SR60: Spleen and Splenectomy
What is the Tx for a ruptured or injured spleen?
1. Nonoperative in a stable pt with an isolated splenic injury without hilar involvement / complete rupture 2. If pt is unstable, DPL/FAST laparotomy with splenorrhaphy or splenectomy 3. embolization is an option in some pts
A subcapsular hematoma or pseudoaneurysm may rupture some time after blunt trauma that classically occurs about 2 weeks after the initial injury and presents with shock / abdominal pain.
Delayed splenic rupture
What are the "I's" of ITP?
Immune etiology (IgG antiplatelet antibodies) Immunosuppressive Tx (initially Tx with steroids) Immune globulin Improvement with splenectomy
Is G6PD deficiency an indication for splenectomy?
No
Patient presents with fever, lethargy, common cold, sore throat, URI followed by confusion, and shock that can lead to coma with death ensuing within 24 hrs in up to 50% of patients.
OPSS
Hemoperitoneum, left shoulder pain (Kehr's sign), LUQ dullness to percussion (Balance's sign), LUQ abdominal pain are symptoms of what?
Ruptured/injured spleen
What lab tests are abnormal after splenectomy?
WBC count (increases by 50% over the baseline) marked thrombocytosis occurs RBC smear is abnormal
When and how should thrombocytosis be treated in a postsplenectomy pt?
When PLT count is > 1 million. Most surgeons treat with aspirin.
What is the MC cause of splenic vein thrombosis?
pancreatitis
What are the findings on postsplenectomy RBC smear?
peripheral smear will show Pappenheimer bodies, Howell-Jolly bodies, and Heinz bodies
What is the Tx of choice for TTP?
plasmapheresis (splenectomy is reserved as last resort)
phrenic nerve compression causing neck tenderness in splenic rupture
seagesser's sign
What is a spenorrhaphy?
splenic salvage operation: wrapping vicral mesh, aid of topical hemostatic agenst or partial splenectomy (vast majority of pedi patietns undergo nonoperative Tx for blunt spleen injury)
What is the MC cause of ISOLATED GASTRIC varices? What is Tx of gastric varices caused by this?
splenic vein thrombosis (usually from pancreatitis) splenectomy
What is the MC physical finding of portal HTN?
splenomegaly
What are the possible postsplenectomy complications?
thrombocytosis, subphrenic abscess, atelectasis, pancreatitis gastric dilation, and ***overwhelming postsplenectomy sepsis (OPSS)
What is preventive Tx of OPSS?
vaccinations for pneumococcus, H. flu, and meningococcus Prophylactic penicillin for all minor infections / illnesses and immediate medical care if febrile illness develops
Which arteries supply the spleen? What is the venous drainage of the spleen?
Splenic artery, a branch of the celiac trunk, and short gastric arteries The portal vein (via the splenic and left gastroepiploic veins)
What is said to "tickle" the spleen?
The tail of the pancreas
What are the typical organisms associated with OPSS? Which is most common?
encapsulated organisms: strep pneumoniae, N. meningitides, H. flu strep pneumo
Define splenomegaly.
enlarged spleen
What are the functions of the spleen?
filters abnormal RBCs (does NOT store RBCs!) stores platelets produces tuftsin and properdin (opsins) produces antibodies (esp. IgM) site of phagocytosis
Which patients develop hypersplenism?
hyperfunctioning spleen documented loss of blood elements (WBC, Hct, PLTs) large spleen (splenomegaly) hyperactive bone marrow (trying to keep up with loss of blood elements)
What causes OPSS?
increased susceptibility to fulminant bacteremia, meningitis, or pneumonia bc of loss of splenic function (incidence less than 1% in adults; higher in children)
What is the best time to give immunizations to splenectomy patients?
preoperatively if possible if emergent, then 2 weeks post-op
What opsonins does the spleen produce?
properdin, tuftsin (think PROfessionally TUF spleen)
a. left shoulder pain seen w/ splenic rupture b. LUQ dullness to percussion
a. Kehr's b. Balance's
How is a spleen injury diagnosed?
abdominal CT - IF THE PT IS STABLE! DPL or FAST exam if the patient is unable
What is ITP?
autoimmune platelet destruction leading to troublesome bleeding and purpura usually IgG antiplatelet antibodies
What is the MC cause of failure to correct thrombocytopenia after splenectomy for ITP?
missed accessory spleen
