THE SPLEEN

BY DR(MRS) BAULCH
 THE SPLEEN

 The spleen is an ovoid,purplish,pulpy mass about the size

of one’s fist.
 It is the largest lymphoid organ in the body
 It is delicate and the most vulnerable abdominal organ to
rupture
THE SPLEEN
THE SPLEEN
SPLEEN

 The spleen both as haemopoietic and immune

functions
 Prenatally it is haemopoietic and after birth it
performs immune functions
ANATOMY OF THE SPLEEN

 The spleen is located in the left upper abdominal quadrant or

hypochondrium and receives protection from the lower
thoracic cage, it lies beneath the left coastal margin, normal
weight is 150-250g and a length between 5-13cm. Its not
palpable but becomes palpable when enlarged (>14cm)
 ANATOMY OF THE SPLEEN

 The spleen soft and vascular(sinusoidal) mass with relatively

delicate fibroelastic capsule surrounded by peritoneum except at
the splenic hilum where branches of the splenic artery and vein
enters and leave
 It is capable of marked expansion and mass retraction
ANATOMY OF THE SPLEEN

 Its mobile but does not normally descends inferior to the coastal region, it rest
on the colic flexures
 Relations of the spleen-

-anteriorly the stomach

-posteriorly the left part of the diaphragm,

-inferiorly the left colic flexure and medially the left kidney
 ANATOMY OF THE SPLEEN

 Blood enters the spleen through the splenic artery which divides to give
the trabecular arteries which permeates and give rise to central arterioles
 Majority of the arterioles ends in cords which lack endothelial lining and
form an open blood supply which is unique to the spleen, with a loose
reticular connective tissue network lined by fibroblast and macrophages.
 ANATOMY OF THE SPLEEN

 The blood re-enters the circulation by passing across the endothelium of

the venous sinuses. Blood then passes into the splenic vein back into the
general circulation.
 The cords and sinuses form the red pulp which is about 75% of the
spleen and has an essential role in monitoring the intergrity of the red
blood cells
 ANATOMY OF THE SPLEEN

 A minority of the splenic vasculature is closed in which the arterial

and venous systems are connected by capillaries with a continuous
endothelial layer
 The central arterioles are surrounded by a of lymphatic tissue
known as white pulp has an organization similar to lymph nodes.
 ANATOMY OF THE SPLEEN

 The periarteriolar lymphatic sheath (PALS) lies directly around

the arteriole and is equivalent to the T zone of the lymph node
B cell follicles are found adjacent to the PALS and these are
surrounded by the marginal and perifollicular zones which are
rich in macrophages and dendritic cells
 ANATOMY OF THE SPLEEN

 Lymphocytes migrate into the white pulp from the sinuses of the red
pulp or from vessels that ends directly in the marginal and
perifollicular zones
 There are both rapid and slow blood circulations through the spleen.
 FUNCTIONS OF THE SPLEEN

 Thespleen is the largest filter of the blood and several of the

functions are derived from this, these functions are
-Control of red cell intergrity
-Immune function
-Extramedullary haemopoiesis
 FUNCTIONS OF THE SPLEEN-
CONTROL OF RED CELL INTERGRITY

 The spleen plays an important role in the quality control of red

cells. Excess DNA, nuclear remnants (howell-jolly bodies) and
siderotic granules are removed. In relatively hypoxic environment
of the red pulp, the membrane flexibility of aged and abnormal
red cells is impaired and they are trapped within the sinus where
they are ingested by macrophages
 IMMUNE FUNCTION

The spleen has unique lymphoid tissue that responds to antigens filtered
from blood and entering the white pulp.

Macrophages and dendritic cells in the marginal zone initiates an immune

response and present antigens to B and T cells to start adaptive immune
response. This arrangement is effective at mounting immune response to
encapsulated bacteria.
 EXTRAMEDULLARY HAEMOPOIESIS

 The spleen undergoes period of haemopoiesis around 3-7 months of fetal

life but It is not an erythropoetic site in normal/healthy adults just like the
liver. Haemopoiesis may be reestablished as extramedullary haemopoiesis
in disorders like myelofibrosis or chronic severe haemolytic and
megaloblastic anaemia.
 EXTRAMEDULLARY HAEMOPOIESIS

 Extramedullary haemopoiesis may result either either from

reactivation of dormant stem cells within the spleen or homing
of stem cells from the bone marrow to the spleen
 SPLENOMEGALY

 The spleen increases in size in many conditions

 Splenomegaly is felt below the left coastal margin but in massive
splenomegaly it can be felt as far as right iliac fossa because the spleen
enlarges diagonally.
 The spleen moves with respiration and a medial notch can be felt in some
cases.
 CAUSES OF SPLENOMEGALY

 Malaria and schistosomiasis are the prevalent causes globally

but in developed countries infectious mononucleosis,
haematological malignancies and portal hypertension are the
most common causes
CAUSES OF SPLENOMEGALY
HAEMATOLOGICAL CAUSES
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Acute leukaemia
Malignant lymphoma
Primary melofibrosis
CAUSES OF SPLENOMEGALY

HAEMATOLOGICAL CAUSES CONT’D

Polycythemia vera
Hairy cell leukaemia
Thalassaemia major or intermedia
Sickle cell anaemia (befor splenic infarction)
Haemolytic amaemia
Megaloblastic anaemia
CAUSES OF SPLENOMEGALY

Portal hypertension
cirrhosis
Hepatic, portal, splenic vein thrombosis
Causes of splenomegaly

Storage diseases
Histocytosis X
Niemann-Pick disease
Gaucher’s disease
Causes of splenomegaly

SYSTEMIC DISEASES
sarcoidosis
amyloidosis
Collagen disease SLE
Rheumatoid arthritis
Systemic mastocytosis
CAUSES OD SPLENOMEGALY

INFECTIONS

ACUTE- septicaemia, bacterial endocarditis, typhoid, infectious

mononucleosis

CHRONIC –tuberculosis, brucellosis, syphilis, malaria,

leishmaniasis, schistosomiasis
 TROPICAL SPLENOMEGALY
SYNDROME(TSS)

 This is a syndrome of massive splenomegaly of uncertain aetiology

found in malaria endemic zones of the tropics like Nigeria, Uganda,
New Guinea and Congo. Some patients are seen in southern Arabia,
Sudan and Zambia.
 It was formerly referred to as African macroglobinaemia, big spleen
disease and cryptogenic splenomegaly.
 TROPICAL SPLENOMEGALY SYNDROME(TSS)

 Malaria is probably the fundamental cause but it is not the result of active
malarial infection as parasitaemia is usually scanty and malarial pigment is not
seen in biopsy material from the spleen and liver. Abnormal host response to
continual presence of malarial antigen which results in a reactive and relatively
benign lymphoproliferative disorder that predominantly affects the liver and
spleen seems more likely
 TROPICAL SPLENOMEGALY
SYNDROME(TSS)

 There is gross splenomegaly and there’s hepatomegaly too.

 Portal hypertension may also be present
 Severe anaemia and leucopenia usually present
 Marked lymphocytosis in some patients
 Serum IgM levels are high and titre of malarial antibody is high
 TROPICAL SPLENOMEGALY
SYNDROME(TSS)

 Management/treatment: antimalarial therapy is successful in the

management of many cases
 Splenectomy corrects the pancytopenia but there is increased risk
of fulminant malarial infection
 HYPOSLENISM

 Functional hyposplenism is revealed by the blood film finding of

howell-Jolly bodies or pappenheimer bodies (siderotic granules on
iron staining)
 The most frequent cause is surgical removal of the spleen e.g
traumatic rupture
Causes of hyposplenism

 Splenectomy
 Sickle cell disease
 Essential thrombocythaemia
 Adult gluten-induced enteropathy
 Dermatitis herpetiformis
 amyloidosis
Rare causes of hyposplenism

 Inflammatory bowel disease

 Splenic arterial thrombosis
 HYPERSLENISM

 Hypersplenism is clinical syndrome that can be seen in splenomegaly.

 It is characterized by enlargement of the spleen and reduction of at
least on cell line in the blood in the presence of normal bone marrow
function
 HYPERSPLENISM

 Approximately 5% of the total red cell mass (30-70Ml) is present in

the spleen, about 30% of the platelets mass and half of the total
marginating neutrophil pool may be located in the spleen
 As the spleen enlarges, the proportion of haemopoietic cells within
the organ increases such that up to 40% of the red mass and 90% of
platelets may be pooled in the spleen
HYPERSPLENISM

Splenectomy is indicated if it is symptomatic

It is followed by a rapid improvement in the peripheral blood

count
 SPLENECTOMY

 Is the surgical removal of the spleen Splenectomy may be indicated

for treatment of haematological disorders and after splenic rupture
or splenic tumours or cysts.
 Splenectomy can be performed by open abdominal laparotomy or by
laparoscopic surgery
 INDICATIONS FOR SPLENECTOMY

 Splenic rupture
 Some cases of :

-chronic immune thrombocytopenia

- haemolytic anaemia- hereditary spherocytosis, autoimmune

haemolytic anaemia, thalasaemia major or intermedia
 Indications for splenectomy

 Chronic lymphocytic leukaemia and lymphoma

 Primary myelofibrosis
 Tropical splenomegaly
 Prevention of infection in hyposplenic patients

 Hyposplenic patients have increased risk of infection from a variety

of organisms, they are mor susceptible to encapsulated bacteriae
like streptococcus pneumonia, haemophilus influenza type B and
Neiseria meningitides, streptococcus pneumonia cause rapid and
fulminant disease, Malaria also tends to be more severe
 PREVENTION OF INFECTION IN HYPOSPLENIC PATIENTS

 Patients should be informed about increased susceptibility to

infection
 Prophylactic oral penicillin for life
 vaccination against encapsulated organisms, for influenza
pneumococcal, and haemophilus influenza infection