Splenic Pathology Flashcards
why is splenic infarction rare?
collateral circulation thanks to dual supply from the splenic artery and the left gastroepiploic artery
what is a splenic infarct?
occlusion of the splenic artery or one of its branches –> necrosis
what are the causes of splenic infarction?
haematological disorders: sickle cell, leukaemia or lymphomas, chronic myeloid leukaemia
emboli: post-Mi mural thrombus, a-fib, endocarditis
rarer: trauma, vasculitis, surgery e.g liver transplant
what are the clinical features of splenic infarction?
can be completely asymptomatic
pain and tenderness in LUQ
N&V, fever, pleuritic chest pain –> not common
may present with complications e.g. splenic abscess or auto-splenectomy
what are the differential diagnoses for splenic infarcts?
important ones:
- pyelonephritis
- peptic ulcer disease
- ureteric colic
- left-sided basal pneumonia
what investigations should be performed in suspected splenic infarct?
what are the relevant findings?
bloods:
FBC, U&E, LFT, coagulation screen –> aid diagnosis of haematological cause
CT abdomen with IV contrast - gold standard
- a segmented wedge pointing to the hilum will be hypoattenuated
(if the splenic artery is occluded the entire spleen may be hypoattenuated)
*scan on teach me surgery
what is the management for splenic infarcts in the short and long-term?
there are no specific treatments
short-term management :
monitor and provide appropriate analgesia and iv hydration.
the underlying cause should be identified
long-term management :
splenectomy avoided - risk of overwhelming post-surgical infection (OPSI) however may be required in recurrent disease
vaccination against encapsulated bacteria (H. influenzae, S. pneumoniae, Niesseria Meningitides) in severe infarcts
prophylactic Abx - low dose penicillin V
what are the complications of splenic infarcts?
when do they develop?
Splenic abscess:
seen in non-sterile embolus e.g infective endocarditis
embolus seeds infection in necrotic splenic tissue
-difficult to differentiate (CT and explorative surgery)
Auto-splenectomy:
repeated splenic infarction –> fibrosis and atrophy –> complete atrophy –> auto-splenectomy
- most common cause in sickle-cell anaemia (crises result in recurrent occlusions)
what are the causes of splenic rupture?
most common cause –> blunt trauma e.g seat belt injuries
iatrogenic
splenomegaly –> stretches capsule –> more disposed to rupture
what are the clinical features of splenic rupture?
- clinical features of hypovolemic shock
- abdo pain (pain in the left shoulder as blood irritates the diaphragm)
- LUQ tenderness
what are the investigations performed in splenic rupture and what are the findings??
patients with haemaeodynamic instability with peritonism = abdo bleeding until proven otherwise–> immediate laparatomy
haemodynamically stable = urgent CT CAP with IV contrast –> identify and assess splenic injury
what scoring scale is used to determine the management of splenic ruptures?
the scoring system used is the American Association for the surgery of trauma (AAST) splenic injury scale
the scoring system is 1 - 5 and determines management
what is the management of splenic rupture?
resuscitation and ALTS for all patients
haemodynamically unstable / grade 5 injury –> urgent laparatomy
haemodynamically stable, grade 1-3 = conservative treatment:
- high dependancy for observation with serial abdo exam for deterioration
- strict bed rest and repeat CT 1 week post-injury
- increasing tenderness/periotonitis –> imaging/laparoomy
- prophylactic vaccinations on discharge
what are the complications of conservative treatment?
- ongoing bleeding
- splenic necrosis
- splenic abcess/cyts
- thrombocytosis –> DVT and portal vein thrombosis
what is OPSI?
why does it occur and who is it avoided?
overwhelming post-splenectomy inefction (OPSI)
occurs in asplenic patients as they cannot mount an immune response against encapsuated bacteria –> sepsis
avoided via vaccinations against the three encapsulated bacteria and prophylactic Penicilin V
