Spleen
Central role: - Regulating the immune system - Influencing metabolic and endocrine functions
Anatomy: An encapsulated mass of vascular and lymphatic tissue The largest RES organ 9-11th ribs 4 impressions ligamentous attachments Related to pancreatic tail Blood supply
Embryonic anomaly: Accessary spleen Functions: Removal of RBCs ,WBCs and Platelets Extramedullary hemopoeisis Recycling Iron Immunological (T and B cell lymphocytes )
Splenomegaly: Weight 500 gms Average 15 cm Massive, > 1 Kgm > 15 cm
Imaging studies: - USS - CT …… Imaging studies: - USS - CT …….Trauma scoring - MRI - Angiography (embolization)
Indications for splenectomy: The commonest is trauma For elective ,the commonest is ITP 1. Benign disorders: Hereditary spherocytosis G6PD deficiency Auto immune hemolytic disease Sickle cell disease Thalassemia
Indications foe splenectomy…. continued 2 Indications foe splenectomy…..continued 2. Malignant diseases: WBCs disorders Hodgkins disease Non Hodgkins lymphoma Chronic lymphocytic lukemia Myeloproliferative disorders Acute myeloid lukemia Essential thrombocytopenia Polycythemia
Indications for splenectomy…. continued 3. Others: 3a Indications for splenectomy…..continued 3. Others: 3a. Infections: Infectious mononucleosis EB virus CMV ( spontaneous rupture ) 3b. Abscess 3c. Cysts: Parasitic Traumatic Dermoid 3d. Tumors: Primary (Sarcoma) Metastatic
Indications for splenectomy…. continued 3e Indications for splenectomy…..continued 3e. Storage diseases: Gauchers disease Niemann-Pick disease 3f. Splenic artery aneurysm 3g. Portal H.T 3h. Feltys syndrome 3i. Wandering spleen
Preoperative considerations: Patient Education Overwhelming sepsis Splenic vein thrombosis Vaccinations: Encapsulated pathogens More with hematological and malignant disorders More in children Greatest risk, 1st 2 years Timing
The Liver The largest organ (1500 Gm) Two lobes 8 segments Protected by rib cage Fibrous capsule (Glissons ) 8 ligaments Foramen of Winslow Dual supply Hepatic artery 25% Portal vein 75% Portosystemic anastomosis
Physiology: Storage Proteins ( AA) Glucose (Glycogen) Fat (Cholesterol) Production All plasma proteins All coagulation factors Secretion Detoxification
Bile: I litre per day Bilirubin metabolism Composition: water Organic molecules: Bile pigments Bile salts Phospholipids (Lecithin) Cholesterol Enterohepatic circulation
Jaundice: Bilirubin more than 2 Jaundice: Bilirubin more than 2.5 – 3 mgs/dl Causes: Prehepatic Intrahepatic, Gilberts syndrome Crigler-Najjar syndrome Dubin-Johnson syndrome Posthepatic…..extrinsic or intrinsic obstruction of the biliary tree
Imaging: - USS - CT - MRI - PET - Angiography
Liver cirrhosis: The final sequela of chronic hepatic insult Morphology Micronodular Macronodular
Liver Cirrhosis …..continued Etiology: Viral hepatitis Autoimmune hepatitis Drug induced Cholestasis Metabolic Hemochromatosis Wilsons disease Hepatic vein outflow obstruction Budd chiari syndrome Congestive cardiac failure Constrictive pericarditis
Portal Hypertension: Portal venous system contributes 75% of the blood supply 72% of the Oxygen Normal pressure 5-10 mmHg
Portal HT ……continued Etiology: 1 Portal HT ……continued Etiology: 1. Presinusoidal Extrahepatic Splenic vein thrombosis Splenomegaly Splenic A-V fistula Intrahepatic Schistosomiasis Congenital hepatic fibrosis Idiopathic portal fibrosis Myeloproliferative disorders Sarcoid
Portal HT etiology……continued 2. Sinusoidal Intrahepatic cirrhosis 3 Portal HT etiology……continued 2. Sinusoidal Intrahepatic cirrhosis 3. Post sinusoidal Intrahepatic Vascular occlusive disease Posthepatic Budd Chiari CCF IVC web Constrictive pericarditis
Varices: 30% of patients with compensated cirrhosis 60% of patients with decompensated cirrhosis 1/3 of all patients with varices will experience variceal bleeding Each episode 20-30% mortality if untreated 70% of patients who survive the initial episode will experience recurrent haemorrhage within 2 years
Prevention of variceal bleeding: Non selective Beta blockers Prophylactic endoscopic suveillance and band ligation
Acute Vareceal Bleeding: Admission to ICU Careful blood replacement FFP Platelets Antibiotics Vasopressin Luminal tamponade Blackmore-Sengstaken tube TIPS Surgery: Shunting Portocaval Mesocaval Distal lienorenal (Warren) Non shunting Sigiura Liver transplant
Budd Chiari syndrome: Congestive Hepatopathy Primary Thrombosis Secondary Compresion
Liver Abscess: Pyogenic Amebic
Hydatid Disease: 70% in the liver May be silent May become infected or may rupture Diagnosis: ELISA 80% Positive (Weinburg) Casoni Eosinophilia 30% Imaging
Hydatid disease ……continued Treatment: Albendazole Mebendazole Surgery E.multilocularis (in the west )
Ascariases: Retrograde locomotion into the bile ducts Treatment: Piperazine citrate Albendazole Mebendazole ERCP
Schistosomiasis: Perisinosoidal portal HT Education Hygiene Praziquantel Single dose 40-70 mg/kilo wt.
Liver Cysts: Congenital Benign cystadenoma Polycystic liver disease Caroli’s disease Biliary lithiasis 33% Cholangitis Biliary abscesses Cholangiocarcinoma 7%
Benign Liver Lesions: 1. Cysts Primary ( congenital) Secondary (traumatic) Seromas Bilomas 2. Hemangiomas 3. Adenoma Females OCP Significant risk of rupture Risk of malignant transformation to HCC
Benign Liver Lesions…….continued 4. Focal nodular hyperplasia
Malignant Liver tumors: 1. Primary 1a Malignant Liver tumors: 1. Primary 1a. From liver cells (HCC) Hepatocellular carcinoma 1b. From bile ducts (CC) Cholangiocarcinoma
Malignant Liver Tumors ……continued HCC: The 5th common malignancy High fatality Risk factors Viral hepatitis Alcoholic cirrhosis Hemochromatosis Aflatoxin
Malignant liver Lesions…… Malignant liver Lesions…….continued Cholangiocarcinoma An adenocarcinoma of the biliary tree Peripheral ( intrahepatic) Central(extrahepatic) Distal Proximal(hilar) Klatskin tumor
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