Spleen Flashcards
(17 cards)
Possible locations of accessory spleens
Splenic hilum and vascular pedicle (80%)
- Other locations
- gastrocolic ligament
- tail of the pancreas
- greater omentum
- the greater curve of the stomach
- splenocolic ligament
- small and large bowel mesentery
- left broad ligament in women
- left spermatic cord in men
Avascular plane (splenic ligaments)
- Splenocolic
- phrenosplenic
- splenorenal
gastrosplenic contains short gastric vessels.
The tail of the pancrea has been demonstrated to lie within 1cm of the splenic hilum (75%) of the time to actually abut the spleen in 30% of patients
Functions of the spleen
- Clearance of damaged or aged RBC from the blood
- Extramedullary site for hematopoeisis and recycling iron
- CLearance of encapsulated bacteria from the bloodstream
The spleen has both fast and slow circulation of blood. It is during slow circulation that blood travels through the reticular spaces and splenic cords
Proteins altered in hereditatry spherocytosis
- spectrin
- ankyrin
- band 3 protein
- protein 4.2
destabilization of the membrane lipid bilayer, Allows a release if lipids from the membrane causing a reduction in membrane surface area and a lack of deformability
The disproportionately high rate of overwhelming post splenectomy infection in thalassemia patients is thought to be due to an immune deficiency. What strategies has been shown to reduce mortality?
Partial splenectomy
- Iron overload is associated with both thalassemia as well as transfusions
- splenectomy should be delayed until the patient is older than 4 years unless absolutely
- Transfusion >9 mg/dL
A 30 year old woman presents to her primary care provider with complaints of bleeding gums while brushing her teeth as well as menorrhagia and several episodes of epixtaxis. She has been previously healthy with no prior medical problems or surgeries. Examination reveals petechiae and ecchymosis over the lower extremities. Lab resutls show WBC 7000/mm3, Hgb 15 g/dL, hematocrit 42% and platelet count 28000/mm3 with numerous megakaryocytes on peripheral smear. First line therapy for this condition would be
Oral prednisone
- ITP - autoimmune disorder characterized by a low paltelt count and mucocutaneous and petechial bleeding
- response occuring within the first 3 weeks after initiating therapy
- IV immunoglobulin is given for internal bleeding with platelt counts <5000/mm3, when extenive purpura exists
- Rituximab and thrombopoetin receptor anatgonists are second line treatment options
- Splenectomy is an option for refractory ITP
The most common physical finding in apatient with hairy cell leukemia (HCL) is
Massive splenomegaly
- Hairy cell leukemia - 2% of all adult leukemias
- splenomegaly, pancytopenia, and large number of abnormal lymphocytes in the bone marrow
- irrgeluar hair-like cytoplasms
- Most common PE splenomegaly (80%), spleen is often palpable 5cm below the costal margin
- Splenectomy does not correct underlying disorder
- Newer chemotherapeutic agents
- 2 deoxycoformycin
- 2-chlorodeoxyadenosine
Indication for splenectomy in a patient with CML
Symptomatic relief of early satiety
- splenectomy is indicated to ease pain and early satiety
- CML - primitive puripotent stem cells in the bone marrow, resulting in a significant increase in erythroid, megakaryocytic and pluripotent progenitors in the peripheral blood smear
- Chromosome 9 and the abl gene on chromosome 22
Idication for splenectomy in Polycythemia ver
Symptoms related to splenomegaly
- Polycythemia vera is a clonal, chronic progressive myeloproliferative disorder characterized by an increase in RBC mass
- leukocytosis, thrombocytosis and splenomegaly
- rsik for malignant transformation to myelofibrosis or AML
- Diagnosis is established by an elevated RBC mass (>25% of mean predicted value), thrombocytosis, leukocytosis, normal arterial oxygen saturation in the presence of icnreased RBC mass, splenomegaly and low EPO
Which of the following is the most common etiology of splenic cysts worldwide?
Parasitic infection
- echinococcal. Symptomatic parasitic cysts are best treated with splenomectomy.
- other treatment
- percutaneous aspiration
- Nonparasitic cysts (pseudocyst)
- trauma
- dermoid, epidermoid, and epithelial cells
Indication for surgical treatment of a splenic aneurysm
Pregnancy (70% mortality due to tuptue)
- splenic artery aneurysm is the most common visceral artery aneurysm
- usually arises in the middle to distal portion of the spelnic artery
- risk of rupture: 3% to 9%
- mortality is significantly higher in patients with underlying portal hypertension (>50%)
- Asymptomatic patients,
- size gretaer than 2cm
- Aneursym resection or ligation alone is acceptable for amenable lesions in the mid-splenic artery, but distal lesions in close proximity to the splenic hilum should be treated with concomitant splenectomy
A 45 year old man presents to the emergency department with emesis of bright red blood. Lab results include Hgb 10 g/dL, Hct 30%, platelets 300,000, INR 1.0 , AST 30 ALT 45 and albumin 4 g/dL. Adter appropriate resuscitation he undergoes EGD which is notable for gastric varices. What is the appropriate treatmetn for his condition?
Splenectomy
- While portal hypertension is msot commonly a result of cirrhosis it can result from other causes such as splenic vein thrombosis
- can present with bleeding from gastric varices in the setting of normal liver function test results
Felty syndrome
Triad of Rheumatoid arthritis, splenomegaly, and neutropenia
- Immune complexes coat the surface of WBCs, leading to their sequestration and clearance in the spleen with subsequent neutropenia
Which of the following is the most effective prevention strategy against OPSI?
Vacciantion 2 weeks before splenectomy
True regarding laparoscopic splenectomy
- Shorter hospital stays
- decreased intraoperative blood loss
- associated with decreased morbidity
- patients are positioned in the rigth lateral decubitus position or the 45 degrees right lateral decubitus position
Most common complication following open splenectomy
Left lower lobe atelectasis
- Pulmonary complications
- left lower lobe atelectasis
- pleural effusion
- pneumonia
- left lower lobe atelectasis
- Hemorrhagic
- intraoperative hemorrhage
- postop hemorrhage
- subphrenic hematoma
- Infectious complications
- subphrenic abscess
- left upper quadrant
- wound infection
- subphrenic abscess
- Pancreatic complications
- pancreatitis
- pseudocyst formastion
- pancreatic fistula
- Thromboembolic complications
- Deep venous thrombosis
- portal vein thrombosis
Prophylactic antibiotic therapy for asplenic patients
Antibiotic therapy in splenic patients fall into three categories
- Deliberate therapy for established or presumed infections
- prophylaxis in anticipation of invasive procedures
- general prophylaxis
Common recommendations include daily antibiotics until 5 years of age or at least 5 years after splenectomy with some advocating continuing antibiotics until young adulthood
