The Spleen Splenic Trauma Diagnosis Injury should be

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 ® ® Hematologic processes ® ® ® Hemolytic anemia: Congenital, acquired Extramedullary hematopoiesis: thalassemia, osteopetrosis, myelofibrosis Neoplasms ® ® ® Bacterial: Typhoid fever, endocarditis, septicemia, abscess Viral: E-B virus, CMV, and others Protozoal: Malaria, toxoplasmosis 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 or secondary can be categorized as primary

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.