The spleendr.saad M attash
It weighs 75 – 250 gIt lies in the left hypochondrium
Along the line of tenth rib
Its hilum lies in the angle between the stomach and kidney, and is in contact with the tail of pancreas
There is a notch in its inferolateral border.
Immune function Major site of IgM production Opsonins, tuftsin, and properdin Filter function Macrophages in the reticulum capture cellular and non-cellular material from the blood and plasma. Effeet platelets & RBCs Bacteria , pneumococci
Pitting Removal of particulate particles from RBCs, like the Howell-Jolly & Heinz bodies. Reservoir function It is less marked but dose the spleen contain approximately 8% of the red cell mass.
Cytopoiesis Haemopoiesis during fetal life. Proliferation of T & B cells and macrophages following antigenic stimulation.
Investigations of spleen
Imaging:
n Plain radiology:
Rarely used, but incidental finding of calcification of the splenic artery __ splenic artery aneurysm
calcification of spleen__an old infarct, a benign cyst or Hydatid cyst.
multiple calcifications__tuberculosis
Ultrasonography; Determine the size & consistency SOL, cystic or solid CT scan; Better in determing the nature of suspected splenic pathology. MRI scan similar value to CT scan
Radioisotope: Less commonly requested Technetium99mm-labelled colloid is restricted to determine whether the spleen is a significant site of destruction of RBCs.
Diseases of spleenCongenital abnormalities of the spleen: Splenic agenesis, is rare but present in 10% of children with congenital heart disease. Polysplenia, is a rare condition resulting from failure of splenic fusion.
Splenunculi:
Are single or multiple accessory spleens that are found in approximately 10-30% of the population.
Located near the hilum in 50%,
Related to the splenic vessels or behind the tail of pancreas in 30%.
Remainder are located in the mesocolon or the splenic ligaments.
Hamartomas: Are rarely found in life Non-parasitic cysts: Are rare. True cysts form from embryonal rests.
Splenic trauma Aetiology: Blunt abdominal trauma, splenic injury should be suspected in any case of blunt abdominal trauma, particularly when the injury occurs to the left upper quadrant of the abdomen. And specially if there are fractures of the overlying ribs ( 9th ,10th ,11th).
Penetrating abdominal trauma: Stab and missile injury Iatrogenic: Splenic injury is a frequent complication of any surgical procedure, particularly those in the left upper quadrant. Presentation: may present in three ways The patient succumbs rapidly Initial shock, recovery, signs of late bleeding The delayed case
Clinical signs of ruptured spleen: General signs of internal hge Left upper quadrants guarding and tenderness.Kehr’s sign Shifting dullness Fullnes in the pelvis Diagnosis: Abdominal ultrasonography (FAST) CT scan
Management:
Conservative: applied in blunt trauma
Only in Haemodynamically stable patients
Minimal or no abdominal findings
CT scan *isolated injury.
absence of hilar involvement or massive disruption of spleen.
Immediate laparotomy:
Obvious evidence of continuous blood loss despite adequate resuscitation.
Strong suspicion of trauma to other organs
Splenic preservation should be considered wherever possible.
Persons with splenomegaly like in malaria are more liable to splenic rupture after trivial trauma. Trend for early splenectomy
Splenic abscessMay arise from: Infected splenic embolus In association with typhoid and paratyphoid fever, osteomyelitis, otitis media, and purperal sepsis. Panreatic necrosis In association with intraabdominal infection.
Complications: Rupture: Subphrenic abscess Peritonitis Diagnosis: Ultrasound CT scan Treatment: Underlying cause drainage
SplenectomyIndications: Urgent Splenic injury, accidental or iatrogenic Ellective 1- Oncological: Part of en bloc resection Diagnostic Therapeutic
Indications: 2- Haematological ITP Haemolytic anaemias 1- Hereditary spherocytosis 2- Acquired autimmune haemolyic anaemia 3- Thalassaemia 4- Sickle cell anaemia Hypersplenism 3- Portal hypertension Variceal surgery
Preoperative preparation
I- Normalization of coagulation profile:
In the presence of bleeding tendency;
Transfusion of blood
Fresh-frozen plasma
Cryoprecipitate
platelets
Preoperative preparation III- Vaccination; against Pneumococcus (those over 2 years) H. influenzae ( for all ages ) Meningococcus ( recommended in high risk areas ) Influenza virus. Note: in trauma victim, vaccination can be given in the postoperative period.
Technique: Open splenectomy Laparoscopic splenectomy Postoperative complications: Local: Haemorrhage Haematemesis Gastric dilatation
Postoperative complications: Local: Iatrogenic injury to adjacent organs; like § 1- Pancreas; may lead to: § Pancreatitis § Local abscess § Pancreatic fistula 2- Stomach; a fistula may result from damage to the greater curvature during ligation of short gastric vessels. 3- Colon, splenic flexure
Postoperative complications: Systemic: 1- Left basal atelectasis. 2- Pleural effusion. 3- Thrombocythemia; Prophylactic aspirin is recommended if platelet count exceeds one million per millilitre, to prevent axillary or other venous thrombosis.
Postoperative complications: Systemic: 4- Post-splenectomy septicaemia. 5- Opportunist pos-splenectomy infection. May result from S. pneumonia, N. meningitidis, H. influenzae, and E. coli. Is a major concern for children who undergone splenectomy before the age of 5 years.
Postoperative complications: Systemic: The risk is increased in: Young patients Chemotherapy Splenectomy for haematological disorders. How do we can decrease the risk: Vaccination Prophylactic antibiotics
Postoperative recommendation II- Antibiotic prophylaxis; Daily oral penicillin, or erythromycin, or amoxicillin, or co-amoxiclav until the age of 10 years for those children who have undergone splenectomy before the age of 5 years. For older children and adults is controversial; but since the risk of overwhelming sepsis is greatest during the first 2 – 3 years of splenectomy it seems reasonable to give prophylaxis antibiotics during this time.
NEOPLASMSHaemangioma Lymphoma is the most common cause of neoplastic enlargement The spleen is rarely the site of metastatic disease
Cysts 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