Spleen- surgical recall
functions of the human spleen [5]
- FILTERS abnormal RBCs (does NOT store RBCs like the canine spleen!) - stores platelets - produces tuftsin and properdin (opsins) - produces antibodies (esp. IgM) - site of phagocytosis
indications for splenectomy: - malignant diseases [3]
- Hodgkin's staging not conclusive by CT scan - Splenic tumors (primary/ metastatic/ locally invasive) - Hypersplenism d/t other leukemias/ non-hodgkin lymphomas
what labs are abnormal after splenectomy>
- WBC count increases by 50% over baseline - marked THROMBOCYTOSIS occurs - abnormal RBC smear
define hypersplenism
- hyperfunctioning spleen - documented loss of blood elements (WBC, Hct, platelets) - splenomegaly - hyperactive bone marrow (trying to keep up with the loss of blood elements)
indications for splenectomy: - anemias [7]
- medullary fibrosis w/ myeloid metaplasia - hereditary elliptocytosis - hereditary spherocytosis - sickle cell anemia - pyruvate kinase deficiency - autoimmune hemolytic anemia - Thallassemias
what are the possible post-splenectomy complications? [7]
- thrombocytosis - subphrenic abscess - atelectasis - pancreatitis - gastric dilation - OPSS: Overwhelming PostSplenectomy Sepsis - pancreatic tail injury
misc. indications for splenectomy
- variceal bleeding w/ splenic vein thrombosis - Gaucher's disease - splenic abscess - refractory splenic cysts - hypersplenism - Felty's syndrome
what are the findings on a postsplenectomy RBC peripheral smear?
-Pappenheimer bodies - Howell-Jolly bodies - Heinz bodies
what is the incidence and overall mortality of OPSS in children?
1-2% incidence 50% mortality rate
tx of spleen injury
1. nonoperative in a stable patient with an isolated splenic injury without hilar involvement/ complete rupture 2. if unstable, DLP/FAST laparotomy w/ splenorrhaphy or splenectomy 3. Embolization is an option in selected patients
% of total body platelets stored in the spleen
33%
what is the incidence of OPSS in adults?
< 1%
what is Ballance's sign?
LUQ dullness to percussion
sx of a ruptured/injured spleen? [4]
hemoperitoneum, Kehr's sign, LUQ pain, Ballance's sign.
what is Kehr's' sign?
left shoulder pain, seen with splenic rupture
is G6PD deficiency an indication for splenectomy?
no
what is the mcc of splenic vein thrombosis?
pancreatitis
which patients develop hyposplenism?
patients with ulcerative colitis
what vaccinations should every patient with a splenectomy receive?
pneumococcus meningococcus H. influenza B
what is the venous drainage of the spleen?
portal vein, via the splenic vein and the left gastroepiploic vein
what is the treatment of gastric varices caused by splenic vein thrombosis?
splenectomy
which arteries supply the spleen?
splenic artery (branch of the celiac artery) and the short gastric arteries that arise from the gastroepiploic
what is splenorrhaphy?
splenic salvage operation: wrapping vicryl mesh, aid of topical hemostatic agents or partial splenectomy, sutures (buttressed)
what is the mcc of ISOLATED gastric varies?
splenic vein thrombosis, usually from pancreatitis
mc physical finding of portal HTN
splenomegaly
what is delayed splenic rupture?
subscapular hematoma or pseudoaneurysm may rupture some time after blunt trauma, causing "delayed splenic rupture"; classically occurs 2 weeks s/p injury - presents w/ shock and abdominal pain
what is the preventative tx for OPSS?
vaccinations for pneumococcus, H. flu, and meningococcus, ppx PCN for all minor infections/ illnesses and immediate medical care if febrile
when and how should thrombocytosis be treated?
when platelet count is > 1 million, most sureaons will treat with ASPIRN
% of ppl w/ an accessory spleen
~20%
what are the common organisms assoc. w/ OPSS?
*encapsulated*: strep. pneumoniae , N. meningitides, H. flu
what is the typical presentation of OPSS?
fever, lethargy, common cold, sore throat, URI followed by confusion, shock and coma with death ensuing within 24 hours
indications for splenectomy: - thrombocytopenias [2]
idiopathic thrombocytopenia purpura thrombotic thrombocytopenic purpura
what causes OPSS? (Overwhelming PostSplenectomy Sepsis)
increased susceptibility to fulminant bacteremia, meningitis, or pneumonia because of splenic function
how is a spleen injury diagnosed?
Abdominal CT *if patient is stable* DLP or FAST if unstable
what is the best time to give immunizations to splenectomy patients
PREOPERATIVELY if at all possible - if emergent, then 2 weeks post op.
what opsonins does the spleen produce?
PROperdin & TUFtsin - think professionally tough spleen
what is Seagesser's sign
Phrenic nerve compression causing neck tenderness in splenic rupture
what is ITP? (idiopathic thrombocytopenic purpura)
autoimmune destruction of platelets leading to troublesome bleeding and purpura
what is the mcc of failure to correct thrombocytopenia after splenectomy for ITP?
missed accessory spleen
what is the mc bacteria in OPSS?
strep. pneumoniae
what is said to "tickle" the spleen?
tail of the pancreas
