
• Inflammatory bowel disease Systemic amyloidosis
• Old age
• Sickle cell anemia
• Systemic lupus erythematosus
Etiology of splenic abscess
• Hematogenic spread
• Infected trauma Infected splenic infarction
• Alcoholism
• DM
• Immunosuppression
• Drug abuser
Clinical features of splenic abscess
• Fever
• Abdominal Pain(maximum in the left hypochondria )
• Shoulder pain (Involvement of the diaphragmatic pleura )
• Pleuritic chest pain
• General malaise
• Dyspeptic symptoms
Imaginings investigations
Pyogenic splenic on axial CECT
- US
- CT
-MRI
Treatment of splenic abscess
• Splenectomy for most cases • Percutaneous drainage
Complications of splenic abscess
• Spontaneous rupture • Peritonitis sepsis
Treatment of splenic cyst
- Surgical treatment is only necessary for large symptomatic cysts after confirmation of the diagnosis by ultrasound or CT.
- Spleen-preserving excision is possible unless the cyst is very large or presents acutely with rupture and bleeding
INDICATIONS OF SPLENECTOMY
• Absolute Indications for Splenectomy
1. Splenic tumors
2. Echinococcal cyst
3. Hereditary spherocytosis – most common hemolytic anemia for which
splenectomy is indicated
4. Bleeding esophageal varices
5. Chronic lymphocytic leukemia
6. Hairy cell leukemia
7. Chronic myeloid leukemia – more to ease the pain 8. Sarcomas
9. Trauma
RELATIVE INDICATIONS FOR SPLENECTOMY
- Congenital hemolytic anemias
- Sickle cell anemia
- Idiopathic autoimmune hemolytic anemia
- Thrombocytic thrombocytopenic purpura
- Felty’s syndrome (non-caseating granulomas)/gaucher’s disease (lipid storage disease)/ Niemann-pick disease (abnormal storage of cholesterol and sphingomyelin)/amyloidosis (abnormal extracellular storage of protein)
- Hodgkin’s lymphoma and non-hodgekin’s lymphoma
- Idiopathic thrombocytopenic purpura
SURGICAL APPROACH
Open splenectomy = Emergency/ very large / Trauma
Laparoscopic splenectomy = small size
POSTOPERATIVE COMPLICATIONS early complications
Early complications:
1. Bleeding: slipped ligatures or from oozing of raw areas and sites of splenic adhesions.
2. Atelectasis, pneumonia and pleural effusion
3. Thrombosis and hypercoagulable state
4. Acute gastric dilation and hematemesis
5. Injury to surrounding organs like stomach , colon and pancreas.
6. Portal vein thrombosis.
Post op late complications
- Risk of thrombosis and pulmonary embolism
- Late recurrence of disease may complicate splenectomy like anemia and
thrombocytopenia, due to enlarged messed splenuculi . - C:post-splenectomy septicemia may result from streptococcus pneumoniae,
Neisseria meningitides, haemophilus influenzae and Escherichia coli. - D: the most important complication is overwhelming(opportunist) post
splenectomy infection(OPSI).
SPLENECTOMY OUTCOMES Post-operative appearance of:
A. Siderocytes
B. Howell-jolly bodies
C. Leukocytosis
D. Increased platelet count
OPPORTUNIST POST-SPLENECTOMY INFECTION (OPSI)
- Lifetime risk of severe infection
- Incidence of 3.2% post-splenectomy
- Loss of the spleen’s ability to filter and phagocytose bacteria and infected
RBC - Presents with pneumonia or meningitis
Most common sources of infection after splenectomy OPSI
a. Streptococcus pneumoniae – most common
b. Heamophilus influenzae B
c. Meningococcus
d. Group A streptococci
RISK FACTORS FOR THE DEVELOPMENT OF OPSI
A. Indication for splenectomy - hematologic disorder vs trauma
B. Overall immune status
C. Interval from the date of surgery – usually within 2 years
Prevention
• Appropriate and timely immunization
• Antibiotic prophylaxis
• Education
• Prompt treatment of infection.
VA C C I N AT I O N S
• Vaccinating against pneumococcus, meningococcus (both repeated every 5
years) and H. influenzae (repeated every 10 years).
• Such vaccinations should be administered at least 2 weeks before elective surgery and as soon as possible after recovery from surgery but before
discharge from hospital in all other cases.
• Annual influenza vaccine
ANTIBIOTIC PROPHYLAXIS
• Daily dose of penicillin or amoxycillin for the first 2–3 years after splenectomy
, as the risk of overwhelming sepsis is greatest within this period.
• It is thought that children who have undergone splenectomy before the age
of 5 years should be treated with a daily dose of penicillin until the age of 10
years.
• Prophylaxis in older children should be continued at least until the age of 16
years.
