1. Spleen

2. Central role: - Regulating the immune system - Influencing metabolic and endocrine functions

3. 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

4. Embryonic anomaly: Accessary spleen Functions: Removal of RBCs ,WBCs and Platelets Extramedullary hemopoeisis Recycling Iron Immunological (T and B cell lymphocytes )

5. Splenomegaly: Weight 500 gms Average 15 cm Massive, > 1 Kgm > 15 cm

6. Imaging studies: - USS - CT ……
Imaging studies: - USS - CT …….Trauma scoring - MRI - Angiography (embolization)

7. 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

8. 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

9. 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

12. 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

13. 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

14. 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 %
Portosystemic anastomosis

15. Physiology: Storage Proteins ( AA) Glucose (Glycogen) Fat (Cholesterol) Production All plasma proteins All coagulation factors Secretion Detoxification

16. Bile: I litre per day Bilirubin metabolism Composition: water Organic molecules: Bile pigments Bile salts Phospholipids (Lecithin) Cholesterol Enterohepatic circulation

17. 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

18. Imaging: - USS - CT - MRI - PET - Angiography

19. Liver cirrhosis: The final sequela of chronic hepatic insult Morphology Micronodular Macronodular

20. 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

21. Portal Hypertension: Portal venous system contributes 75% of the blood supply 72% of the Oxygen Normal pressure 5-10 mmHg

22. 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

23. 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

24. 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

25. Prevention of variceal bleeding: Non selective Beta blockers Prophylactic endoscopic suveillance and band ligation

26. 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

27. Budd Chiari syndrome: Congestive Hepatopathy Primary Thrombosis Secondary Compresion

28. Liver Abscess: Pyogenic Amebic

29. Hydatid Disease: 70% in the liver May be silent May become infected or may rupture Diagnosis: ELISA 80% Positive (Weinburg) Casoni Eosinophilia 30% Imaging

30. Hydatid disease ……continued Treatment: Albendazole Mebendazole Surgery E.multilocularis (in the west )

31. Ascariases: Retrograde locomotion into the bile ducts Treatment: Piperazine citrate Albendazole Mebendazole ERCP

32. Schistosomiasis:
Perisinosoidal portal HT
Education
Hygiene
Praziquantel Single dose mg/kilo wt.

33. Liver Cysts: Congenital Benign cystadenoma Polycystic liver disease Caroli’s disease Biliary lithiasis 33% Cholangitis Biliary abscesses Cholangiocarcinoma 7%

34. 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

35. Benign Liver Lesions…….continued 4. Focal nodular hyperplasia

36. Malignant Liver tumors: 1. Primary 1a
Malignant Liver tumors: 1. Primary 1a. From liver cells (HCC) Hepatocellular carcinoma 1b. From bile ducts (CC) Cholangiocarcinoma

37. Malignant Liver Tumors ……continued HCC: The 5th common malignancy High fatality Risk factors Viral hepatitis Alcoholic cirrhosis Hemochromatosis Aflatoxin

38. Malignant liver Lesions……
Malignant liver Lesions…….continued Cholangiocarcinoma An adenocarcinoma of the biliary tree Peripheral ( intrahepatic) Central(extrahepatic) Distal Proximal(hilar) Klatskin tumor

39. Questions ?