SPLEEN

Question 1

Vascular vs. avascular ligaments of spleen

Answer 1

vascular: splenorenal (hilar vessels + panc tail), gastrosplenic (short gastrics)
avascular: splenocolic, splenophrenic

Question 2

What are: Howell-Jolley bodies

Answer 2

nuclear remnant; most reliable to detect asplenic smear

Question 3

What are: target cells

Answer 3

immature RBC (target is nucleus)

Question 4

What are: Pappenheimer bodies

Answer 4

iron granules

Question 5

What are: Heinz bodies

Answer 5

intracellular denatured Hgb

Question 6

What are: Spur cells

Answer 6

deformed RBC membranes

Question 7

For splenectomy, what do you ligate first: splenic vein vs. artery?

Answer 7

artery

Question 8

Patho: idiopathic thrombocytopenic purpura

Answer 8

Ab to glycoproteins GP2b3A and GP1A2A

Question 9

Patho: hereditary spherocytosis

Answer 9

autosomal defect in cell membrane (spectrin)

Question 10

Prophylactic mgmt children w/ hereditary spherocystosis

Answer 10

splenectomy for symptomatic children >6yo (time to develop immunity) + 2-wk pre-op vaccinations

Question 11

Anemia + splenomegaly in child, suspect…?

Answer 11

hereditary spherocytosis

Question 12

MCC hereditary reason for splenectomy that is not structure-related

Answer 12

pyruvate kinase def: hemolytic anemia 2/2 defect in glucose metabolism

Question 13

Mgmt for splenic cysts

Answer 13

if symptomatic or >5cm -> laparoscopic cyst excision or fenestration

Question 14

Mgmt: splenic artery aneurysm

Answer 14

> 2cm -> repair

female of child-bearing age of ANY size -> repair (coil embolize, covered stent)

Question 15

Mgmt splenic artery aneurysm at distal hilum of spleen

Answer 15

splenectomy

Question 16

Sxs splenic artery aneurysm rupture

Answer 16

“double rupture sign” = acute abdominal pain, but stabilize (bc tamponade by lesser sac) -> lesser sac ruptures -> intraperitoneal blood

Question 17

Splenectomy population most at risk of OPSI

Answer 17

children, particularly if splenectomy 2/2 beta-thalassemia

Question 18

MC location accessory spleen

Answer 18

hilum

Question 19

MC organism responsible for OPSI

Answer 19

strep pneumo

Question 20

Hypotensive + tender abdominal exam post-splenectomy, suspect…?

Answer 20

short gastric bleed

Question 21

Fluid collection s/p splenectomy, concern for…?

Answer 21

pancreatic leak from tail

Question 22

Patho: TTP (thrombotic thrombocytopenic purpura)

Answer 22

ADAMTS13 metalloproteinase defect -> cannot break down wWF -> platelet aggregation in microvasculature

Question 23

Sxs TTP

Question 24

MC primary splenic neoplasm

Answer 24

non-Hodgkin’s lymphoma

Question 25

When give platelets intra-op splenectomy for ITP?

Answer 25

after ligating splenic artery, unless bleeding and need to give for hemostasis

Question 26

What else do you need to check for in pts with hereditary spherocytosis that you would have to intervene for?

Answer 26

gallstones from hemolysis; may do cholecystectomy at time of splenectomy

Question 27

MC visceral artery aneurysm

Answer 27

splenic artery

Question 28

Mgmt splenic hemangioma

Answer 28

if symptomatic -> splenectomy

Question 29

Splenic hemangiosarcoma associated with ... exposure?

Answer 29

vinyl chloride and thorium dioxide

Question 30

First step in child w/ fever + hx splenectomy

Answer 30

immediate broad spectrum Abx (high mortality)

Question 31

Mgmt TTP

Answer 31

emergency plasmaphoresis

Question 32

s/p sleeve gastrectomy + CT w/ infarcted superior pole of spleen

Answer 32

normal after takedown of short gastrics - non-op mgmt, pain mgmt, will resolve spontaneously

Question 33

Spleen in RLQ + abd US shows no flow in splenic vein... suspect?

Answer 33

wandering spleen 2/2 failure of fusion of dorsal mesogastrium -> lack of splenic ligaments

Question 34

Mgmt wandering spleen

Answer 34

increased risk splenic torsion/infarction -> splenopexy (unless infarcted, then need splenectomy)

Question 35

If isolated gastric varices, suspect...?

Answer 35

splenic vein thrombosis

Question 36

Isolated gastric varices 2/2 retrograde flow through...?

Answer 36

short gastric and posterior gastric veins

Question 37

Dx splenic vein thrombosis

Answer 37

abdominal ultrasound

Question 38

Mgmt nonparasitic splenic cysts

Answer 38

obs, most asymptomatic. if symptomatic, relief with aspiration (often recur) suggests benefit of operative mgmt

Question 39

Mgmt splenic abscess

Answer 39

perQ drain + IV Abx (high mortality rate)

Question 40

The most consistent predictor of response to splenectomy from ITP is...?

Answer 40

young age

Question 41

DVT prophylaxis during non-op mgmt spleen lac

Answer 41

early use of LWMH (<3d) does NOT increase failure rate for non-op mgmt of spleen lac - must have trauma pts on DVT ppx

Question 42

After non-op spleen lac, child should be kept on bed rest until what criteria is fulfilled?

Answer 42

- Hct stabilizes | - abdominal pain resolves

Question 43

After non-op spleen lac, how long before can return to full activity?

Answer 43

Grade of splenic injury + 2 weeks

Question 44

Etiology of popliteal artery entrapment syndrome

Answer 44

MC 2/2 congenital anomaly where medial/lateral gastrocnemius head shifted to artery -> compression during knee flexion

Question 45

Popliteal entrapment causes ?? pathology of popliteal artery that -> parasthesia and complete occlusion or thrombosis of artery

Answer 45

popliteal artery fibrosis

Question 46

Mgmt splenic injury by grade + unstable, or requiring continued transfusions

Answer 46

Grade 1 = topical hemostatic agents, cautery 2/3 = splenorrhaphy with suture or absorbable mesh repair (or omentum 4/5 = splenectomy required

Question 47

How to mobilize spleen?

Answer 47

Must medialize spleen. - ligate splenorenal ligament (contains splenic vessels) - ligate splenocolic ligament - divide splenophrenic ligament (avascular)

Question 48

Should drain be placed after splenectomy?

Answer 48

Not routinely (associated with devel of abscess) - only if coexisting injury to pancreatic tail or renal collecting duct

Question 49

Mgmt splenic injury by grade + unstable, or requiring continued transfusions

Answer 49

Grade 1 = topical hemostatic agents, cautery 2/3 = splenorrhaphy with suture or absorbable mesh repair (or omentum 4/5 = splenectomy required

Question 50

How to mobilize spleen?

Answer 50

Must medialize spleen. - ligate splenorenal ligament (contains splenic vessels) - ligate splenocolic ligament - divide splenophrenic ligament (avascular)

Question 51

Should drain be placed after splenectomy?

Answer 51

Not routinely (associated with devel of abscess) - only if coexisting injury to pancreatic tail or renal collecting duct