Diseases of Spleen

prof. tariq al-aubaidi

Splenic rupture:

should be suspected after any trauma but particularly if there had been
direct injury to left upper quadrant of the abdomen from any angle.
Occasionally , a fall without direct trauma to the trunk can rupture of
spleen especially if it is diseased or enlarged as in malaria or infectious
mononucliosis. Splenic injury should be suspected if there are fractures
of overlying ribs. Splenic injury can be divided in to three groups:
• *(1): The patient succumbs rapidly, never rallying from the initial shock:
that tearing of splenic vessels and complete avulsion of spleen from its
pedicle give rise to rapid bloods loss which can be fatal with in minutes.

• *(2): Initial Shock, recovery from Shock, sign of ruptured spleen: these
are usual signs seen in surgical practice. After initial shock has passed off
there are signs which point to intra-abdominal bleeding.
A: General signs as increasing pallor, rising pulse rate, falling blood pressure,
sighing respiration & restlessness.

B: Local signs:

1. Abdominal guarding is present in more than 50% of cases in upper

quadrant.
2. Local bruising & tenderness in upper quadrant.
3. Abdominal distention commences about three hours of after the accident,
and due to irritative effect of intraperitoneal blood which produce
peritonism and ileus.
4. Kehr, s sign is pain referred to left shoulder .There may be hyperesthesia in
this area, this sign can be demonstrated a quarter of an hour after
elevation of the foot. It is due to blood in contact with under surface of
diaphragm.
5. Shifting dullness in the flanks is often present
6. Rectal examination frequently reveals tenderness and sometimes a soft
swelling due to blood loss or clot in rectovesical pouch.
(3) The delayed type of case; After the initial sign have passed off the
symptoms of serious intra-abdominal catastrophe are postponed for a
variable period up to 15 days or even more . As rule it is only a matter of
minutes to an hour or so, during which time the patient often appears to
have recovered from blow .

Thus a rugby footballer may continue to play after a short rest, only to
collapse later from internal bleeding. The cause of delayed hemorrhage is
local vasoconstriction with or without the formation of blood clot which
seals the tear. The cause of hemorrhage is those of reactionary or
secondary hemorrhage.
Investigation: Focused assessment with sonography for trauma

(1) Ultra sound of spleen can be visualized & surrounding haematoma

suggest rupture. Serial U\S show change of size of spleen &
formation of haematoma.
(2) X-ray: plain x-ray show
(a) obliteration of splenic out line.
(b) fractures ribs.
(c) Obliteration of psoas shadow.
(d) elevation of left side of diaphragm.
(e) free fluid between gas-filled intestinal coils.
(f) indentation of left of gastric air-bubble.
Treatment:
laparatromy with splenectomy or splenorraphy. Blood
transfusion is needed.
Long term antibiotic after splenectomy is given.
Splenectomy in haemolytic anemias as hereditary spherocytosis,
hereditary elliptocytosis, pyruvate-kinase deficiency,
thalassaemia & acquired autoimmune haemolytic anemia.
Nonoperative Management of
Splenic Trauma
Protocol for Nonoperative Management
• Grade I & II
• Awake + alert, isolated injury
• monitored observation
• BR, H/H q6h, serial abdominal exams
• Regular floor in 48º
• If remain stable and asymptomatic – D/C in 5 days
• F/U CT scan in 4 wks
• Avoid prophylactic and therapeutic heparinization
• Grade III, IV, & V
• Monitored observation x5 days
• Repeat CT scan
• Transfer to floor if stable
• F/U CT scan in 6-8 wks after discharge
Splenorrhaphy
• Topical Hemostasis
• Small injuries (I & II)
• Bovie electrocautery
• Argon beam
• Gelfoam
• Surgicel
• Avitene
• Suture Repair & Partial Resection A pledgeted suture is one that is supported by a pledget, that
• Pledgeted horizontal mattress sutures is, a small flat non-absorbent pad normally composed of
polytetrafluoroethylene, used as buttresses under sutures
• Segmental blood supply when there is a possibility of sutures tearing through tissue.

• Monofilament sutures
The usual indication for splenectomy:

1: Trauma either following an accident or during surgical operation e.g.

when mobilizing the splenic flexure of the colon.
2: Removal enbloc with the stomach as part of radical gastrectomy.
3: Removal as part of the staging laparatomy under taken before
treatment of Hodgkin's lymphoma , it is rare now because recent
imaging techniques as MRI
4: To reduce anemia, thrombocytopenia in spherocytosis, idiopathic
thrombocytopenic purpura or hyperspleism.
5: In association with shunt or variceal surgery for portal hypertension.
Post-operative complications of splenectomy:

1. Haemorrhage, if a ligature slips off the splenic artery.

2. Gastric dilatation following partial mobilization of the stomach when
ligating the short gastric artery.
3. Haematemesis may rarely occur possibly due to damage to the mucosa of
the stomach when ligating the short gastric artery.
4. Left basal atelectasis, some time with pleural effusion, this might be due to
damage to or irritation of the left hemi-diaphragm or subphrenic abscess&
associated by persistent hiccough.
5. Damage to the tail of pancreas during mobilization of splenic pedicle. This
may produce a localized abscess or fistula.
6. Splenectomy usually followed by rise in white cells & platelet count a few
days after operation. There may be a risk of thrombosis.
7. Gastric fistula due to damage of the greater curvature when ligating the
short gastric arteries.
8. Post-operative septicaemia. Spleen phagocytes bacteria particularly
encapsulated bacteria so splenectomized patients show reduced antibodies
production when challenged with particular antigen, see this patients are at
risk of septicaemia due to streptococcus pneumonia, neisseria meningitides,
H. influenza.

This exaggerated when these patients on cytotoxic drugs or radiation or have

sickle cell anemia or thalassaemia so opportunist post-splenectomy infection (
OPSI) is now of major concern.
Antibiotics prophylaxis as amoxicillin is recommended in children under the age
of 15 years.
Pneumococcal antitoxin should be given 2 weeks pre-operatively. It is important
to advised the patient to the dangers of (OPSI) & prescribe antibiotics with all
infections & splenectomized patients who live in malarial prophylaxis. In
practice we give benzathine penicillin 600000- 2400000I.U once monthly for
two years.
• Spleen - mostly secondary involvement
• non-Hodgkin’s Lymphoma – most common malignancy
• Main Tx: Chemo +/- RT
• Spleen is the primary site
• 10% Hodgkin’s disease
• 30% of resected spleens (staging procedure) have (+)
histology
• Hairy cell leukemia
• Resect for symptomatic splenomegaly
• Improved survival
• CML & CLL
• symptomatic splenomegaly = splenectomy
• Angiosarcoma
• Nonlymphoid malignant tumor of the spleen
• Early metastatic disease
• Aggressive with rapid growth
• Spontaneous splenic rupture and hemolytic anemia
• Palliation

• Benign Tumors
• Hemangioma most common benign neoplasm of the spleen
• Risk of rupture + platelet sequestration (Syndrome?)
• No treatment unless symptomatic
• Hamartoma
• Lymphangioma
Splenic Cyst
•Splenic Cysts
• Splenic Pseudocysts
• Lack epithelial lining
• Account for most cystic splenic disease in US
• Pancreatic pseudocyst
• Posttraumatic
• Splenectomy is indicated when:
• Size >10 cm or
• symptomatic
Uncommon, but fatal
Erode into adjacent structures
Most are secondary in etiology
• Bacterial endocarditis
• Intrabdominal infections (pyelo-, etc)
• IV drug abuser
• Infected splenic hematoma
• Infected splenic infarctions (embolizations, ischemia, etc)

S/S: fever, WBC; 50% (+) blood cultures

Dx by CT scan + IV contrast
Staphylococcus & Streptococcus
E.coli, Salmonella, anaerobes

Tx:
Splenectomy + IV Abx
Percutaneous drainage