Splenomegaly and post splenectomy care


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A presentation about
* causes of splenomegaly (in the tropics);
* treatment options
* splenectomy and post-splenectomy care

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  • The human spleen is located in the upper left part of the abdomen, behind the stomach and just below the diaphragm. In normal individuals this organ measures about 125 × 75 × 50 mm (5 × 3 × 2 inches) in size, with an average weight of 150 gramsApproximately 10% of people have one or more accessory spleens. They may form near the hilum of the main spleen, the junction at which the splenic vessels enter and leave the organ.There are several peritoneal ligaments that support the spleen[3] (to understand their naming it helps to know that "lien" is an alternate root for "spleen") * gastrolienal ligament (gastrosplenic) - connects stomach to spleen. * lienorenal ligament (splenorenal) - connects spleen to kidney. * phrenicocolic ligament - connects left colic flexure to the thoracic diaphragm. The middle connects to the spleen.
  • G6PD Deficiency gives rarely splenomegaly
  • For parasitic spleen cyst a splenectomy is only indicated when the spleen is the only involved organNon parasitic cysts only require splenectomy when there are symptoms or > 10cm
  • But in the case splenomegaly, the cause of this splenomegaly is usually also causing hepatomegaly.Hyper reactive malarial splenomegaly is caused by an abnormal response to repeated malaria infections that results in overproduction of IgM. The consequent immune complexes are removed by the spleen which can enlarge to huge proportions. The disorder is more common in woman and predominantly affects those aged between 20-40 years. Pregnant woman with hyper-reactive malarial splenomegaly commonly experience sudden episodes of hemolysiswhich may be life threatening. A Spleen which is over 10 cm from the left costal margin is almost always duetohyperreactive malarial splenomegaly.
  • When S. mansoni eggs are carried in the portal venous bloodstream as far as the liver, they cause a physical obstruction of the bloodstream. Local inflammation around the eggs exacerbates this. Because the eggs obstruct the branches of the portal venous system and fibrosis occurs around these foreign bodies, periportal fibrosis develops. The result is increased pressure in the portal circulation (portal hypertension). Clinically, it takes the form of:Enlargement of the spleen (splenomegaly)Collateral circulation with oesophagealvarices and increased venous markings on the abdominal skin, principally around the navel, the so-called "caput medusa". Eggs can also reach other organs subsequently via this collateral circulation (lung).Ascites is a late sign.
  • Erythromycin in case of penicillin allergy
  • Splenomegaly and post splenectomy care

    1. 1. Splenomegaly &Post Splenectomy Care<br />Dr Christian van Rij<br />July 2008, Wasso DDH<br />1<br />
    2. 2. Overview Lecture<br />2<br />
    3. 3. Anatomy<br />3<br />
    4. 4. Function & Histology<br />Red pulp; for phagocytosis of debris, composed: <br />Sinuses filled with blood (expulsion of reservoir blood in animals)<br />Splenic cords<br />Marginal zone<br />White pulp: composed of Malpighian corpuscles, composed of:<br />Lymphoid follicles; rich in B-lymphocytes<br />Periarteriolar lymphoid; sheaths; rich in T-lymphocytes<br />4<br />
    5. 5. Causes for Splenomegaly1/6<br />Non malignant hematological disorders with Splenic Sequestration:<br />Hereditary Spherocytosis<br />Chronic Autoimmune Hemolytic Anemia<br />Pyruvatekinase Deficiency<br />Sickle Cell Disease<br />Thalassemia<br />Thrombotic Thrombocytopenic Purpura (TTP)<br />(Idiopathic Thrombocytopenic Purpura (ITP) doesn’t give splenomegaly, but needs sometimes splenectomy)<br />5<br />
    6. 6. Causes for Splenomegaly2/6<br />Malignancies causing Splenomegaly<br />Lymphoma’s<br />Spleen usually secondary involved, but in 10% of Hodgkin Lymphoma’s the spleen is the primary site<br />Leukemias<br />Myelofibrosis & Myeloproliferative disorders<br />Angiosarcoma<br />6<br />
    7. 7. Causes for Splenomegaly3/6<br />Benign Spleen Tumors<br />Hemangioma<br />Hamartoma<br />Lymphangioma<br />Abcesses<br />Rare but fatal<br />Hematoma<br />If large, then high risk for splenic rupture<br />7<br />
    8. 8. Causes for Splenomegaly4/6<br />Parasitic Cysts<br />Echinococcusgranulosus / Hydatid cysts<br />Non-parasitic<br />Epithelium-lined cysts<br />Epidermoid cysts – most common<br />SplenicPseudocysts<br />Pancreatic pseudocyst<br />Posttraumatic cyst<br />8<br />
    9. 9. Causes for Splenomegaly5/6<br />Infectious:<br />Hyperreactive Malarial Splenomegaly<br />All spleens which are over 10cm from the costal margin palpable<br />Tuberculosis<br />Leishmaniasis<br />9<br />
    10. 10. Causes for Splenomegaly6/6<br />Portal Hypertension<br />Caput Medusae<br />10<br />
    11. 11. Splenomegaly Consequences<br />Splenic Sequestration<br />Trombocytopenia:<br />Normally 30% of platelets are trapped in the spleen, in extreme splenomegaly this can be 90%<br />Normally no significant clinical problems<br />Significant increased risk for Splenic Rupture<br />Most patients with a ruptured spleen die within a few hours after arriving at the hospital<br />11<br />
    12. 12. Investigations with Splenomegaly<br />Abdominal Ultrasound<br />Bloodslide for MPS<br />Thin blood film for Sickling(if patient is < 25 years)<br />Full bloodpicture to exclude malignancy<br />Urine and stool for Schistosomiasis<br />Leishmaniasis<br />Trypanosomiasis<br />12<br />
    13. 13. Care for Splenomegaly Patients<br />Chronic malaria preventive treatment lifelong<br />Proguanil: 100mg daily<br />Chloroquine: 300mg once a week<br />Mefloquine: 1 tab of 250mg once a week<br />Maloprim(Pyrimethamine + Dapson)<br />Earlier antibiotic treatment for infections<br />Always ultrasound after abdominal trauma<br />13<br />
    14. 14. Reasons for Splenectomy 1/3<br />Always with<br />Splenic Rupture<br />Very large hematoma after trauma<br />Malignancy<br />HereditarySpherocytosis (at the age of 4 years)<br />Pyruvate kinase Deficiency<br />Very large non-parasitic cysts<br />Parasitic cysts when no other organs are involved<br />Splenicabcess<br />14<br />
    15. 15. Reasons for Splenectomy 2/3<br />If other treatment fails with:<br />Thrombotic Thrombocytopenic Purpura (TTP)<br />AutoimmuneHemolyticAnemia<br />15<br />
    16. 16. Reasons for Splenectomy 3/3<br />In case of the following if symptomatic spleen:<br />Benign tumors<br />Non-Hodgkin’s Lymphoma (usually only Chemo/Radiotherapy)<br />Myelofibrosis & Myeloproliferative disorders<br />Thalassemia<br />Pseudocysts<br />Splenectomy as paliative measure only:<br />Angiosarcoma<br />Sickle cell crisis<br />16<br />
    17. 17. Major Risk Post Operatively<br />Bleeding<br />Abdominal Abcess<br />Pancreatitis or fistula formation<br />LLL atelectasis, pneumonia, effusion<br />Deep vein thrombosis (DVT)<br />Portal veinthrombosis (PVT)<br />17<br />
    18. 18. Post Splenectomy Risks<br />Overwhelming Post-Splenectomy Sepsis<br />Estimated life-time risk of 5%<br />Mortality of 50%<br />Coping difficulties with specific infections<br />Especially those involving encapsulated bacteria, (e.g. Streptococcus pneumoniae)<br />18<br />
    19. 19. Post Splenectomy Care 1/2<br />Pneumococcalimmunisation<br />Reimmunisation every 5 years <br />Haemophilusinfluenzae type b (HIB) vaccine<br />Meningococcal group C vaccine <br />Meningococcal group A vaccine<br />Influenza vaccine yearly<br />19<br />
    20. 20. Post Splenectomy Care 2/2<br />Life-long prophylactic antibiotics are recommended<br />In need of early broad spectrum if any infection<br />Malaria prophylaxis only if inadequate immunity<br />20<br />
    21. 21. Auto Transplantation<br />21<br />Transplant small slices of spleen and cover them into the peritoneum / omentum<br />If they have attached you will see target cells and Holley Jones body in the peripheral blood after 4 weeks<br />
    22. 22. Alternatives for Splenic Rupture<br />Splenorrhaphy<br />22<br />
    23. 23. Alternatives for Splenic Rupture<br />Splenorrhaphy<br />23<br />