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 SpleenSplenic preservation operationsPartial splenectomyCapsular repairNon 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 SplenectomyThe 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

SplenectomyPrior 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

EducationMedic alert bracelet etc.