SPLEEN

I. Anatomy
- weight approximately 100-150
grams
- located in the left upper and
protected
by the lower portion of the rib cage
- its position is maintained by several
ligaments
a. splenophrenic
b. splenorenal
c. splenocolic
d. gastrosplenic short gastric a.

Spleen

- it is supplied by the splenic artery,

which is a branch of the coeliac artery.
- accessory spleens have been
reported in 14% to 30%, ususally seen
at the hilum, greater omentum, and
ligaments of the
spleen

Blood supply

- consists of the capsule and trabeculae which

enclose the pulp.
- 3 zones of the pulp
a. White pulp lymph node; contains
lymphocytes, macrophages, and plasma
cells in a reticular network
b. Red pulp consists of the cord and
sinuses; contains the cellular elements of
the blood
c. Marginal zone poorly defined vascular
space between pulps; contains sequestered
foreign material and plasma as well as
abnormal cellular elements

histology

II. Physiologic Functions

A. Filtering splenic blood flow 350
ml/day
1. removal of abnormal red blood cells
approximately 20 ml of aged RBC are
removed daily
2.removal of abnormal WBC, plateletes

B. Immunologic Function
1. opsonin production
2. antibody synthesis (IgM)
3. protection from infection
C. Storage Function
1. plateletes 1/3 are stored in the
spleen
2. in splenomegaly, up to 80% of the
plateletes may be stored in the spleen
thrombocytopenia

splenomegally

splenomegally

III. Diagnostic
A. Evaluation of size
1. physical examination
a. not normally palpable
b. felt in 2% of healthy adults
c. no significant dullness elicited by
percussion over spleen
d. as organ enlarges, dullness is detected at
the level of the 9th ICS in
the left anterior
axillary line

2. CT/MRI depicts the spleen and defines

abnormalities in size, shape and parenchymal
pathology
3. 99 Tc colloid
B. Evaluation of function
1. hypersplenism reduction in number
of RBC,
WBC, plateletes
2. increase in cellular destruction results in
compensatory rise in production in the bone marrow
reticulocytosis

IV. Pathologies
A. Rupture of the Spleen
1. Etiology disruption of the spleens
parenchyma, capsule, and blood supply
a. spleen is the most commonly injured
organ following blunt trauma
b. 2% splenic injury during surgery
in
the LUQ Gastric surgery
c. spontneous rupture hematologic
disorders

CT scan of splenic and liver

trauma

2. Pathology
a. splenic rupture
i. intraperitoneal bleed
ii. 90% of blunt trauma
b. delayed rupture
i. interval of days or weeks between
injury and bleeding; 10%-15%

ii. Quiescent period (of Baudette)

persists for less than 7 days up to
2 weeks
iii. related to temporary
of minor lacerations or
enlarging subcapsular

tamponade
slowly
hematoma

c. occult splenic rupture

- pseudocyst of the spleen (1%)
3. Clinical manifestation
a. hypovolemia/tchycardia
b. hypotension
c. localized (LUQ) or generalized abdominal
pain
d. Kehrs sign pain at the tip of the left
shoulder diaphragmatic irritation
e. Balances sign ( mass or fixed dullness at
the left upper quadrant

4. diagnostic studies
a. CBC serial Hct determination
leukocytosis
b. x-ray of the abdomen
i. fractured ribs
ii. elevated immobile
diaphragm
iii. enlarged splenic shadow
iv. medial displacement of
gastric shadow
v. widening shadow between
splenic flexure and
preperitoneal
fat

c. CT scan
d. angiography
5. Treatment surgery
a. children delayed surgical
management
b. adult - splenectomy
c. splenectomized patients should
receive pneumovax Haemophilus
influenza vaccine and children should also
be given oral penicillin daily until age 18

B. Hypersplenism
1. Primary hyperslenism
a. diagnosis by exclusion made
has been excluded
b. rare entity affecting women
c. anyone or all formed elements
may be affected
d. enlarged spleen
e. recurring fever and infection
f. lymphoma and leukemia
g. responds to splenectomy
h. steroids do not improve condition

after secondary hypersplenism

2. Secondary hypersplenism caused

by an identifiable underlying disease
a. portal hypertension
i. splenic congestion
ii. most common cause of
secondary hypersplenism
iii. does not warrant splenectomy

b. splenic vein thrombosis

i. massive splenomegaly
ii. thrombosis secondary to
pancreatitis
iii. associated with bleeding
esophageal varices
iv. cured by splenectomy

CT and Angiogram of splenic

vein thrombosis

c. other causes
i. neoplasms leukemia,
carcinoma

lymphoma, metastatic

ii. myelproliferative disorders

iii. increase in RBC
major

destruction thalassemia

iv. disorders in immune response

infectious
mononucleosis,
Feltys syndrome
(rheumatoid
arthritis, splenomegally,
neutropenia)
v. diseases that infiltrate the
amyloidosis, sarcoidosis

spleen

Splenic tumor

V. Splenectomy
A. Absolute Indications for Splenectomy
1. splenic tumors echinoccocal cyst
2. metastatic disease
3. splenic abscess
4.hereditary spherocytosis most
common
hemolytic anemia for which
splenectomy is
indicated
5. bleeding esophageal varices

CT scan of splenic abscess

6. chronic lymphocytic leukemia

7. hairy cell leukemia
8. Chronic myeloid leukemia more to
the pain
9. Sarcomas
10 trauma

ease

B. Relative indications for

splenectomy
1. congenital hemolytic anemias
2. sickle cell anemia
3. idiopathic autoimmune hemolytic
anemia
4. Thrombocytic thrombocytopenic
purpura

5. Feltys syndrome/Sarcoidosis (non-caseating

granulomas)/Gauchers disease (lipid storage
disease)/Niemann-Pick disease (abnormal storage
of cholesterol and sphingomyelin)/Amyloidosis
(abnormal extracellular storage of protein)
6. Chronic rheumatoid arthritis
7. granulocytopenia
8. Hodgkins lymphoma
9. Non-hodgekins lymphoma
10. idiopathic thrombocytopenic purpura

VI. Splenectomy Outcomes

- post-operative appearance of:
a. siderocytes
b. Howell-Jolly bodies
c. leukocytosis
d. increased platelete count

A. Complications
1. left lower lobe atelectasis
most common
2. subphrenic hematoma
3. subphrenic abscess can occur
with
placement of a drain
4. pancreatitis trauma to the tail
of the pancreas
5. deep vein thrombosis low
dose anticoagulants

B. Hematologic outcomes
1. initial
a. thrombocytopenia rise in
platelete count within a few days
b. chronic hemolytic anemias
level above 10 g/dl

Hgb

2. long-term
a. increase in platelete count
rise
to >150,000 more than 2
months
after surgery
b. 90-100% success for
hereditary
spherocytosis

C. Overwhelming Post-Splenectomy
Infection (OPSI) 1. lifetime risk of
severe infection
2. incidence of 3.2% post-splenectomy
3. loss of the spleens ability to filter
and phagocytose bacteria and
infected
RBC

4. most common sources of infection

a. Streptococcus pneumoniae
most common
b. Heamophilus influenzae B
c. meninggococcus
d. group A streptococci
5. presents with pneumonia or
meningitis

6. risk factors for the development of

OPSI
a. indication for splenectomy
- hematologic disorder vs trauma
b. overall immune status
c. interval from the date of surgery
usually within 2 years

7. prevention
a.vaccine against
i. pneumoccocus
ii. H. influenzae
iii. meninggococcus
- to be given within 7-14 days
after splenectomy

b. booster dose for pneumococcal

vaccine every 5-6 years
c. annual influenza vaccine
d. daily dose of penicillin or
amoxycillin for 2 years