The Spleen: Anatomy and Common Complications

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Key Points

The spleen is the largest organ in the lymphatic system.

The spleen can usually be removed with almost no problems; however, life-threatening complications may
result if the organ ruptures.
Many patients with splenic masses present with vague clinical signs.

For those who are unfamiliar with its function in the body, the spleen can be a mysterious organ. When a splenic
tumor is diagnosed, the organ is usually removed without any long-term complications. However, a spleen that
ruptures during trauma can cause life-threatening problems. Although most technicians know that animals do not
need a spleen to live, not everyone is familiar with the role that the spleen plays. Despite all the advances in
medicine, some aspects of the spleen continue to be a mystery.

Anatomy

The spleen is the largest of the lymphatic organs; it is located in the upper left region of the abdomen and is
attached to the stomach via small blood vessels.1 The organ is closely associated with the cardiovascular system; it
contains a network of vessels that transports fluid between tissues and the bloodstream.1 The spleen is often
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described as a large lymph node, except that instead of containing lymph fluid it contains blood and is divided into
chambers or lobules.1 Each chamber is similar to an individual lymph node in the sense that it helps filter the blood
through the spleen. There are numerous chambers in the spleen, but the number depends on the species of animal.
The chambers of the spleen are lined with red pulp, which contains arterial capillaries and small venous vessels, 2
and white pulp, which consists mainly of T and B lymphocytes.1

Physiology

The functions of the spleen include hematopoiesis, circulation, destruction and preservation of red blood cells, and
immunologic function.3 Because the organ is directly connected to blood circulation, it responds faster than other
lymph nodes to blood-borne antigens.4 The spleen stores between 10% to 20% of the total blood volume. 3 It also
produces lymphocytes and most of the monocytes as well as plays an important role in producing antibodies.2 All
blood, at some point, gets filtered through the spleen. Despite its importance, there are no tests specific to splenic
function.

Splenic Complications

Biological Insults

Biological insults occur more commonly than traumatic insults and may be encountered by most technicians at
some point in their career, regardless of whether they work in an emergency clinic. There are three kinds of
biological insults: splenic masses, splenic torsion, and splenomegaly.

Splenic Masses

Splenic masses are common in dogs.3 Some canine breeds (e.g., German shepherds, golden retrievers) are
predisposed to developing splenic masses; however, no genetic link has yet been proven.3 It is unknown whether
spayed or neutered dogs are more at risk.5 Splenic masses are not as common in cats; however, the percentage
difference is unknown. In a study conducted at The Ohio State University, of 85 dogs that underwent a splenectomy,
20% were found to have tumors that were nonneoplastic and 50% had tumors that were neoplastic.3 The other 30%
of dogs had their spleens removed for nontumor-related causes. Another study conducted at The Ohio State
University revealed that of 42 dogs undergoing a splenectomy involving a mass, 33% of the masses were benign.6
Many studies seem to show similar results. The chance of having a neoplastic splenic mass is significantly greater
than that of having a nonneoplastic one.

Many patients with splenic masses present with vague clinical signs. The most common signs are lethargy,
weakness, vomiting, and anorexia. Often, clients simply state that their dog "is just not right." Dogs may have a
splenic mass for months and never show signs until their spleen ruptures. Within hours, the dog's disposition may go
from active and playful to lethargic. It is not unusual for a technician or veterinarian to be surprised by a diagnosis of
a large splenic mass when the owner could state only that the dog seemed "tired." Therefore, it is important never to
dismiss a client simply because the signs described do not seem serious. Regardless of whether a tumor is
suspected, the patient's complete history should be obtained and a thorough physical examination performed.

In many patients, the tumor may rupture simply because it has grown too large. Most splenic tumors are very
vascular, and when they rupture, they start to bleed. Sometimes, the bleeding cannot be stopped or is significant in
quantity. Bleeding into the abdomen can cause the animal to become extremely ill very quickly. These animals
typically present in critical debilitated states. Owners may report that the pet was fine in the morning but they found
the animal collapsed when they returned home. Physical findings may include signs of shock, such as tachycardia,
pale mucous membranes, ataxia, tachypnea, and poor pulse quality.7 The patient may be hyper- or hypothermic. 7
Occasionally, the mass may be large enough to palpate in the abdomen. If the pet is in shock, it is important to notify
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the veterinarian immediately so that emergency treatment can be initiated. If the mass has not ruptured, physical
findings may be few to none. Slight pain in the abdomen and a distended abdomen may be the only signs present.

Blood work should be obtained. A complete blood count may show regenerative anemia or other hemolytic
disease.7 In a blood smear with a left shift, spherocytes, schistocytes and leukocytes may also be present. 7
Thrombocytopenia may occur secondary to the mass or from disseminated intravascular coagulation.7 The
chemistry profile may show hypercalcemia, hyperglobulinemia, hemoglobinemia, or hyperbilirubinemia.7 In cats, an
eosinophilia may occur.7 The patient's packed cell volume (PCV) and total protein (TP) should be obtained. If the
splenic mass has ruptured, the patient typically has a low PCV and sometimes a low TP.

These patients may be painful in the abdomen. Therefore, when obtaining abdominal radiographs, it is important to
avoid putting pressure on the abdomen when lifting the pet onto the radiology table. Although large tumors are
generally evident via radiography, ultrasonography is usually a more effective tool.8 Most skilled ultrasonographers
can readily detect splenic masses. An ultrasonogram can often show if the tumor is just encompassing the spleen or
other organs are involved.8 Because an ultrasonogram cannot differentiate between benign and malignant tumors,
an ultrasound-guided biopsy should be conducted to help determine the nature of the mass. The drawback of this
technique, however, is that the sample usually must be sent to a pathologist to be read and it make take 3 to 5 days
to obtain the results. Complications that can occur from conducting an ultrasound-guided biopsy include
hemorrhage and "seeding" (the potential for tumor cells to "fall off" the biopsy needle).

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Common neoplastic splenic tumors include hemangiosarcomas, which are the most common tumors found in dogs,
mast cell tumors, which are found commonly in cats, lymphosarcomas, and fibrosarcomas. Generally, the prognosis
for dogs with hemangiosarcomas is poor because these tumors form from blood vessels and often spread to
various organs throughout the body.5 It is estimated that in 24% to 45% of dogs that are diagnosed with
hemangiosarcomas, the disease will spread to the right atrium of the heart. 5 By the time the client brings the dog to
the clinic, the tumor has metastasized in roughly 50% of patients.5 In most cases of neoplastic splenic tumors, the
median survival time with chemotherapy is about 4 months.3 Many veterinarians give owners the option of electing
euthanasia while the pet is on the surgery table if it appears that the animal's other organs are affected. In general, if
a patient presents with a neoplastic splenic mass, the prognosis is poor.

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The most common nonneoplastic splenic tumors in dogs are hematomas; in cats, benign tumors are rare.6
Underlying diseases, such as splenic lymphoma, should be ruled out as a cause of the hematoma. More often than
not, no underlying causes are present in dogs with splenic hematomas. The problem is simply that the hematoma
has grown too large and is impeding the normal function of the gastrointestinal tract or it has burst and is causing a
hemoabdomen.

Another common nonneoplastic tumor in dogs is nodular hyperplasia. Many researchers have theorized that nodular
hyperplasia and hematoma are related diseases.8 If a benign tumor is detected before it causes serious health
complications, the patient's prognosis is good. Most patients recover well after surgery and live normal, healthy
lives.

Splenic Torsion

Since the spleen is attached to the stomach, when the stomach twists, the spleen may also twist. This condition is
called splenic torsion. A twist can increase the size of the spleen similar to how the stomach increases in size when
it becomes twisted. Depending on the force of the twist, it may also cause the spleen to rupture. This situation can
become life threatening very quickly. Splenic torsion very rarely occurs by itself.5 Typically, this condition is
associated with gastric dilatation-volvulus (GDV) in dogs. Since it is associated most often with GDV, this condition
is seen mainly in large-breed dogs. Affected dogs present with signs of GDV, including nonproductive retching, a
distended abdomen, weakness, and abdominal pain.7 If the spleen is acutely twisted, dogs may present in shock
and cardiovascular collapse simply because the blood flow to and from the spleen stopped so dramatically.5

The proper method of treating splenic torsion is still being debated.5 During surgery, some veterinarians untwist the
spleen and then decide whether the organ is damaged enough to warrant removal. If the spleen is still able to
function normally, untwisting it causes the organ to return to normal size within minutes.5 Other veterinarians always
remove the spleen in patients with splenic torsion. There is no way to secure the spleen permanently, so it is
possible for the spleen to twist again if it is not removed. It appears that the only animals seriously affected by a
splenectomy are those that are immunosuppressed before surgery.5 Of course, GDV patients with splenic torsion
experience increased complications because the nature of the disease is more severe.

Splenomegaly

Splenomegaly can be defined simply as enlargement of the spleen. Cats seem to be more prone to splenomegaly
than are dogs.3 Numerous conditions, including tumors (both neoplastic and nonneoplastic) and splenic torsion, can
cause the spleen to become enlarged. In this section, the term splenomegaly pertains only to conditions that were
not already discussed in the Splenic Masses and Splenic Torsion sections.

It is important to note that when examining a patient, it may not always be possible to palpate the spleen; however,
that does not mean that it is not enlarged.4 In addition, sometimes a spleen that is not enlarged can be palpated.
Therefore, palpation should not be the only method used to determine whether a spleen is enlarged. For example, it
is usually impossible to palpate an enlarged spleen in deep-chested dogs and obese patients. However, some
canine breeds, such as German shepherds and Scottish terriers, have a more prominent spleen.7

Splenomegaly can be grouped into the following four categories3:

Inflammatory splenomegaly typically occurs when the spleen becomes inflamed from a disease process. 6
Second to neoplasia, the most common reason that a spleen becomes enlarged is infection.6 Both viral or
bacterial infections may lead to either generalized or localized splenitis.6 Diseases such as toxoplasmosis,
canine hepatitis, leishmaniasis, feline infectious peritonitis, and brucellosis may all cause an enlarged
spleen.6 Bacterial infections such as sepsis, pyometra, and salmonella have also been known to cause
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 splenitis.6
Hyperplastic splenomegaly occurs less frequently. The spleen commonly reacts to stimulation that occurs
with hyperplasia that results from destruction of red blood cells.3 Hyperplasia is also common with infection
and autoimmune diseases, such as immune-mediated hemolytic anemia and Heinz body hemolysis.3
Congestive splenomegaly occurs when the portal or splenic vein (main veins of the spleen) becomes
blocked.4 Certain drugs, such as barbiturates, can increase blood pooling and, therefore, cause a slight
"back up" of blood to the spleen.3 Affected patients may have a decreased PCV because the blood cannot
filter properly.3 Right-sided congestive heart failure, obstruction of the caudal vena cava (such as with
heartworm disease), and splenic torsion can all cause congestive splenomegaly.3
Infiltrative splenomegaly, one of the most common causes of splenomegaly, occurs when the spleen
becomes enlarged because it has been invaded by a biological cause (e.g., neoplasia).3 In human medicine,
infiltrative splenomegaly is a separate category from cellular causes (e.g., splenic tumors).4 In veterinary
medicine, however, there is no differentiation between the two; therefore, tumors are included as a cause of
infiltrative splenomegaly. Some of the causes of infiltrative splenomegaly include splenic masses, leukemia,
malignant lymphoma (lymphosarcoma), and multiple myeloma.3

Similar to patients with a splenic mass, patients with splenomegaly typically present with nondescriptive signs.
Owners may describe weight loss, inappetence, vomiting, diarrhea, polyuria and polydipsia, and fever.3 Most of
these signs are due to the underlying cause of the splenomegaly.

When the spleen becomes enlarged, it sets off a syndrome called the big spleen syndrome.4 To date, the key
component that causes this syndrome is unknown. However, when the spleen becomes enlarged, the following may
occur4:

Cytopenias (e.g., immune-mediated hemolytic anemia, immune-mediated thrombocytopenia) may develop.

Total blood plasma and PCV values may be altered.
Salt and water retention may occur as well as an increase in extravascular fluid volume.
Hypermetabolism may occur, which may lead to increased blood flow and cardiac output. In animals, this
may cause cardiac arrhythmias.

It is important that bone marrow evaluations be performed in any patient experiencing a cytopenia. These
evaluations provide information on whether the body is making new red blood cells. If the bone marrow has shut
down and is not functioning to compensate for the loss of platelets or blood, the patient's overall prognosis is poor. In
some diseases, the spleen may take over the primary hematopoietic function, and removing the spleen could lead to
death simply because the patient has no way to circulate red blood cells.
***

Although much of this discussion has focused on the spleen becoming enlarged, this organ can also become
smaller. However, this phenomenon occurs rarely in humans and animals. Typically, treatments such as radiation
therapy and surgery of the spleen are the primary causes of the organ becoming decreased in size.4

Traumatic Insults

In addition to biological insults, the spleen can also be affected by traumatic events. Although traumatic injury to the
spleen occurs less commonly, it can produce more life-threatening situations. After the liver, the spleen is the second
most injured organ in the abdomen.9 Cats are less likely to experience splenic trauma because their rib cage
protects almost the entire spleen.9 Cats also are more agile during a fall or when thrown into the air. Splenic trauma
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can be caused by either blunt or penetrating trauma.

Blunt Trauma

Blunt trauma occurs when an animal is impacted at high speed and/or by tremendous weight, such as being hit by a
car, falling out of a building, or being hit intentionally with an object. Depending on the type of trauma, patients
present differently. Because of the release of epinephrine, the animal may seem normal to the client. Despite the
animal's appearance, it is important to urge the client to bring the animal to the clinic for evaluation. Sometimes, an
internal injury to the spleen may not present for hours.

When the patient arrives at the clinic, it is important to perform a complete physical examination. Clinical signs of
splenic trauma include pale mucous membranes, abdominal pain, broken ribs, distended abdomen, tachycardia,
hypotension, and cardiac arrhythmias.9 Patients with blunt trauma may hide their signs. After being hit by a car,
many dogs can walk and wag their tails. The spleen may have ruptured and the dog could be experiencing a slow
bleed into the abdomen. Although the owner says his or her pet is "fine," it is important for all trauma patients to
have a complete workup.

When the spleen undergoes a traumatic event, splenic contraction occurs. The spleen enlarges and releases a
large quantity of red blood cells.4 Studies have shown that when norepinephrine and epinephrine are infused into
the spleen, the same effect occurs.4 Because a dog's epinephrine increases when hit by a car, this event falsely
elevates the PCV shortly after the traumatic event. Consequently, it has also been proven that enlarged spleens
may increase plasma volume.4 It is, therefore, important to obtain a baseline PCV and TP when the patient arrives
at the clinic so that these findings can be used as a comparison later if the patient stays for monitoring. Although the
PCV and TP may appear normal immediately after the event, it is important to recheck these values after an hour or
two because of the splenic contraction that may have occurred.

Radiography is an important tool in diagnosing spleen trauma and may show obvious fluid in the abdomen.8 An
ultrasonogram, however, is a better diagnostic tool for determining whether the spleen is intact or ruptured and
whether there is free fluid in the abdomen.8 An abdominocentesis may help prove if there is blood in this area,
which may indicate that the spleen has ruptured.8 Less commonly, diagnostic peritoneal lavage can be conducted to
confirm the presence of blood. This should be done when an abdominocentesis fails to produce blood. The skin is
surgically prepped and a small amount of local anesthetic, such as lidocaine, is infused under the skin.12 A small
incision is made, and an over-the-needle catheter is inserted into the abdomen. If this still produces a negative
result, saline should be infused into the abdomen and the abdomen gently massaged to help disperse the fluid. The
fluid should then be aspirated to be analyzed for the presence of blood.12 Affected patients often require surgery.

As in human medicine, patients that have a slow bleed are not necessarily taken to surgery right away. An
abdominal wrap should be placed to help apply pressure to the bleeding area.4 Closely monitoring the patient's vital
signs and obtaining blood work can help determine whether the bleeding has stopped. However, if the patient is not
hemodynamically stable, splenectomy is still the treatment of choice.

Penetrating Trauma

Penetrating trauma to the spleen (e.g., gunshot, abdomen impaled with a stick, coyote attack) is not as common as
blunt trauma. However, when penetrating trauma does occur, owners typically respond very quickly because the pet
has an obvious wound. The pet usually presents with bleeding, which is sometimes quite excessive. It is important
to apply pressure or a bandage to the area to help control the bleeding, if possible.

If the spleen suffered a direct insult because of a penetrating object, it is important that the patient be stabilized as
much as possible and taken to surgery for a splenectomy. Conducting ultrasonography or radiography is sometimes
not practical because of the nature or severity of the penetrating wound. Obtaining minimal blood work (e.g., PCV,
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TP) is necessary to assess the patient's status.

Splenectomy

As previously discussed, the spleen plays an important role in the body; however, it can be removed with minimal
complications. Many of the disease processes and traumatic conditions that have been discussed may result in the
patient undergoing a splenectomy. The veterinarian must decide whether the patient would benefit from surgery.
The goal of splenectomy is to stop the bleeding as well as its detrimental effects on the body. Geriatric patients or
patients that are immunocompromised are at the greatest risk of complications from surgery. One of the biggest
complications of splenectomy is intraoperative or postoperative bleeding.5 If the patient has a PCV less than 20%, a
blood transfusion should be given before surgery.5 However, in an emergency, this is not always possible. Ideally, all
patients undergoing surgery should be stable prior to the procedure. This is not usually possible for patients
undergoing splenectomy. Patients undergoing splenectomy are usually doing so because they are unstable;
therefore, splenectomy is always a risky procedure.

Typically, affected patients are anemic, and increasing the oxygen level in their bloodstream may help minimize
complications during induction or recovery. Use of acepromazine should be avoided in these patients because it can
significantly decrease blood pressure.5 Typically, these patients already have compromised vascular systems.

Because these patients may present in very compromised states, it is important to monitor all vital signs during
anesthesia. Blood pressure should be continuously monitored to ensure that the patient does not become
hypotensive because of the anemia. Depending on the PCV value before surgery, a blood transfusion may need to
be given during surgery to ensure that the patient does not become too anemic. Colloids, such as hetastarch, may
be given to help keep blood pressure from falling during surgery. Since red blood cells carry oxygen, these patients
should be monitored via a pulse oximeter to ensure that they are compensating well and not becoming too hypoxic.
Oxyglobin (Biopure Corporation), an oxygen-carrying fluid, can be used to help provide some oxygen support
without the risks associated with blood transfusions. Oxyglobin can also help increase blood pressure.

Most notably during and after surgery, splectomized patients may experience cardiac arrhythmias. Therefore, these
patients should be monitored using a continuous electrocardiogram. Cardiac arrhythmias are not a common side
effect in humans 4; however, they occur often in small animals. Any trauma to the spleen can cause cardiac
arrhythmias. Commonly, these patients have ventricular premature complexes. There is much debate about why
cardiac arrhythmias occur in patients that have had their spleen removed. It is known that patients that have
ruptured splenic masses have a higher incidence of cardiac arrhythmias, including ventricular tachycardia.10 It is
thought that arrhythmias occur because of the following:

Myocardial depressant factor occurs when the spleen releases factors that decrease the function of the
myocardium of the heart. Although this theory has never been proven, it is thought to be the primary cause of
the arrhythmias.11
Sympathetic overstimulation has been thought to be the cause of arrhythmias in patients with acute trauma
or GDV. Since splenic masses grow slowly, the shock to the sympathetic nervous system when the spleen is
removed is most likely limited; however, removal of the organ may initiate the process leading to cardiac
arrhythmias.11

Most cardiac arrhythmias caused by splenic complications do not result in severe problems. If left untreated, many
arrhythmias eventually resolve on their own. It is up to the veterinarian to decide whether to treat the condition.
Overall, few reported complications occur when the spleen is removed. It is known that patients that have had their
spleen removed may be more susceptible to infection.4 Making sure that these patients are not placed in higher risk
situations (e.g., boarding in a kennel) may help decrease this risk. The functions of the spleen are taken over by the
liver and lymphatic system.4 However, it is unknown what specific system takes over what function. It is known only
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that the body compensates for removal of the organ without interruption to the rest of the system.

In humans, splenectomy is considered a last resort.4 Partial splenic resections and managing the spleen rather than
removal are becoming more common in both human and veterinary medicine.4 In addition, laparoscopic surgery to
remove the spleen in humans is becoming increasingly popular.4 Laparoscopic surgery is still considered more of a
risk than opening up the abdomen, but the procedure is slowly being perfected with each operation. As new
information about the spleen becomes available, veterinary professionals may begin to use alternative treatments
rather than splenectomy.

Conclusion

Most technicians will encounter a patient that has a disease or injury affecting the spleen. It is important to
understand how the organ works to be able to effectively treat the patient and keep the client informed. Being able to
work quickly to help the veterinarian form a diagnosis can be the difference between life and death for patients with
splenic disease.

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