The Spleen

Splenic Trauma  Diagnosis  Injury should be suspected in blunt upper abdominal injuries ( MVA and Bike)  Injuries are often associated with fractured ribs of the left chest  Splenic injuries can cause extensive and continued hemorrhage, others can cause subcapsular hematomas that are subject to rupture at any time  If splenic injury is suspected, admission to the hospital for monitoring is mandatory  The signs and symptoms of splenic trauma are those of hemoperitoneum (generalized LUQ pain)

Treatment of Ruptured Spleen  Splenic preservation operations  Partial splenectomy  Capsular repair  Non operative treatment

Delayed Rupture of the Spleen  Injury to the pulp sometimes cannot be contained indefinitely by the splenic capsule  The usual interval between injury and hemorrhage is within two weeks (longer intervals have been reported)  The incidence is between 15-30%  It is hoped that as imaging techniques improve the incidence will decrease

Splenosis  Is the auto transplantation of splenic tissue after splenic trauma  They vary from a few millimeters to several centimeters in diameter  May occur anywhere in the peritoneal cavity  Seldom causes symptoms and is usually discovered as an incidental finding at reoperation  Post splenectomy sepsis has renewed interest in splenosis

Causes of splenomegaly  Infection  Bacterial: Typhoid fever, endocarditis, septicemia, abscess  Viral:E-B virus, CMV, and others  Protozoal: Malaria, toxoplasmosis  Hematologic processes  Hemolytic anemia: Congenital, acquired  Extramedullary hematopoiesis: thalassemia, osteopetrosis, myelofibrosis  Neoplasms  Malignant: Leukemia, lymphoma, histiocytoses, metastatic tumors  Benign: Hemagioma, hamartoma  Metabolic diseases  Lipidosis: Niemann-Pick, Gaucher disease  Mucopolysaccharidosis infiltration: Histiocytosis  Congestion  Cirrhosis  Cysts  Miscellaneous

Hypersplenism  Refers to a variety of ill effects resulting from increased splenic function that may be improved by splenectomy  The criteria for diagnosis included:  Anemia, leukopenia, thrombocytopenia or a combination of the three  Compensatory bone marrow hyperplasia  Splenomegaly  Hypersplenism can be categorized as primary or secondary

Splenic Involvement in Hodgkin’s lymphoma  The probability of splenic involvement increases with increasing spleen size  The absence of splenomegaly does not exclude splenic involvement  Upon gross examination of the spleen a grayish white nodule ranging from several millimeters to several centimeters is apparent with Hodgkin’s disease  Liver involvement with Hodgkin’s disease rarely occurs in the absence of splenic disease

Felty’s Syndrome  Is a syndrome consisting of severe rheumatoid arthritis, granulocytopenia and splenomegaly  It usually occurs in patients with a long history of rheumatoid arthritis  Severe, persistent and recurrent infections are characteristic  Moderate splenomegaly is common  Splenectomy is effective in most patients

Gaucher’s Disease  Is a disorder of lipid metabolism that may result in massive splenomegaly and hypersplenism  Commonly found in the Jewish population  Diagnosis is made by finding the typical Gaucher’s cells in biopsy tissue  Massive splenomegaly is usually the most common form of presentation  The adult form is the most common form  Splenomegaly (subtotal) shows great benefits

Cysts and Tumors of the Spleen  The differential diagnosis of splenomegaly should include splenic masses and primary tumors (these conditions are rare however they must be considered)  Cystic lesions comprise parasitic and nonparasitic cysts  Parasitic cysts are due almost exclusively to echinococcal disease (rare in the United States)  Nonparasitic cysts are classified as primary (true) which have an epithelial lining or pseudocysts (more common  Symptoms of splenic cysts are vague and are caused primarily by mass effect (compression of adjacent viscera)

Cysts and Tumors of the Spleen  Selected nonparasitic cyst may be managed by aspiration  Splenectomy should be performed for all large cyst and those with an uncertain diagnosis  Malignant and benign primary tumors of the spleen are rare  Most primary malignant tumors are angiosarcomas

Infectious Mononucleosis  A disease characterized by fever, sore throat, lymphadenopathy and atypical lymphocytes  Most patients are young  Clinical symptoms are similar to those of a severe upper respiratory tract infection  The spleen is enlarged and palpable in over 50% of patients  Splenic rupture may occur

Incidental Splenectomy  The spleen is vulnerable to injury during operative procedures in the upper abdomen  When the splenic capsule is torn, splenectomy is frequently performed  Morbidity and mortality is higher with iatrogenic injury requiring splenectomy

Splenectomy  Prior to removing the spleen specific preoperative preparation is necessary  All patients should receive polyvalent pneumococcal vaccine, polyvalent meningococcal vaccine and Haemophilus influenzae type b conjugant vaccine  Blood and blood products should be available well in advance of surgery

Blood Compositional Changes in the Asplenic or Hyposplenic Patient  The absence of functional splenic tissue results in characteristic changes in the circulating blood  Some of these are predictable and desirable results  These changes are considered a measure of its success when splenectomy is performed for a hematologic disease  Howell-Jolly bodies (nuclear remnants) and thrombocytosis (desired result)  Other findings include: target cells, acanthocytes (spur cells), Heinz bodies (denatured hemoglobin) and stippled red cells

Postsplenectomy Sepsis  Asplenic patients have an increased susceptibility to the development of overwhelming infection  The risk of sepsis is approximately 60 times greater than normal after splenectomy  The risk is greatest in children younger than four years of age  The risk of sepsis is higher among patients requiring splenectomy for inherited diseases  The risk of sepsis after splenectomy is lowest after trauma

Postsplenectomy Sepsis  Postsplenectomy sepsis syndrome typically occurs in a previously healthy individual after a mild upper respiratory tract infection associated with fever  Within hours, nausea, vomiting, headache, confusion, shock and coma can occur; death follows within 24 hours  The nature of the syndrome makes it difficult to diagnose early enough for therapy to be effective

Postsplenectomy Sepsis  The most common bacteria isolated our streptococcus pneumoniae, Neisseria meningitidis, E. coli or Haemophilus influenzae  Because half of the patients develop sepsis from strep pneumoniae, penicillin can be administered immediately with onset of a febrile URI  Patients are instructed to obtain and wear a Medic alert tag

Hyposplenism  Is a potentially lethal syndrome characterized by diminished splenic function  The patient peripheral blood smears appear as if they are asplenic  Hyposplenism can occur in the presence of abnormal sized or enlarged spleen  The danger of hyposplenism is the risk of developing potentially lethal sepsis  Sickle cell anemia is the most common disease associated with hyposplenism  The most common surgical disease associated with hyposplenism is chronic UC

Management  Immunisations  Pneumococcal – 2 weeks prior to elective surgery otherwise when patient is recovered prior to discharge. Boosters every 5-10 years  H. influenza – recommended but evidence for immunogenicity and boosters lacking  Meningococcal – not routinely recommended  Influenza – may be of value especially in reducing risk of secondary bacterial infection

Mx continued…  Antibiotic prophylaxis  Controversial  Penicillin  In all cases, esp in first 2 years post surgery  All up to 16 and if underlying immune dysfunction  May not prevent sepsis  Local resistence patterns need to accounted for  Home antibiotic supply

Cont………  Travellers  MALARIA PROPHYLAXIS  Meningococcal vaccine  Antibiotic prophylaxis  Education  Medic alert bracelet etc.