Spleen

• Spleen


  One of the reticuloendothelial organs in the body
• Spleen


  • Intra-abdominal wedge shaped organ
  • Located in the left hypochondrium & epigastrium between gastric fundus and left hemidiaphragm
  • Soft and highly vascular
  • Variable size & weight, average 10×7×3 cm, 75-250 gm in weight
• Hilum of spleen


  Sits in the angle between stomach and the kidney and is in contact with the tail of the pancreas

  
• The spleen is normally not palpable
• Axis of spleen


  Lies obliquely along the long axis of the 10th rib, directed downwards, forwards & laterally
• External features of spleen

  • Two ends
  • Three borders
  • Two surfaces
• Peritoneal relations of spleen

  Surrounded by double fold of peritoneum & suspended by gastrosplenic ligament, lienorenal ligament, and phrenicocolic ligament
• Visceral relations of spleen


  Costodiaphragmatic recess of pleura, lung, & 9,10,11th ribs of left side
• Arteries of spleen


  The splenic artery, largest branch of the celiac artery
• Veins of spleen

  The splenic vein, joins the superior mesenteric vein to form the portal vein
• Lymph drainage of spleen

  Lymph vessels emerge from the hilum and drain into the celiac nodes

  
• Immune function of spleen

  • Contains 70.5% and 10-15% of body total T and B lymphocytes
  • Processes foreign antigen and produces specific immunoglobulin IGM
  • Produces the nonspecific opsonin tuftsin and properdin which stimulate bactericidal, tumorcidal and phagocytic activity
• Filter function of spleen

  Macrophages in the red pulp destroy old or bad RBCs and return iron to circulation, and remove cellular and non-cellular material like bacteria from blood and plasma
• Pitting function of spleen

  Removes distorted RBCs, Howell-Jolly bodies, and Heinz bodies from circulation

  
• Reservoir function of spleen

  Contains 8% of red cell mass, can lead to pancytopenia in massive enlargement

  
• Cytopoietic function of spleen

  Produces T cells, B cells, and macrophages in response to antigenic challenge, increased in myeloproliferative disorders
• Congenital anomalies of spleen

  • Splenic agenesis
  • Polysplenia
  • Splenunculi (accessory spleens)

  
• Splenic hamartoma


  Rare, either resembles white or red pulp
• Types of splenic cysts


  • True primary cyst with epithelial lining
  • Secondary (pseudocyst) cyst from trauma or pancreatitis

  
• Splenic artery aneurysm


  Identified in 0.04-1% of postmortem examinations, twice more common in women, usually involves main splenic artery trunk, caused by intra-abdominal sepsis, pancreatic necrosis, or atherosclerosis

  
• Clinical presentation of splenic artery aneurysm

  • Asymptomatic, not palpable, bruit may be present
  • Can rupture into peritoneal cavity, especially in patients under 45 and in pregnant women, high mortality rate
• Diagnosis of splenic artery aneurysm

  CT scan, MRI, angiography of celiac trunk and splenic artery

  
• Treatment of splenic artery aneurysm

  Endovascular stenting and embolization, or splenectomy and removal of diseased artery
• Splenic infarction


  Rare, can be asymptomatic or cause left hypochondrial pain, commonly occurs in hematologic disorders, portal hypertension, or vascular occlusion
• Diagnosis of splenic infarction

  CT scan typically shows perfusion defect in the enlarged spleen

  
• Treatment of splenic infarction

  Conservative, splenectomy only for septic infarct causing abscess
• Splenic rupture due to trauma

  • Spleen is the most commonly injured intra-abdominal organ
  • Causes include blunt trauma, penetrating injury, iatrogenic injury, and rupture of malarial spleen

  
• Clinical features of splenic rupture

  Left hypochondrial pain referred to left shoulder (Kehr's sign), left lower chest pain, abdominal tenderness, signs of shock, signs of associated organ injuries
• Diagnosis of splenic rupture

  Ultrasound, CT scan, MRI, angiography

  
• AAST splenic injury scale

  • Grade I: subcapsular hematoma <10%, parenchymal laceration <1 cm
  • Grade II: subcapsular hematoma 10-50%, intraparenchymal hematoma <5 cm, parenchymal laceration 1-3 cm
  • Grade III: subcapsular hematoma >50%, ruptured subcapsular/intraparenchymal hematoma ≥5 cm, parenchymal laceration >3 cm
  • Grade IV: any injury with splenic vascular injury or active bleeding confined within capsule, parenchymal laceration with >25% devascularization
  • Grade V: shattered spleen, any injury with splenic vascular injury and active bleeding beyond capsule

  
• Treatment of splenic trauma

  ABC with resuscitation, selective splenic angiography with embolization for hemodynamically stable patients (non-operative management), intraoperative splenic salvage procedures, splenectomy for high grade injury, hilar injury, coagulopathy, or multiple organ injuries
• Splenomegaly


  Enlargement of the spleen beyond its normal size, must be 3 times normal size to be palpable, can cause abdominal, chest, or back pain

  
• Hypersplenism


  Clinical syndrome of splenic enlargement, cytopenias, and increased destruction/sequestration of blood cells
• presence of splenic vascular injury* with active bleeding extending beyond the spleen into the peritoneum

  
• Treatment for Splenic Trauma

  1. ABC with resuscitation (fluid , blood ,FFP)

  2. If patient is hemodynamically stable then selective Splenic angiography with embolization of active bleeding as part of non operative management NOM measure(successful up to 80% IN CHILD AGE GROUP)

  3. Intraoperative Splenic salvage procedures splenorrhaphy(suturing),hemostasis by electrocautery , argon beam ,application of thrombin fibrin glue , splenic rapping by absorbable mesh (vicryl), partial resection

  4. Splenectomy for high grade injury , hilar injury ,patient with coagulopathy or life threatening multiple organ injuries

  
• Splenomegaly


  Enlargement of the spleen beyond its normal size

  
• Spleen is normally not palpable in adult

  
• Spleen has to enlarged three times its normal size to be palpable
• Symptoms of Splenomegaly


  • Abdominal pain
  • chest pain
  • back pain
• Signs of Splenomegaly


  • palpable left upper quadrant
  • Abdominal mass