SPLEEN

R.A.M
 Anatomy

• Largest reticuloendothelial organ in the body

• Mesodermal in origin
• Adult spleen weighs between 100 to 150 grams and
about to 7-11cm-length
• Spleen size & weight diminish in the elderly
• Splenomegaly – apply to weight > 500mg and/or
15cm or more in length
If palpable below the left costal margin --->
double normal size
 Anatomy

Blood Supply
• Splenic artery (pattern of terminal branches)
• Distributed type: (70%) – Short trunk w/ many long branches
over ¾ of the medial surface of the spleen
• Magistral type: (30%) – Long main trunk dividing near the hilum
into short terminal branches
• Short gastric artery: - Which are branches of the left
gastroepiploic artery running within the gastrosplenic ligament
 Anatomy

• Accessory Spleen
• The accessory spleens seen here at the hilum of
the normal sized spleen are not uncommon and
by themselves have no significance
• Splenosis
• Autotransplantation of splnenic fragments after
trauma
• Capable of performing some reticuloendothelial
function
 Anatomy
The pulp consist of three (3) zones:
• Red Pulp
• 75% of total volume
• Comprised of venous sinuses, separated by reticulum. Contains macrophages
• Serves as filter, removes microorganism, cellular debris, antigen-antibody
complexes and old erythrocytes
• White Pulp
• Peri-articular lymphatic sheath T-lymphocytes
• B- lymphocytes - lymphoid follicles
• Serves the immunologic function of the spleen
• Marginal Zone
• It contains sequestered foreign materials and plasma as well as abnormal
cellular elements
 Physiologic Functions

• Filtration
• Host defense
• Storage
• Cytopoiesis
 Physiologic Functions
• Filtering Functions
– Most important function o Splenic blood flow is approximately 350 L/day
– Removal of abnormal red blood cells-Howell-jolly bodies, Heinz bodies, Pappenheimer
bodies. Approximately 20 ml of aged RBC are removed during the course of the day
– Removal of abnormal white cells, normal and abnormal platelets and cellular debris o It
can clear organisms contained w/in the erythrocytes( malaria & Bartonella)
– Can clear unopsonized bacteria and microorganisms for w/c the body has no anti-bodies
• Open circulation (90%)
– Blood goes first to reticular space and cords o Comes in contact with macrophages
• Closed circulation(10%)
– Goes directly to the arteriovenous anastomosis
 Physiologic Functions

• Host Defense
– Opsonins-makes organism attractive to phagocytes
– Tuftsin-enhances the phagocytic activity of leukocytes
– Properdin-stimulates the alternative pathway of complement fixation
– Circulating monocytes are converted to fixed macrophages
• –at the red pulp
– Produces !immunoglobulin (IgM) o T and B lymphocytes-from the
lymphatic sheath surrounding the central arteries
 Physiologic Functions

• Storage
– 30% of platelets are stored in the spleen
• Cytopoeisis
– Contributes to the process of RBC maturation
– Minor role in hematopoeisis in the 4th month
– Can be reactivated in childhood if the bone marrow fails to meet the
hematologic need  Myeloid metaplasia - abnormal RBC are
produced
 DIAGNOSTICS

Evaluation of size
• Physical Examination
• Normally not palpable
• Felt in about 2 % of healthy adults
• No significant dullness elicited by percussion over spleen
either anteriorly or laterally
• As organ enlarges, dullness is detected at the level of the 9th
ICS in the left anterior axillary line
 DIAGNOSTICS

ULTRASOUND
• Ultrasound is the least invasive mode of splenic imaging
• Rapid, easy to perform, and does not expose the patient to ionizing radiation
• It is often the first imaging modality applied to the spleen during evaluation and
resuscitation of the trauma patient
• Percutaneous ultrasound-guided procedures for splenic disease are becoming more
common as the safety of these procedures is being increasingly demonstrated
 DIAGNOSTICS

CT SCAN
• Computed tomography (CT) affords a high degree of resolution and detail of the splenic
parenchyma
• In the nontrauma setting, CT is extremely useful for assessment of splenomegaly,
identification of solid and cystic lesions, and guidance of percutaneous procedures
• The use of iodinated contrast material adds diagnostic clarity to CT imaging of the
spleen, although at the cost of the small real risks of renal impairment or allergic
reaction.
 DIAGNOSTICS

PLAIN RADIOGRAPHY
• Rarely is plain radiography used for primary splenic imaging
• Plain films can indirectly provide an outline of the spleen in the left upper quadrant or
suggest splenomegaly by revealing displacement of adjacent air-filled
• Plain films may also demonstrate splenic calcifications – often are found in association
with splenomegaly but are otherwise a nonspecific finding
• Splenic calcifications can indicate a number of benign, neoplastic, or infectious
processes, including phlebolith, splenic artery aneurysm, sickle cell changes, tumors,
echinococcosis, or tuberculosis
 DIAGNOSTICS

MRI
• Although magnetic resonance imaging offers excellent detail and versatility in
abdominal imaging, it is more expensive than CT scanning or ultrasound and
offers no obvious advantage for primary imaging of the spleen

• Magnetic resonance imaging can be a valuable adjunct to the more commonly

used imaging techniques when splenic disease is suspected but not definitively
diagnosed
 DIAGNOSTICS

ANGIOGRAPHY
• Angiography of the spleen most commonly refers to invasive arterial imaging,
and when it is combined with therapeutic splenic arterial embolization (SAE) v
localization and treatment of hemorrhage in select trauma
NUCLEAR IMAGING
• Radioscintigraphy with technetium Tc 99m sulfur colloid demonstrates splenic
location and size v It may be especially helpful in locating accessory spleens
after unsuccessful splenectomy for ITP and has recently proven useful in
diagnosing splenosis
 INDICATIONS FOR SPLENECTOMY

• Trauma to the spleen

• Benign, including red blood cell disorders,
hemoglobinopathies, and platelet disorders
• Malignant, including white blood cell
disorders and bone marrow disorders
(myeloproliferative disorders)
• Others, including cysts and tumors,
infections and abscesses, splenic rupture,
and a number of miscellaneous disorders
and lesions
 Red Blood Cell Disorders

Hereditary Spherocytosis
• Deficiency in one of the membrane proteins
(spectrin,ankyrin,band3 protein)
• Spherical less deformable shape, they
sequestered and destroyed in the spleen
• The only type of hemolytic anemia which
splenectomy is the primary treatment
• In children-delayed until ages of 4-6 years
 Red Blood Cell Disorders

• Red Cell Enzyme Deficiency

– Glucose 6 phosphate dehydrogenase Deficiency
• Most common rbc enzyme deficiency
• Enzyme is necessary in oxidation of glucose
• Common in males
• Hemolysis is triggered by certain foods , medication or stress
– Pyruvate Kinase Deficiency
• Most common congenital hemolytic anemia
• Enzyme needed for glycolysis
 Red Blood Cell Disorders
Hemoglobinopathies
Thalassemia:
– Alpha chains - needed for the production of fetal and adult Hgb and is symptomatic in utero or at birth
– Beta chains - involved in adult Hgb synthesis and is symptomatic at 4-6 months
Thalassemia major (homozygous)
– Hypochromic and microcytic anemia
– Nucleated RBC
– Clinical manifestation present before 2 years old
• Pallor
• Jaundice
• Growth retardation
• Head and Abdominal enlargement
• Leg ulceration
 Red Blood Cell Disorders

• Thalassemia
• Treatment:
– Blood transfusion
– Maintain Hgb > 9 mg/dL
– Iron chelation therapy (deferoxamine)
– Splenectomy
• high risk of pulmonary Hypertension
• Excessive transfusion 200 ml/kg per year
• Discomfort
• Painful splenic infarction
 Red Blood Cell Disorders

• Sickle Cell Anemia

– Mutant B chains of hemoglobin- HbS
– Substitution of valine for glutamic acid
of B chain
– Reduced oxygen tension - HbS
undergoes crystallization and sickling
of RBC
• Increased viscosity
• Microvascular stasis
• Thrombosis
• Ischemia
• Tissue necrosis
 Platelet Disorder

• Idiopathic Medical Therapy

◦ Prednisone 1 mg/kg
Thrombocytopenic ◦ Effective in 75% of patient (1 - 3
Purpura weeks)
– Premature removal of platelets opsonized ◦ Goal: platelet count of > 100,000/cu
by antiplatelet IgG autoantibodies produced mm Initiated when fall to < 20,000 -
by the spleen 30,000/cu mm
– Children - 70 - 80% spontaneous remission
◦ Only 15% - 25% achieve a lasting
– 30,000 - 50,000/cu.mm - easy bruising
response
– 10,000 - 30,000/cu.mm - spontaneous
petechiae and echymosis ◦ IV IgG
– < 10,000/cu.mm - internal bleeding ◦ Given when platelet count remains
low after steroid therapy
◦ given for 2 days
 Splenic Cyst
• Primary true cyst
– Small (< 8 cm) asymptomatic
– Can be observed  8 cm with symptoms
• partial splenectomy, unroofing
• Parasitic cyst
– Secondary to echinococcus
– Treatment by splenectomy after sterilization by NaCl or silver nitrate
• Pseudocyst
– Secondary to trauma
– Most are small and undergo spontaneous resolution
– can be observed safely
 SPLENIC ABCESS
– Hematogenous spread-most
common cause
– Most are solitary and unilocular
• Treatment:
– Solitary and unilocular--
image guided percutaneaous
drainge+antibiotics
– Multilocular---splenectomy+
antibiotics
SARCOIDOSIS
◦ Non-caseating inflammatory
granulomatous lesion
◦ Second organ most commonly
affected
◦ Indications for splenectomy
◦ Massive splenomegaly (>1kg)
◦ Thrombocytopenia
◦ Anemia
◦ Compression of adjacent organ
◦ Pain
 SPLENECTOMY

• Open Splenectomy
• Indication:
– traumatic rupture of the spleen (most
common)
– massive splenomegaly
– ascites
– portal hypertension
– multiple prior operations
– extensive splenic radiations
– possible splenic abscess
 SPLENECTOMY

• Laparoscopic Splenectomy for normal size

spleens
• Position:
– supine or low lithotomy position (needs 5-6
trocars)
– Right lateral decubitus (needs 3-4 trocars)
• Excised spleen placed in a durable nylon sac and
is morcellated and extracted piecemeal using a
blunt instrument avoiding spillage ----> splenosis.
 SPLENECTOMY
• Partial Splenectomy
• Indicated:
– children (risk of splenectomy sepsis)
– Lipid storage disorders (Gaucher’s dse)
– Some blunt & penetrating splenic injuries
• Open or laparoscopically
• Bleeding from cut surface of the spleen is controlled by
– Cauterization
– argon coagulation
– application of hemostatic agents (cellulose gauze / fibrin glue)
 Splenectomy Outcomes

– Increase in circulating abnormal RBC

– Pulmonary: Left lobe atelectasis-the most common complication
– Thromboembolic phenomena- esp. those w / hemolytic disorders,
myeloprolifertive , splenomegaly-portal vein thrombosis
– Overwhelming postsplectomy infection:
• More common if splenectomy is done for hematologic problem
• Strep. Pneumoniae -most common organism (50-90%)
• Most occur 2 years after splenectomy
• Children < 5 years and adults > 50 years old
 Preventive Measures Against OPSI

– Elective splenectomy in children should postponed if possible until child is 4 - 10 years

old
– Role of Vaccination
• Must be vaccinated against Strep pneumonia
• Type b H. influenza, meningococcus
• Elective splenectomy 2 - 4 weeks before surgery
• Emergency splenectomy - should be give ASAP or within 7 - 10 days after
• Annual vaccination
– Role of Antibiotics
• Daily dose of antibiotics until 5 years old
• Daily dose of antibiotics 5 years after splenectomy
Thank you