(7) spleen - oct. 28, 2014 - dr. s. cosme

8/10/2019 (7) Spleen - Oct. 28, 2014 - Dr. S. Cosme

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Spleen

Samuel C. Cosme, MD,FPSGS, FPCS, FPSO

2009 WebMD


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Case Scenario 1

25 year-old male

Blunt thoracoabdominal trauma, left-side 20to fall

Stable ital si!ns, multi"le abrasionsand contusions on anterolateral sideof thora# $ abdoment, abdomen softand nontender

%&' "elic (oint dislocation on ri!ht


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Case Scenario 2

1) year-old female

*aracelis, Mt+ *roince

a!ue, !eneralied abdominal "ain #2 days

B* 110./0, 110,

20.min, an#ious, "allor %&' s"lenome!aly ith sli!ht

abdominal tenderness


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Topic Guide Objectives

Anatomy

Physioloy and Pathophysioloy Dianostic !main

!ndications "o# Splenectomy

Summa#y

Sch$a#t%&s P#inciples o"Su#e#y'()e *)(+


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O-CT!/S

3o reie the anatomy, function andimmunolo!ic role of the humans"leen in defense a!ainst inadin!

microbes+ 3o 4no the arious indications for

s"lenectomy includin! trauma,, hematologic,

malignancy, infectious and othermiscellaneous diseases+


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A0ATOM1


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Anatomy

enca"sulated mass of ascular and lym"hoid tissue

lar!est reticuloendothelial or!an in the body

average adult spleen

/ to 11 cm in length, weighs 150 !(range 70 to 250 g), diminishin! inthe elderly and in those ith

underlyin! "atholo!ic conditions

splenomegaly abnormal enlar!ement of the s"leen

weighing500 ! and.or aera!in! 15cm in length


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Splenomealy%dio"athic 3hrombocyto"enic *ur"ura'

ma!e source6 sur!ical tutor+or!+u4


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lies relatie tothe 9th and11th ribs

lefthy"ochondrium$ "artly in thee"i!astrium

Spleen, $ith itsnotched ante#io#bo#de#, and its#elation toadjacentnell7s Clinical 8natomyy e!ions - )th d+


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2ilum o" the spleen alon $ith

anatomy o" the splenic a#te#y 3a4 andthe s lenic vein 3v4.

splenic a#te#ysu""lies most

of the blood tothe s"leen

sho#t ast#icvessels %left

!astroe"i"loicartery'

splenic veindrains thes"leen $ (oinsthe su"eriormesenteric einto form the"ortal ein

8shin *ai, S"leen 8natomy, Medsca"e 8rticle, Se"t+ 2), 2012


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Suspenso#y liaments o" the spleen.

: ; ;


12/129Splenic a#chitectu#e

567 o" total splenicvolume

venous sinuses%surrounded $se"arated byreticulum; lined

by endothelial cells' splenic co#ds

%intersinusoidalregions -?broblasts,

reticular ?bers@ lac4endothelium Ao"en'

splenicmac#ophaes

dynamic 8lt#ation%lym"hoid tissues'

9hite pulp

:ed

pulp


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(periarteriolarlymphoid sheath,

PA!)

Ma#inal %one

T;cell %one;cell "ollicle

St#uctu#e o" the spleen+ 3he a


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P21S!O=OG1 A0DPAT2OP21S!O=OG1

d l


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Function

lar!ely immunolo!ic "rotection

?ltration and host defense

0o#mal#edcells

sphe#ocyte

remoin! of2o$ell

;-ollybodies

enoussinus

ed "ul"cord

enoussinus

defense spleen

minor functions

stora!e and cyto"oiesis


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Mechanical ?ltration

remoes senescent and dama!ederythrocytes

clear circulatin! "atho!ens that reside

ithin erythrocytes (eg" malarial parasites,or bacteria such as #artonella species)

remoal of unopsonized, noningestedbacteriafrom the circulation

clearin! microor!anisms for hich the hosthas no s"eci?c antibody

contributes to control of infection


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/enous sinuses in the #ed pulp co#ds o" the spleeBlood from the cords collects in the sinuses %shon byarros'+ 3he enous sinuses consist of a linin! ofendothelial cells that are "ositioned in "arallel andconnected by stress ?bres to annular ?bres+

Mebius and raal, S3EC3E 8FD GEFC3HF HG 3 S*


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Biolo!ic Substances emoed by theS"leen

0o#mal Subjectsed blood cell membrane

ed blood cell surface "its $craters

oell-olly bodies(nuclear remnant)

ein bodies(denatured hemoglobin)

*a""enheimer

bodies.siderocytes (iron granules)

8canthocytes %s"i4ed cellmembrane'

Senescent red blood cells

Patients 9ith DiseaseS"herocytes

(hereditaryspherocytosis)

Sic4le cells, hemo!lobin Ccells

8ntibody-coated red bloodcells

8ntibody-coated "latelets

8ntibody-coated hiteblood cells

Sabiston7s 3e#tboo4 of Sur!ery 1)e


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e"h C 3urbyille, *ediatric 8s"lenia , Medsca"e article, 8"r =, 2012

*eri"heral blood smearshos 2o$ell;-olly 32-4bodies in BCs+


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ost defense

stora!e site for B and 3 lym"hocytes

deelo"ment of B and 3 lym"hocytes u"onanti!enic challen!e

release of immuno!lobulins

(predominantlyimmunoglobulin $)u"on anti!enic

challen!e by B

lym"hocytesrto et al, 8ssessment of s"lenic function, ur Clin Microbiol nfect Dis %2010' 2961>:5;1>/=

9hite pulpT cell zone (periarterial lympaticseat) andB cell zone (follicles)


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ost defense

production of immune mediators

9hite pulpT cell zone (periarterial lympaticseat, !"#$) andB cell zone(follicles)

antien clea#ance facilitated bythe splenic

andhepatic#eticuloendothelial

complement, opsonins , (opsonic antibodies),properdin

(initiation of the alternate pathway of

complementacti%ation) andtuftsin (immunostimulatory

tetrapeptide)

rto et al, 8ssessment of s"lenic function, ur Clin Microbiol nfect Dis %2010' 2961>:5;1>/=


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ost defense

"ha!ocytosis of circulatin!microor!anisms and

immune com"le#es by mar!inal onemacro"ha!es

deelo"ment of mar!inal one B

lym"hocytes u"on3-2 anti!enic challen!e

blood traNc4in! of B and 3 lym"hocytes

release of immuno!lobulins u"on anti!enicrto et al, 8ssessment of s"lenic function, ur Clin Microbiol nfect Dis %2010' 2961>:5;1>/=

9hite pulp

%arginal zone


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ost defense

circulatin! monocytes are conerted into?#ed

macro"ha!es(phagocytic acti%ity of

unopsoni&ed

bacteria)

defence a!ainst bacteria usin! the iron

metabolism of its macro"ha!esO

ra"id release of anti!en-s"eci?c antibodies

into therto et al, 8ssessment of s"lenic function, ur Clin Microbiol nfect Dis %2010' 2961>:5;1>/=

:ed pulp


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Stora!e and Cyto"oiesis%ed *ul"'

reseroir for iron (for recycling),erythrocytes, "latelets, "lasmablastsand "lasma cells

e#tramedullary hemato"oiesis ifnecessary

rto et al, 8ssessment of s"lenic function, ur Clin Microbiol nfect Dis %2010' 2961>:5;1>/=

source of hemato"oietic cells inseere anemia, e#tramedullarys"lenic hemato"oiesis can bereactiated


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y"ers"lenism

the "resence of one or more cytopeniasin theconte#t of a normally functionin! bone marro

%a' those in hich increased destruction ofabnormal

blood cells occurs in an intrinsicallynormal s"leen

(e"g", hemolytic anemias) or %b' "rimary disorders of the s"leen

resultin! in

increased sePuestration and destructionof normal

blood cells (e"g", in'ltrati%e disorders)


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D!AG0OST!C !MAG!0G


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ndications for s"lenicima!in!

assess its sie before electie s"lenectomy

trauma

inesti!ations of left u""er Puadrant "ain

characteriation of s"lenic lesions suchas tumors, cysts, and abscesses

!uidance for "ercutaneous "rocedures


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?lt#asound initial ima!in! modality durin! ealuation and

resuscitation of the trauma "atient %G8S3'

"ercutaneous ultrasound-!uided "rocedures

Plain :adio#aphy indirectly "roide an outline of the s"leen in

the left u""er Puadrant

su!!est s"lenome!aly by reealin!

dis"lacement of ad(acent air-?lled structures may demonstrate splenic calci'cations


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Computed Tomo#aphy hi!h de!ree of resolution and detail of the

s"lenic "arenchyma "referred ima!in! modality

ealuation and mana!ement of the blunt

trauma "atient assessment of s"lenome!aly, identi?cation of

solid and cystic lesions, and !uidance of"ercutaneous "rocedures

Manetic :esonance !main e#cellent detail and ersatility in abdominal ima!in!


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Terapeutic splenic arterial embolization ($"&)

localiation and treatment of hemorrha!e in selecttrauma "atients

deliery of a ariety of thera"ies in "atients ithcirrhosis or "ortal and sinistral hy"ertension, and intrans"lant "atients

alternati%e to splenectomy for treatment ofhematolo!ic disorders such as 3* or hy"ers"lenism

reduced o"eratie blood loss from a deascularieds"leen and reduced s"leen sie (preoperati%e)

Anio#aphy inasie arterial

ima!in!


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0uclea# !main

adioscinti!ra"hy ith6 3echnetium 3c 99m sulfur colloid

3echnetium-99m heat-dama!ed erythrocytes%BC'O

ndium 111-labeled "latelets O

demonstrates s"lenic location (accessoryspleens)and sie

may dia!nose splenosis

remont $ ice, S"lenosis6 8 eie, South Med + 200/@100%:'65)9-59=+


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Splenic !nde@ olume of the s"leen in milliliters

normal alues 120 m< to >)0 m2R ofcases %2: to =/R upgraded, / to 15Rdowngraded'

sta!in! information aects treatment "atients ith earlystage disease ho hae

no s"lenic inolement radiothera"y alone

splenic in%ol%ement chemothera"y or

multimodality thera"y

Malignant

White cell-related indications

Malignant


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on;2odins =ymphoma

most common mali!nant disease that inolesthe s"leen %>0R of all "atients ith F


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on;2odins =ymphoma

subentities clinically classi?ed into6

nodal or e#tranodal

indolent, a!!ressie, $ erya!!ressie !rou"s indolent lymphomas mild or no sym"toms

aggressi%e ? %ery aggressi%e lymphomas

"ain, sellin! due to obstruction ofessels,

feer $ ni!ht seats

Malignant


Malignant


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on;2odins =ymphoma sur!ical sta!in! not indicated

combination of history $ *, C[ andabdominal."elic C3 scan, bio"sy of inoledlym"h nodes (including laparoscopicallydirected nodal ? li%er biopsies), $ bonemarro bio"sy

s"lenectomy im"roe cyto"enias

sym"tomatic s"lenome!aly

Malignant


Malignant


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Myelop#oli"e#ative diso#de#s

abnormal !roth of cell lines in the bone marrow

Chronic myeloid leu4emia

8cute myeloid leu4emia

Chronic myelomonocytic leu4emia

ssential thrombocytosis

*olycythemia era Myelo?brosis %a!no!enic myeloid

meta"lasia'

Malignant

Bone marro-related indications

Malignant


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Myelop#oli"e#ative diso#de#sCommon underlyin! "roblem leadin! to s"lenectomy6

sym"tomatic s"lenome!aly

early satiety, "oor !astric em"tyin!, heainess or"ain in the left u""er Puadrant, diarrhea

Fonsur!ical treatment of s"lenome!aly6

Chemothera"eutic a!ents (busulfan,hydroyurea, interferon@)

adiation hen s"lenectomy is not an o"tion

Malignant


Malignant


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disorder of theprimiti%e pluripotent stem cellin the bone marro

si!ni?cant erythroid, me!a4aryotic, $"luri"otent "ro!enitors in the "eri"heralblood smear

!enetic hallmar4 trans"osition beteen the

bcr gene on chromosome I$ theabl geneon

chromosome **

Ch#onic myeloid leuemia

Malignant


Malignant


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/ to 15R of all leu4emias

often asym"tomatic

can hae fati!ue, anore#ia, seatin!, andleft u""er Puadrant "ain $ early satietydue to splenomegaly (+2 of patients)

S"lenectomy ease "ain and early satiety

Ch#onic myeloid leuemia

Malignant


Malignant


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abnormal !roth of stem cells in the bonemarro

"resentation more ra"id $ dramatic "roliferation$ accumulationof hemato"oietic

stem cells in the bone marro $ blood inibitthe growtand maturationof normal BCs,

WBCs, $ "latelets deathresults (within wees to months if

untreated)

Acute myeloid leuemia

g


Malignant


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S.S include a iral-li4e illness ith feer,malaise, $ frePuently bone "ain

S"lenectomy unbearable left u""er Puadrant"ain

and early satiety

Acute myeloid leuemia

ncreased ris4 for leu4emic transformation to 8M


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"roliferation of hemato"oietic elements inthe bone marro and blood

monocytosis in the "eri"heral smear %1 #10= monocytes.mm=' and in the bonemarro

s"lenectomy sym"tomatics"lenome!aly

(+2 of patients)

Ch#onic myelomonocyticleuemia

g


Malignant


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abnormal !roth of the me!a4aryocyte cell line

increased leels of "latelets in the bloodstream

dia!nosis by e#clusion ($, polycythemia%era, and myelo'brosis)

S.S include asomotor sym"toms,thrombohemorrha!ic eents, recurrent fetal

loss, transformation to myelo?brosis ithmyeloid meta"lasia or 8M


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ydro#yurea reduce thrombotic eents

S"lenectomy later sta!es of disease

(when myeloid metaplasia has de%eloped)

ssentialth#ombocythemiaJth#ombocytosis

g


Malignant


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clonal, chronic, "ro!ressie myelo"roliferatie disorder

BC mass, accom"anied by leu4ocytosis,thrombocytosis, and s"lenome!aly

lon!er surial than those aected by hematolo!icmali!nancies

at ris4 for transformation to myelo?brosis or 8M

(7) spleen - oct. 28, 2014 - dr. s. cosme

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