Spleen

Question 1

Spleen responsibility

Answer 1

To remove old RBCs and bacteria from circulation

Question 2

Spleen anatomical boundaries

Answer 2

Superior = L diaphragm leaf

Inferior = Colon, splenic flexure, phrenocolic ligament

Medial = Pancreas tail and stomach

Lateral = rib cage

Anterior = rib cage, stomach

Posterior = rib cage

Question 3

What percent of patients have an accessory spleen?

Answer 3

20%

Question 4

Most common indications for splenectomy

Answer 4

1) Trauma
2) ITP refractory to steroids

In past, staging for Hodgkins required this but no more

Others:

1) Red cell disorders
- spherocytosis
- hemoglobinopathies (sickle cell, thalassemia, enzyme def)
- acquired AIHA, parasitic diseases

2) Platelet issues
- ITP and TTP

3) Lymphoid disorders
- Non-Hodgkin’s
- portal HTN
- splenic artery aneurysm

4) Bone marrow disorders
- myelofibrosis
- CML
- AML
- chronic myelomonocytic leukemia
- essential thrombocythemia
- polycythemia vera

5) Miscellaneous
- infections/abscess
- Storage diseases/infiltrative diseases like Gaucker’s, Nieman-pick, amyloidosis
- Felty syndrome’s
- cysts and tumors
- portal HTN
- splenic artery aneurysm

Question 5

Conditions associated with rupture of the spleen

Answer 5

1) Mono (spontaneous rupture)
2) Malaria
3) Blunt LUQ trauma (esp 9th and 10th ribs - 20% of cases)
4) Splenic abscess

Question 6

Complications following splenectomy

Answer 6

1 = sepsis!!!

Atelectasis (not taking deep breaths due to pain)/pneumonia (due to atelectasis sequestering bacteria)

Pleural effusion (left side)

Subphrenic abscess

Injury to pancreas (tail of pancreas hugs the spleen)

Postop hemorrhage

Thrombocytosis - many of the platelets that were sequestered in the spleen are now in circulation

Question 7

Benign tumors of spleen

Answer 7

Hemangioma/lymphangioma

Hamartomas

Primary cyst/echinococcal cyst

Question 8

Malignant tumors of spleen

Answer 8

Lymphomas or myeloproliferative diseases

Rare site for solid tumor metastatic disease

A common site for mets esp in lung and breast. But, it is rarely clinically significant and usually an autopsy finding

Question 9

H&P for splenic injury

Answer 9

H = check for preexisting disease that causes splenomegaly (more vulnerable to injury), details of injury mechanism

P = look for peritoneal irritation, Kehr’s sign, L-sided lower rib fractures, external signs of injury

Question 10

Treatment of splenic injury

Answer 10

Initial

1) ABCs
2) Patients who are stable or who stabilize with fluids can be managed conservatively
3) Further diagnostics:
- CT to define injury
- US maybe for initial assessment to detect hemoperitoneum (FAST)
- Angiogram - can use in stable patient (embolization of CT-identified injury)

Definitive:

1) Nonoperative management criteria:
- stable
- injury grade 1 or 2
- no evidence of injury to other intra-abdominal organs
- consists of bed rest, NGT decompression, monitored setting, serial exam, hematocrits

* patients with vascular blush on CT are likely to fail nonoperative measures*

2) operative management
- Signs of ongoing hemorrhage
- injury greater than grade 3
- failure of nonop therapy

3) ExLap
- splenectomy if spleen is primary source of exsanguinating hemorrhage
- If not, pack the area and search for other more life-threatening injuries and address those first
- Capsular bleeding and most grade 2 can be fixed with pressure and hemostatic stuff
- Persistent grade 2/3 bleeding= suture
- Multiple injuries = mesh to preserve spleen especially in kids

Question 11

What percentage of patients with splenic injury will present with hypotensive shock due to hemorrhage?

Answer 11

30%

Question 12

Grading spleen injury (AAST scale)

Answer 12

Grade 1 = hematoma/laceration. Subcapsular, nonexpanding 3cm deep or involving trabecular vessels

Grade 4 = Hematoma that is ruptured with active bleeding

Lac involving segmental or hilar vessels producing major devascularization (25% of spleen)

Grade 5 = shattered ass spleen with hilar vesicular injury resulting in devascularized spleen

Question 13

Causes of splenic abscess

Answer 13

Sepsis seeding

Infection from adjacent structures

Trauma

Hematoma

IV drug use

Question 14

Signs of splenic abscess

Answer 14

Fever, chills

LUQ tenderness and guarding

Spleen may or may not be palpable

Question 15

Diagnosis of splenic abscess

Answer 15

US = enlarged spleen with areas of lucency contained within

CT = abscess will show lower attenuation than surrounding spleen parenchyma. Defines the abscess better than US

Question 16

Tx for splenic abscess

Answer 16

Splenectomy for most cases

Percutaneous drainage for a large, solitary juxtacapsular abscess

Question 17

Complications fo splenic abscess

Answer 17

Spontaneous rupture

Peritonitis

Sepsis

Question 18

Diagnostic pentad for TTP

Answer 18

FAT RN

Fever
Anemia
Thrombocytopenia 
Renal dysfunction
Neuro dysfunction

Question 19

Platelet infusion during TTP

Answer 19

can fuel the fire

Exacerbate the consumption of platelets and clotting factors resulting in more thrombi in microvasculature

Plasmophoresis is treatment of choice

Question 20

HUS vs TTP

Answer 20

HUS is from EColi O157:H7

HUS does NOT have neuro signs