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General Surgery: Quid Refert, Dummodo Non Desinas, Tardius Ire
General Surgery: Quid Refert, Dummodo Non Desinas, Tardius Ire
Ire
GENERAL
SPLEEN
ANATOMY
o Red
pulp:
75%
of
total
volume.
Comprised
of
venous
Since
this
is
not
discussed
by
doc,
I
included
the
book
as
part
of
the
trans
J
sinuses.Separated
by
reticulum.Contains
macrophages.Serves
as
filter,
removes
microrganisms,
v Adult
spleen
weighs
between
100
to
150
grams.
7-‐11cm-‐length
cellular
debris,antigen-‐antibody
complexes
and
old
v It
is
located
in
the
left
upper
quadrant
and
protected
by
the
lower
erythrocytes
portion
of
the
rib
cage
o White
pulp-‐consists
of
lymphoid
follicles
v Its
position
is
maintained
by
several
ligaments:
• Serves
the
immunologic
function
of
the
spleen
o Splenophrenic
-‐-‐
Marginal
zone
-‐
poorly
defined
vascular
space
between
pulps.
It
contains
o Splenorenal
sequestered
foreign
materials
and
plasma
as
well
as
abnormal
cellular
elements
o Splenocolic
o Gastrosplenic
(contains
the
short
gastric
vessels)
BOOK
v It
is
supplied
by
the
Splenic
Artery
(branch
of
the
celiac
artery);
venous
drainage
course
through
the
splenic
vein
v Largest
reticuloendothelial
organ
in
the
body
v Accessory
spleens
have
been
reported
in
14
to
30
%
of
patients
v Arising
from
the
primitive
mesoderm
as
an
outgrowth
of
the
left
usually
seen
at
the
hilum
of
the
spleen,
gastrosplenic,
splenocolic,
side
of
the
dorsal
mesogastrium.
gastrocolic,
splenorenal
ligaments
and
greater
omentum
v By
the
fifth
week
of
gestation
the
spleen
is
evident
in
an
embryo
8
mm
long
v MC
anomaly
of
splenic
embryology-‐
accessory
spleen
v Over
80%
of
accessory
spleens
are
found
in
the
region
of
the
splenic
hilum
and
vascular
pedicle.
v
Other
locations
for
accessory
spleens
in
descending
order
of
frequency
are:
the
gastrocolic
ligament,
the
tail
of
the
pancreas,
the
greater
omentum,
the
greater
curve
of
the
stomach,
the
splenocolic
ligament,
the
small
and
large
bowel
mesentery,
the
left
broad
ligament
in
women,
and
the
left
spermatic
cord
in
men.
v The
abdominal
surface
of
the
diaphragm
separates
the
spleen
from
the
lower
left
lung
and
pleura
and
the
ninth
to
eleventh
ribs.
v The
visceral
surface
of
the
organ
faces
the
abdominal
cavity
and
contains
gastric,
colic,
renal,
and
pancreatic
impressions.
v Spleen
size
and
weight
vary
with
age
and
underlying
pathologic
conditions,
but
spleen
size
and
weight
diminish
in
the
elderly.
v 7
to
11
cm
in
length
and
weighs
150
g
(range
70
to
250
g)-‐average
adult
spleen
• Accessory
spleen:
The
accessory
spleens
seen
here
at
the
hilum
of
v Most
authors
would
agree
that
"splenomegaly"
would
apply
to
the
normal-‐sized
spleen
are
not
uncommon
and
by
themselves
have
organs
weighing
500
mg
or
more
and/or
15
cm
or
more
in
length.
no
significance
v To
be
palpable
below
the
left
costal
margin,
a
spleen
must
be
at
least
double
normal
size.
v The
superior
border
of
the
spleen,
which
separates
the
diaphragmatic
surface
from
the
gastric
impression
of
the
visceral
surface,
often
contains
one
or
two
notches,
which
can
be
pronounced
when
the
spleen
is
greatly
enlarged.
v Of
particular
clinical
relevance,
the
spleen
is
suspended
in
position
by
several
ligaments
and
peritoneal
folds
to
the
colon
(splenocolic
ligament);
the
stomach
(gastrosplenic
ligament);
the
diaphragm
(phrenosplenic
ligament);
and
the
kidney,
adrenal
gland,
and
tail
of
the
pancreas
(splenorenal
ligament)
Blood
supply:
v The
spleen
derives
most
of
its
blood
from
the
splenic
arterythe
longest
and
most
tortuous
of
the
three
main
branches
of
the
celiac
artery.
Accessory
Spleen
v The
splenic
artery
can
be
characterized
by
the
pattern
of
its
terminal
branches.
v Splenosis
v The
distributed
type
of
splenic
artery
is
the
most
common
(70%)
o Autotransplantation
of
splnenic
fragments
after
trauma
and
is
distinguished
by
a
short
trunk
with
many
long
branches
o Capable
of
performing
some
reticuloendothelial
function
entering
over
three
fourths
of
the
medial
surface
of
the
spleen.
v The
pulp
is
consist
of
three
(3)
zones:
I PUSH MO LANG YAN! J
¬ istepania¬
Page
1
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7
v The
less
common
(30%)
magistral
type
of
splenic
artery
has
a
DIAGNOSTICS
long
main
trunk
dividing
near
the
hilum
into
short
terminal
branches,
which
enter
over
25
to
30%
of
the
medial
surface
of
1.
Evaluation
of
size
the
spleen.
a.
Physical
Examination
v The
spleen
also
receives
some
of
its
blood
supply
from
the
short
• Normally
not
palpable
gastric
vessels,
which
are
branches
of
the
left
gastroepiploic
• Felt
in
about
2
%
of
healthy
adults
artery
running
within
the
gastrosplenic
ligament.
• No
significant
dullness
elicited
by
percussion
v The
splenic
vein
accommodates
the
major
venous
drainage
of
over
spleen
either
anteriorly
or
laterally
the
spleen.
• As
organ
enlarges,
dullness
is
detected
at
the
th
v
It
joins
the
superior
mesenteric
vein
to
form
the
portal
vein
level
of
the
9
ICS
in
the
left
anterior
axillary
line
b.
MRI
–
depicts
the
spleen
and
define
abnormalities
in
size,
shape
and
parenchymal
PHYSIOLOGY
pathology,
e.g.
cyst,
abscess
or
tumor
c.
99Tc
sulfur
colloid
–
defines
the
organ
v Filtering
Functions
2.
Evaluation
of
Function
o Most
important
function
– Functional
abnormality
of
hypersplenism
is
manifested
by
o Splenic
blood
flow
is
approximately
350
L/day
reduction
in
number
of
RBC,
neutrophils,
platelets
in
the
o Removal
of
abnormal
red
blood
cells-‐Howell-‐jolly
peripheral
blood
bodies,Heinz
bodies,
Pappenheimer
bodies.
– Increase
in
the
rate
of
red
cell
destruction
will
always
Approximately
20
ml
of
aged
RBC
are
removed
during
the
result
in
compensatory
rise
in
the
rate
of
production
course
of
the
day
unless
disease
in
bone
marrow
coexists
–
the
hallmark
of
o Removal
of
abnormal
white
cells,
normal
and
abnormal
reticulocytosis
in
the
absence
of
blood
loss
platelets
and
cellular
debris
o It
can
clear
organisms
contained
w/in
the
erythrocytes(
SPLENECTOMY
malaria
&
Bartonella)
o Can
clear
unopsonized
bacteria
and
microrganisms
for
w/c
the
body
has
no
anti-‐bodies
PRE
OPERATIVE
AND
POST
OPERATIVE
indications
– Splenic
rupture
(trauma)-‐the
most
common
indication
– Platelet
disorders
(ITP)-‐the
most
common
indication
for
elective
splenectomy
v Open
circulation-‐(90%)
– Red
bld
cell
disorders(HS)
o Blood
goes
first
to
reticular
space
and
cords
– Cyts
and
tumors
o Comes
in
contact
with
macrophages
– Infections
and
abscesses
v Closed
circulation-‐(10%)
o Goes
directly
to
the
arteriovenous
anastomosis
BOOK
v Host
Defense
o Opsonins-‐makes
organism
attractive
to
ULTRASOUND
phagocytes
v Ultrasound
is
the
least
invasive
mode
of
splenic
imaging;
rapid,
o Tuftsin-‐enhances
the
phagocytic
activity
of
easy
to
perform,
and
does
not
expose
the
patient
to
ionizing
leukocytes
radiation
o Properdin-‐stimulates
the
alternative
pathway
v It
is
often
the
first
imaging
modality
applied
to
the
spleen
during
of
complement
fixation
evaluation
and
resuscitation
of
the
trauma
patient
o Circulating
monocytes
are
converted
to
fixed
v Percutaneous
ultrasound-‐guided
procedures
for
splenic
disease
macrophages
–at
the
red
pulp
(e.g.,
cyst
aspiration,
biopsy),
historically
avoided
due
to
the
risk
o Produces
!immunoglobulin
(IgM)
of
hemorrhage
and
other
complications,
are
becoming
more
o T
and
B
lymphocytes-‐from
the
lymphatic
common
as
the
safety
of
these
procedures
is
being
increasingly
sheath
surrounding
the
central
arteries
demonstrated
v Storage-‐
30%
of
platelets
are
stored
in
the
spleen
CT
SCAN
v Cytopoeisis-‐
v Computed
tomography
(CT)
affords
a
high
degree
of
resolution
o Contributes
to
the
process
of
RBC
maturation
and
detail
of
the
splenic
parenchyma
th
o Minor
role
in
hematopoeisis
in
the
4
mo.
v In
the
nontrauma
setting,
CT
is
extremely
useful
for
assessment
o Can
be
reactivated
in
childhood
if
the
bone
marrow
fails
of
splenomegaly,
identification
of
solid
and
cystic
lesions,
and
to
meet
the
hematologic
need.
guidance
of
percutaneous
procedures
o Myeloid
metaplasia-‐abnormal
RBC
are
produced
v The
use
of
iodinated
contrast
material
adds
diagnostic
clarity
to
CT
imaging
of
the
spleen,
although
at
the
cost
of
the
small
but
Page
2
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7
real
risks
of
renal
impairment
or
allergic
reaction.
• Related
to
temporary
tamponade
of
a
minor
lacerations
or
presence
of
a
slowly
enlarging
PLAIN
RADIOGRAPHY
subcapsular
hematoma
that
eventually
v
Rarely
is
plain
radiography
used
for
primary
splenic
imaging.
ruptures
v Plain
films
can
indirectly
provide
an
outline
of
the
spleen
in
the
3.
Occult
splenic
rupture
left
upper
quadrant
or
suggest
splenomegaly
by
revealing
• Term
applied
to
pseudocyst
of
the
spleen
(1%)
displacement
of
adjacent
air-‐filled
structures
(e.g.,
the
stomach
or
splenic
flexure
of
the
colon)
Clinical
Manifestations:
v Plain
films
may
also
demonstrate
splenic
calcifications
–
often
1.
Signs
and
symptoms
vary
according
severity
and
are
found
in
association
with
splenomegaly
but
are
otherwise
a
rapidity
of
infra-‐abdominal
hemorrhage
and
the
nonspecific
finding
interval
between
injury
and
examinations
v Splenic
calcifications
can
indicate
a
number
of
benign,
2.
Hypovolemia
and
tachycardia
neoplastic,
or
infectious
processes,
including
phlebolith,
splenic
3.
Slight
reduction
in
blood
pressure
artery
aneurysm,
sickle
cell
changes,
tumors
(e.g.,
hemangioma,
4.
Generalized
abdominal
pain
while
½
of
patients
complain
of
v hemangiosarcoma,
lymphoma),
echinococcosis,
or
tuberculosis
localized
left
upper
quadrant
pain
5.
Kehr’s
sign
–
at
the
tip
of
the
shoulder
indicative
MRI
of
diaphragmatic
irritation
v Although
magnetic
resonance
imaging
offers
excellent
detail
6.
Balance’s
sign
(mass
or
fixed
dullness
at
the
left
and
versatility
in
abdominal
imaging,
it
is
more
expensive
than
quadrant
secondary
to
subcapsular
hematoma)
CT
scanning
or
ultrasound
and
offers
no
obvious
advantage
for
primary
imaging
of
the
spleen
DIAGNOSTICS
v Magnetic
resonance
imaging
can
be
a
valuable
adjunct
to
the
1.
CBC
–
serial
Hct
determination;
WBC
count
frequently
more
commonly
used
imaging
techniques
when
splenic
disease
greater
than
15,000/cu
ml
is
suspected
but
not
definitively
diagnosed
2.
X-‐ray
of
the
abdomen
–
fractured
ribs
should
arouse
suspicion
of
injury
to
the
spleen;
more
specific
findings:
ANGIOGRAPHY
• Elevated
immobile
diaphragm
v Angiography
of
the
spleen
most
commonly
refers
to
invasive
• Enlarged
splenic
shadow
arterial
imaging,
and
when
it
is
combined
with
therapeutic
• Medial
displacement
of
gastric
shadow
splenic
arterial
embolization
(SAE)
• Widening
of
space
between
splenic
flexures
v localization
and
treatment
of
hemorrhage
in
select
trauma
and
preperitoneal
fat
3.
CT
scan
NUCLEAR
IMAGING
4.
Angiography
v
Radioscintigraphy
with
technetium
Tc
99m
sulfur
colloid
demonstrates
splenic
location
and
size
v It
may
be
especially
helpful
in
locating
accessory
spleens
after
unsuccessful
splenectomy
for
ITP
and
has
recently
proven
useful
in
diagnosing
splenosis
SPLENIC
RUPTURE
American
Association
for
the
Surgery
of
Trauma
Organ
Injury:
Scale
for
the
Spleen
TREATMENT
v Surgery
• Children
–
delayed
surgical
treatment
• Adult
–
require
surgical
intervention;
splenectomy
as
a
life-‐saving
procedure
is
still
standard
treatment
• Old
age
–
contraindication
for
non
operative
treatment
v Non-‐operative:
– Grades
1-‐3
splenic
injuries
Pathology
– 70-‐90%-‐success
in
children
1.
Acute
splenic
rupture
– 40-‐50%-‐success
in
adults
• Immediate
intraperitoneal
bleeding
• Criteria:
• Occurs
in
about
90
%
of
the
cases
in
blunt
• Hemodynamic
stability
trauma
to
the
spleen
• Absence
of
other
abdominal
injury
2.
Delayed
rupture
• CT-‐scan
documentation
of
grade
of
• Interval
in
days
or
weeks
between
injury
and
injury
intraperitoneal
bleeding
in
10
–
15
%
of
• Tranfusion
requirement
of
<
2
units
patients
of
blood
• The
quiescent
period
(latent
period
of
Baudet)
-‐less
than
2
weeks
in
75%
of
cases
PLATELET
DISORDERS
Page
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7
IDIOPATHIC
THROMBOCYTOMPENIC
PURPURA
v Idiopathic
thrombocytopenic
purpura
– Low
platelet
count
with
mucocutaneous
and
petechial
bleeding
– Premature
removal
of
platelets
opsonized
by
antiplatelet
IgG
autoantibodies
produced
by
the
spleen
• 30,000-‐50,000/cu.mm-‐easy
bruising
• 10,000-‐30,000/cu.mm-‐spontaneous
petechiae
and
eccymosis
<10,000/cu.mm-‐internal
bleeding
Treatment:
– Oral
prednisone-‐first
line
of
tx.
• Most
respond
after
3
weeks
(50-‐75%)
– IV
immunoglobulin-‐for
those
w/
internal
bleeding.
BOOK
• competes
for
binding
to
macrophage
receptors.given
for
2-‐3
days
Hereditary
Spherocytosis
– SPLENECTOMY
v
Hereditary
spherocytosis
(HS)
results
from
an
inherited
• Failure
of
medical
tx
dysfunction
or
deficiency
in
one
of
the
erythrocyte
membrane
• Prolonged
use
of
steroids
w/
undesirable
proteins
(spectrin,
ankyrin,
band
3
protein,
or
protein
4.2)
effects
(>
10-‐20mg/d
for
3-‐6
months
to
v The
resulting
destabilization
of
the
membrane
lipid
bilayer
maintain
platelet
ct
of
>30,000/cu.mm
allows
a
pathologic
release
of
membrane
lipids
• Provides
permanent
response
(75-‐85%)
in
1
v
The
red
blood
cell
assumes
a
more
spherical,
less
deformable
week
shape,
and
the
spherocytic
erythrocytes
are
sequestered
and
destroyed
in
the
spleen
v Hemolytic
anemia
ensues;
HS
is
the
most
common
hemolytic
anemia
for
which
splenectomy
is
indicated
v HS
is
inherited
primarily
in
an
autosomal
dominant;
the
v Patients
with
typical
HS
forms
may
have
mild
jaundice.
v Splenomegaly
usually
is
present
on
physical
examination.
v Laboratory
examination
reveals
varying
degrees
of
anemia
-‐
patients
with
mild
forms
of
the
disease
may
have
no
anemia;
patients
with
severe
forms
may
have
hemoglobin
levels
as
low
as
4
to
6
g/dL
v The
mean
corpuscular
volume
is
typically
low
to
normal
or
slightly
decreased
v For
screening,
a
combined
elevated
mean
corpuscular
hemoglobin
concentration
and
an
elevated
erythrocyte
distribution
width
are
an
excellent
predictor
v Dramatic
clinical
improvement—even
despite
persistent
hemolysis—often
occurs
after
splenectomy
in
patients
with
severe
disease
v children
can
be
affected
with
HS,
the
timing
of
splenectomy
is
important
and
is
aimed
at
reducing
the
quite
small
possibility
of
overwhelming
postsplenectomy
sepsis
v Delaying
such
an
operation
until
the
patient
is
between
the
ages
of
4
and
6—unless
the
anemia
and
hemolysis
accelerate—is
THROMBOTIC
THROMBOCYTOPENIC
PURPURA
recommended
v Gallstones
are
more
likely
to
develop
in
patients
with
HS,
and
v Thrombotic
throbocytopenic
purpura
(TTP)
– Occlusion
of
arterioles
and
caplillaries
with
hyalin
over
half
of
patients
between
the
ages
of
10
and
30
with
HS
have
deposits
composed
of
aggregated
platelets
and
fibrin.
cholelithiasis
v For
children
with
cholelithiasis
prophylactic
cholecystectomy
is
– Pentad:
recommended
at
the
time
of
splenectomy
• Fever
• Purpura
v Hereditary
elliptocytosis
(HE)
merits
brief
discussion
to
distinguish
it
from
HS
• Anemia
v Both
HS
and
HE
are
conditions
of
the
red
blood
cell
membrane
• Neurological
manifestation
• Renal
dysfunction
that
result
from
genetic
defects
in
skeletal
membrane
proteins.
v With
the
HE
defect,
the
red
blood
cell
elongates
as
it
circulates,
so
that
far
fewer
red
blood
cells
are
sequestered
or
destroyed
RED
BLOOD
CELL
DISORDERS
when
transiting
the
splenic
parenchyma
HEREDITARY
SPHEROCYTOSIS
• Hereditary
spherocytosis
– Deficiency
in
one
of
the
membrane
proteins
CONGENITAL
HEMOLYTIC
ANEMIA
(spectrin,ankyrin,band3
protein)
– Spherical
less
deformable
shape,
they
sequestered
and
destroyed
in
the
spleen
– The
only
type
of
hemolytic
anemia
which
splenectomy
is
the
primary
treatment
– In
children-‐delayed
until
ages
of
4-‐6
years
Page
4
of
7
coexisting
immune
deficiency,
in
large
part
brought
about
by
iron
overload,
which
may
be
associated
both
with
the
thalassemia
itself
and
with
transfusions
SICKLE
CELL
ANEMIA
BOOK
v Sickle
cell
disease
is
an
inherited
chronic
hemolytic
anemia
that
BOOK
results
from
the
mutant
sickle
cell
hemoglobin
(HbS)
within
the
red
blood
cell
and
is
inherited
in
an
autosomal
codominant
THALASSEMIA
fashion
v Thalassemia
is
the
term
for
a
group
of
inherited
disorders
of
v Persons
who
inherit
an
HbS
gene
from
one
parent
hemoglobin
synthesis
prevalent
among
people
of
(heterozygous)
are
carriers;
those
who
inherit
an
HbS
gene
Mediterranean
extraction
and
classified
according
to
the
from
both
parents
(homozygous)
have
sickle
cell
anemia.
hemoglobin
chain
(alpha,
beta,
or
gamma)
affected
v In
sickle
cell
disease
the
underlying
abnormality
is
the
mutation
v As
a
group
the
thalassemias
are
the
most
common
genetic
of
adenine
to
thymine
in
the
sixth
codon
of
the
B-‐globin
gene,
diseases
known
to
arise
from
a
single
gene
defect
which
results
in
the
substitution
of
valine
for
glutamic
acid
as
v
Most
forms
of
this
disorder
are
inherited
in
Mendelian
recessive
the
sixth
amino
acid
of
the
B-‐globin
chain
fashion
from
asymptomatic
carrier
parents
v Mutant
B-‐chains
included
in
the
hemoglobin
tetramer
create
v
In
all
forms
of
thalassemia
the
primary
defect
is
absent
or
HbS.
Deoxygenated
HbS
is
insoluble
and
becomes
polymerized
reduced
production
of
hemoglobin
chains.
From
this
and
sickled
abnormality
two
significant
consequences
arise:
(1)
reduced
v The
subsequent
lack
of
deformability
of
the
red
blood
cell,
in
functioning
of
hemoglobin
tetramers,
yielding
hypochromia
and
addition
to
other
processes,
results
in
microvascular
congestion,
microcytosis;
and
(2)
unbalanced
biosynthesis
of
individual
and
which
may
lead
to
thrombosis,
ischemia,
and
tissue
necrosis
subunits,
which
results
in
insoluble
red
blood
cells
that
cannot
v
The
disorder
is
characterized
by
painful
intermittent
episodes.
release
oxygen
normally
and
may
precipitate
with
cell
aging.
v Sequestration
occurs
in
the
spleen,
with
splenomegaly
resulting
v Both
underproduction
of
hemoglobin
and
excess
production
of
early
in
the
disease
course.
In
most
patients
subsequent
unpaired
hemoglobin
subunits
contribute
to
infarction
of
the
spleen
and
autosplenectomy
occur
at
some
thalassemiaassociated
morbidity
and
mortality.
later
time
v A
diagnosis
of
thalassemia
major
(homozygous
form)
is
made
by
v The
most
frequent
indications
for
splenectomy
in
sickle
cell
demonstrating
hypochromic
microcytic
anemia
associated
with
disease
are
recurrent
acute
sequestration
crises,
hypersplenism,
randomly
distorted
red
blood
cells
and
nucleated
erythrocytes
and
splenic
abscess
(target
cells)
on
peripheral
blood
smear
v The
occurrence
of
one
major
acute
sequestration
crisis,
v Elevated
reticulocyte
count
and
white
blood
cell
count
are
characterized
by
rapid
painful
enlargement
of
the
spleen
and
among
the
associated
findings.
Because
chains
are
needed
to
circulatory
collapse,
generally
is
considered
sufficient
grounds
form
both
fetal
hemoglobin
and
adult
hemoglobin,
Athalassemia
for
splenectomy
becomes
symptomatic
in
utero
or
at
birth.
By
v Preoperative
preparation
should
include
special
attention
to
contrast,
B-‐thalassemia
becomes
symptomatic
at
4
to
6
months,
adequate
hydration
and
avoidance
of
hypothermia.
because
B-‐
chains
are
involved
only
in
adult
hemoglobin
v Splenectomy
does
not
affect
the
sickling
process,
and
therapy
synthesis.
for
sickle
cell
anemia
remains
largely
palliative
v Heterozygous
carriers
of
the
disease
are
usually
asymptomatic.
v Transfusions
are
indicated
for
anemia,
for
moderately
severe
v Homozygous
individuals,
on
the
other
hand,
typically
present
episodes
of
acute
chest
syndrome
(i.e.,
a
new
infiltrate
on
chest
before
2
years
of
age
with
pallor,
growth
retardation,
jaundice,
radiograph
associated
with
new
symptoms,
such
as
fever,
cough,
and
abdominal
swelling
due
to
liver
and
spleen
enlargement.
sputum
production,
or
hypoxia)
and
preoperatively
before
v Among
other
characteristics
of
thalassemia
major
are
splenectomy
intractable
leg
ulcers,
head
enlargement,
frequent
infections,
v Patients
experiencing
stroke
or
a
severe
crisis
may
require
and
the
need
for
periodic
blood
transfusions
hydration
and
an
exchange
transfusion,
which
may
be
v Untreated
individuals
usually
die
in
late
infancy
or
early
performed
manually
or
with
automated
apheresis
equipment
childhood
from
severe
anemia
v Hydroxyurea
is
an
oral
chemotherapeutic
agent
that
v Treatment
for
thalassemia
involves
red
blood
cell
transfusions
v upregulates
fetal
hemoglobin,
which
interferes
with
to
maintain
a
hemoglobin
level
of
>9
mg/dL,
along
with
v polymerization
of
HbS
and
thus
reduces
the
sickling
process
intensive
parenteral
chelation
therapy
with
deferoxamine
v Splenectomy
is
indicated
for
patients
with
excessive
transfusion
SPLENIC
CYST
requirements
(>200
mL/kg
per
year),
discomfort
due
to
splenomegaly,
or
painful
splenic
infarction.
v True
cyst-‐
v
Thalassemia
patients
are
at
high
risk
for
pulmonary
• Small
(<8cm)
asymptomatic.
Can
observed.
hypertension
after
splenectomy;
the
precise
etiology
of
this
•
>8cm
w/
symptoms-‐partial
sequela
is
under
investigation
splenectomy,unroofing
v The
increase
in
infectious
complications
is
likely
to
be
due
to
a
v Parasitic
cyst
Page
5
of
7
Secondary
to
Echinococcus
• v
cirrhosis-‐most
common
cause
Tx.
by
splenectomy
after
sterilization
by
NaCL
• v Splenic
vein
thrombosis
or
silver
nitrate
o Secondary
to
pancreatitis
v Pseudocyst
o w/
bleeding
gastric
varices
• Secondary
to
trauma
o w/
massive
splenomegaly
• Most
are
small
(<4cm)
and
undergo
o Splenectomy
is
curative
spontaneous
resolution
• Can
be
observed
safely
BOOK
v Splenic
cysts
can
be
categorized
according
to
a
number
of
criteria;
one
clinically
relevant
scheme
is
to
characterize
splenic
cysts
as
either
parasitic
or
nonparasitic.
v Parasitic
infection
is
the
most
common
cause
of
splenic
cysts
worldwide,
and
the
majority
are
due
to
Echinococcus
species.
v Such
cysts
are
more
commonly
found
in
areas
where
the
pathogen
is
endemic.
• One
of
the
most
common
findings
with
portal
hypertension
is
v Symptoms,
when
present,
generally
are
related
to
the
presence
splenomegaly,
as
seen
here.
The
spleen
is
enlarged
from
the
of
a
mass
lesion
in
the
left
upper
quadrant
or
a
lesion
that
normal
300
grams
or
less
to
between
500
and
1000
gm.
impinges
on
the
stomach.
v Ultrasound
can
establish
the
presence
of
a
cystic
lesion
and
occasionally
incidentally
detect
asymptomatic
lesions
as
well.
v Serologic
testing
for
echinococcal
antibodies
can
confirm
or
SPLENIC
VEIN
THOMBOSIS
exclude
the
cystic
lesion
as
parasitic,
an
important
piece
of
information
when
planning
operative
therapy.
v Symptomatic
parasitic
cysts
are
best
treated
with
splenectomy.
v Avoidance
of
spillage
of
parasitic
cyst
contents
into
the
peritoneal
cavity
to
avoid
the
possibility
of
anaphylactic
shock
is
an
important
principle
in
surgical
management.
v Cysts
resulting
from
trauma
are
termed
pseudocysts
due
to
their
lack
of
cellular
lining.
v Less
common
examples
of
nonparasitic
cysts
are
dermoid,
epidermoid,
and
epithelial
cysts.
v The
treatment
of
nonparasitic
cysts
depends
on
whether
or
not
BOOK
they
produce
symptoms.
v Asymptomatic
nonparasitic
cysts
may
be
observed
with
close
v the
most
common
visceral
artery
aneurysm
follow-‐up
by
ultrasound
to
exclude
significant
expansion.
v Women
are
four
times
more
likely
to
be
affected
than
men.
v Patients
should
be
advised
of
the
risk
of
cyst
rupture
with
even
v The
aneurysm
usually
arises
in
the
middle
to
distal
portion
of
minor
abdominal
trauma
if
they
elect
nonoperative
the
splenic
artery.
management
for
large
cysts.
v Indications
for
treatment:
v Small
symptomatic
nonparasitic
cysts
may
be
excised
with
o
presence
of
symptoms,
pregnancy,
intention
to
become
splenic
preservation,
and
large
symptomatic
nonparasitic
cysts
pregnant,
and
presence
of
pseudoaneurysms
associated
may
be
unroofed.
with
inflammatory
processes.
v Both
of
these
operations
may
be
performed
laparoscopically.
v Aneurysm
resection
or
ligation
alone
is
acceptable
for
amenable
lesions
in
the
midsplenic
artery,
but
distal
lesions
in
close
proximity
to
the
splenic
hilum
should
be
treated
with
concomitant
splenectomy.
SPLENIC
ABCESS
v Splenic
artery
embolization
has
been
used
to
treat
splenic
artery
aneurysm,
but
painful
splenic
infarction
and
abscess
may
follow
v Hematogenous
spread-‐most
common
cause
v Most
are
solitary
and
unilocular
ESOPHAGEAL
VARICES
v Treatment:
– Solitary
and
unilocular-‐-‐image
guided
percutaneaous
ESOPHAGEAL
VARICES
drainge+antibiotics
– Multilocular-‐-‐-‐splenectomy+
antibiotics
SARCOIDOSIS
v Non-‐caseating
inflammatory
granulomatous
lesion
v Second
organ
most
commonly
affected
v Indications
for
splenectomy
– Massive
splenomegaly
(>1kg)
• Thrombocytopenia
• Anemia
• Compression
of
adjacent
organ
• Pain
MISCELLANOUS
DISORDERS
SECONDARY
HYPERSLENISM
Portal
Hypertension
v Leads
to
splenic
congestion,sequestration
and
destruction
of
circulationg
cells
BOOK
Page
6
of
7
NON
HODGKIN’S
LYMPHOMA
v Patients
with
bleeding
from
isolated
gastric
varices
who
have
BOOK
normal
liver
function
test
results,
especially
those
with
a
history
of
pancreatic
disease,
should
be
examined
for
splenic
vein
v Non-‐Hodgkin's
lymphoma
(NHL)
encompasses
all
malignancies
thrombosis
and
treated
with
splenectomy
if
findings
are
positive.
derived
from
the
lymphoid
system
except
classic
HD.
v A
proliferation
of
any
one
of
the
three
predominant
lymph
cell
types—natural
killer
cells,
T
cells,
or
B
cells—may
be
included
HODGKIN’S
DISEASE
in
the
category
of
NHL.
v Because
of
the
wide
net
cast
by
NHL,
the
clinical
presentations
of
the
disorders
under
its
umbrella
vary.
v The
subentities
of
NHL
may
be
clinically
classified
into
nodal
or
extranodal,
as
well
as
indolent,
aggressive,
and
very
aggressive
groups.
v Patients
with
indolent
lymphomas
may
present
with
mild
or
no
symptoms
and
seek
medical
attention
for
a
swollen
lymph
node,
whereas
the
aggressive
and
very
aggressive
lymphomas
create
easily
noticeable
symptoms,
such
as
pain,
swelling
due
to
obstruction
of
vessels,
fever,
and
night
sweats.
v Surgical
staging
is
no
longer
indicated
for
NHL,
because
the
combination
of
history
and
physical
examination,
chest
radiograph
and
abdominal/pelvic
CT
scan,
biopsy
of
involved
lymph
nodes
(including
laparoscopically
directed
nodal
and
BOOK
liver
biopsies),
and
bone
marrow
biopsy
is
sufficient.
v Splenomegaly
exists
in
some,
but
not
all,
forms
of
NHL,
and
v Hodgkin's
disease
(HD)
is
a
disorder
of
the
lymphoid
system
splenectomy
is
indicated
for
management
of
symptoms
related
characterized
by
the
presence
of
Reed-‐Sternberg
cells
(which
to
an
enlarged
spleen
as
well
as
for
improvement
of
cytopenias
actually
form
the
minority
of
the
Hodgkin's
tumor).
v More
than
90%
of
patients
with
HD
present
with
SPLENECTOMY
OUTCOME
lymphadenopathy
above
the
diaphragm.
v Lymph
nodes
can
become
particularly
bulky
in
the
v Increase
in
circulating
abnormal
RBC
mediastinum,
which
may
result
in
shortness
of
breath,
cough,
or
v Pulmonary:
left
lobe
atelectasis-‐the
most
common
obstructive
pneumonia.
complication
v Lymphadenopathy
below
the
diaphragm
is
rare
on
presentation
v Thromboembolic
phenomena-‐
esp
those
w
/
hemolytic
but
can
arise
with
disease
progression.
dsordrs,
myeloprolifertive
,
splenomegaly-‐portal
vein
v The
spleen
is
often
an
occult
site
of
spread,
but
massive
thrombosis
splenomegaly
is
not
common.
v Overwhelming
postsplectomy
infection:
v In
addition,
large
spleens
do
not
necessarily
signify
o More
common
if
splenectomy
is
done
for
involvement.
hematologic
problem
v Four
major
histologic
types
exist:
lymphocyte
predominance
o Strep.
Pneumoniae-‐most
common
org.(50-‐90%)
type,
nodular
sclerosis
type,
mixed
cellularity
type,
and
o Most
occur
2
years
after
splenectomy
lymphocyte
depletion
type
o children,<5
years
and
adults
>50years
old
v The
histologic
type,
along
with
location
of
disease
and
symptomatology,
influence
survival
for
patients
with
HD.
Preventive
measures
against
OPSI
v Stage
I
disease
is
limited
to
one
anatomic
region;
stage
II
disease
v Elective
splenectomy
in
children
should
postponed
if
possible
until
is
defined
by
the
presence
of
two
or
more
contiguous
or
child
is
4-‐10
years
old
noncontiguous
regions
on
the
same
side
of
the
diaphragm;
stage
v Prophylactic
antibiotics
III
disease
involves
disease
on
both
sides
of
the
diaphragm,
but
o
<
10
years
old.
For
5
years
after
splenectomy
limited
to
lymph
nodes,
spleen,
and
Waldeyer's
ring
(the
ring
of
v Role
of
vaccination:
lymphoid
tissue
formed
by
the
lingual,
palatine,
and
o Elective
splenectomy-‐2
weeks
before
surgery
nasopharyngeal
tonsils);
stage
IV
disease
includes
involvement
o Emergency
splenectomy-‐should
be
given
ASAP
or
w/in
7-‐
of
the
bone
marrow,
lung,
liver,
skin,
GI
tract,
or
any
organ
or
10
days
after
tissue
other
than
the
lymph
nodes
or
Waldeyer's
ring.
o Annual
vaccination
v Staging
laparotomy
for
HD
is
less
commonly
performed
in
the
current
era
of
minimally
invasive
surgery
and
advanced
imaging
techniques.
v Current
indications
for
surgical
staging
include
clinical
stage
I
or
II
disease
of
the
nodular
sclerosing
type
and
no
symptoms
referable
to
HD.
v The
surgical
staging
procedure
for
HD
includes
a
biopsy
of
the
liver,
splenectomy,
and
the
removal
of
representative
nodes
in
the
retroperitoneum,
mesentery,
and
hepatoduodenal
ligament.
v An
iliac
marrow
biopsy
generally
is
included.
Unlike
in
nonHodgkin's
lymphoma,
studies
have
concluded
that
surgical
staging
has
altered
clinical
staging
in
as
many
as
42%
of
cases
(26
to
37%
upgraded,
7
to
15%
downgraded).
v Staging
information
affects
treatment,
because
patients
with
early-‐stage
disease
who
have
no
splenic
involvement
may
be
candidates
for
radiotherapy
alone.
v Those
with
splenic
involvement
generally
require
chemotherapy
or
multimodality
therapy
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7
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