Spleen and Splenectomy, C60 P458-463

Question 1

Which arteries supply the
spleen?
P458

Answer 1

Splenic artery (a branch of the celiac
trunk) and the short gastric arteries that
arise from the gastroepiploic arteries

Question 2

What is the venous drainage
of the spleen?
P458

Answer 2

Portal vein, via the splenic vein and the

left gastroepiploic vein

Question 3

What is said to “tickle” the
spleen?
P459

Answer 3

Tail of the pancreas

Question 4

What percentage of people
have an accessory spleen?
P459

Answer 4

≈20%

Question 5

What percentage of the total
body platelets are stored in
the spleen?
P459

Answer 5

33%

Question 6

What are the functions of
the human spleen?
P459

Answer 6

Filters abnormal RBCs (does NOT store
RBCs like canine spleen!), stores platelets,
produces tuftsin and properdin (opsins),
produces antibodies (especially IGM) and
is site of phagocytosis

Question 7

What is “delayed splenic
rupture”?
P459

Answer 7

Subcapsular hematoma or
pseudoaneurysm may rupture some time
after blunt trauma, causing “delayed
splenic rupture”; rupture classically
occurs about 2 weeks after the injury and
presents with shock/abdominal pain

Question 8

What are the signs/symptoms
of ruptured/injured spleen?
P459

Answer 8

Hemoperitoneum and Kehr’s sign, LUQ

abdominal pain, Ballance’s sign

Question 9

What is Kehr’s sign?

P459

Answer 9

Left shoulder pain seen with splenic

rupture

Question 10

What is Ballance’s sign?

P459

Answer 10

LUQ dullness to percussion

Question 11

What is Seagesser’s sign?

P459

Answer 11

Phrenic nerve compression causing neck

tenderness in splenic rupture

Question 12

How is a spleen injury
diagnosed?
P459

Answer 12

Abdominal CT, if the patient is stable;
DPL or FAST exam if the patient is
unstable

Question 13

What is the treatment?

P459

Answer 13

1. Nonoperative in a stable patient with
    an isolated splenic injury without hilar
    involvement/complete rupture
2. If patient is unstable, DPL/FAST
    laparotomy with splenorrhaphy or
    splenectomy
3. Embolization is an option in selected
    patients

Question 14

What is a splenorrhaphy?

P460

Answer 14

Splenic salvage operation: wrapping vicral
mesh, aid of topical hemostatic agents or
partial splenectomy, sutures (buttressed)

Question 15

What are the other
indications for splenectomy:
Malignant diseases?
P460

Answer 15

Hodgkin’s staging not conclusive by CT
    scan (rare)
Splenic tumors (primary/metastatic/
    locally invasive)
Hypersplenism caused by other
    leukemias/non-Hodgkin’s lymphomas

Question 16

What are the other
indications for splenectomy:
Anemias?
P460

Answer 16

Medullary fibrosis with myeloid
    metaplasia
Hereditary elliptocytosis
Sickle cell anemia (rare, most
    autosplenectomize)
Pyruvate kinase deficiency
Autoimmune hemolytic anemia
Hereditary spherocytosis
Thalassemias (e.g., 	ℬ-thalassemia major
    a.k.a. Cooley’s)

Question 17

What are the other
indications for splenectomy:
Thrombocytopenia?
P460

Answer 17

ITP (Idiopathic Thrombocytopenic
Purpura)
TTP (Thrombotic Thrombocytopenic
Purpura)

Question 18

What are the other
indications for splenectomy:
Miscellaneous indications?
P460

Answer 18

Variceal bleeding with splenic vein
thrombosis, Gaucher’s disease, splenic
abscess, refractory splenic cysts,
hypersplenism, Felty’s syndrome

Question 19

Is G6PD deficiency an
indication for splenectomy?
P460

Answer 19

NO

Question 20

What are the possible
postsplenectomy
complications?
P460

Answer 20

Thrombocytosis, subphrenic abscess,
atelectasis, pancreatitis gastric dilation,
and Overwhelming PostSplenectomy
Sepsis (OPSS)

Question 21

What causes OPSS?

P460

Answer 21

Increased susceptibility to fulminant
bacteremia, meningitis, or pneumonia
because of loss of splenic function

Question 22

What is the incidence of
OPSS in adults?
P461

Answer 22

< 1%

Question 23

What is the incidence and
overall mortality of OPSS in
children?
P461

Answer 23

1% to 2% with 50% mortality rate

Question 24

What is the typical
presentation of OPSS?
P461

Answer 24

Fever, lethargy, common cold, sore
throat, URI followed by confusion, shock,
and coma with death ensuing within 24
hours in up to 50% of patients

Question 25

What are the common organisms associated with OPSS? P461

Answer 25

Encapsulated: Streptococcus pneumoniae, Neisseria meningitides, H. influenzae

Question 26

What is the most common bacteria in OPSS? P461

Answer 26

Streptococcus pneumoniae

Question 27

What is the preventive treatment of OPSS? P461

Answer 27

``` Vaccinations for pneumococcus, H. influenzae, and meningococcus Prophylactic penicillin for all minor infections/illnesses and immediate medical care if febrile illness develops ```

Question 28

What is the best time to give immunizations to splenectomy patients? P461

Answer 28

Preoperatively, if at all possible If emergent, then 2 weeks postoperatively

Question 29

What lab tests are abnormal after splenectomy? P461

Answer 29

WBC count increases by 50% over the baseline; marked thrombocytosis occurs; RBC smear is abnormal

Question 30

What are the findings on postsplenectomy RBC smear? P461

Answer 30

Peripheral smear will show Pappenheimer bodies, Howell-Jolly bodies, and Heinz bodies

Question 31

When and how should thrombocytosis be treated? P461

Answer 31

When platelet count is > 1 million, most | surgeons will treat with aspirin

Question 32

What is the most common cause of splenic vein thrombosis? P461

Answer 32

Pancreatitis

Question 33

What opsonins does the spleen produce? P461

Answer 33

PROperdin, TUFtsin (Think: | “PROfessionally TUF spleen”)

Question 34

What is the most common cause of ISOLATED GASTRIC varices? P462

Answer 34

Splenic vein thrombosis (usually from | pancreatitis)

Question 35

What is the treatment of gastric varices caused by splenic vein thrombosis? P462

Answer 35

Splenectomy

Question 36

Which patients develop hyposplenism? P462

Answer 36

Patients with ulcerative colitis

Question 37

What vaccinations should every patient with a splenectomy receive? P462

Answer 37

Pneumococcus Meningococcus Haemophilus influenzae type B

Question 38

Define hypersplenism. | P462

Answer 38

``` Hyperfunctioning spleen Documented loss of blood elements (WBC, Hct, platelets) Large spleen (splenomegaly) Hyperactive bone marrow (trying to keep up with loss of blood elements) ```

Question 39

Define splenomegaly. | P462

Answer 39

Enlarged spleen

Question 40

What is idiopathic thrombocytopenic purpura (ITP)? P462

Answer 40

Autoimmune (antiplatelet antibodies IgG in 90% of patients) platelet destruction leading to troublesome bleeding and purpura

Question 41

``` What is the most common cause of failure to correct thrombocytopenia after splenectomy for ITP? P462 ```

Answer 41

Missed accessory spleen

Question 42

What are the “I’s” of ITP? | P462

Answer 42

``` Immune etiology (IgG antiplatelets ABs) Immunosuppressive treatment (initially treated with steroids) Immune globulin Improvement with splenectomy (75% of patients have improved platelet counts after splenectomy) ```

Question 43

What is TTP? | P462

Answer 43

Thrombotic Thrombocytopenic Purpura

Question 44

What is the treatment of choice for TTP? P463

Answer 44

Plasmapheresis (splenectomy reserved as | a last resort—very rare)

Question 45

What is the most common physical finding of portal hypertension? P463

Answer 45

Splenomegaly