Spleen

Two things are important in any  surgical exam:
 
First the ability to recollect. Realize the feeling that I have recently read or discussed this topic.
 
Second: the ability to remember and recollect a topic read some time back
 
Q1. Which of the following is not an indication for splenectomy in Non Hodgkin Lymphoma?
 
a)  Massive splenomegaly
b) Signs of hypersplenism
c) Diagnosing and staging of isolated splenic disease
d) All are indications for splenectomy
 
 Q2. The most common cystic disease of the spleen is
a) Hydatid cyst of spleen
b) Pseudo cyst of the spleen
c) Columnar lined cyst of spleen
d) Cystic lymphangioma
 
 
 
Q3 Which is not an indication of splenectomy in idiopathic thrombocytopenia
A) asymptomatic patients with platelet count between 30000-50000 mm3
b) refractory thrombocytopenia
c) relapse after glucocorticoid therapy
d) platelet count of 10000 despite management for 6 weeks but no bleeding.
 
 
 
Q4 ) True regarding abscess of the spleen are all except
a) Majority of splenic abscess result from hematogenous spread from other sites
b) Both Gram positive and gram negative organisms are responsible for abscess of spleen
c) Splenomegaly (enlargement of spleen)  is present in most of the patients.
d) 2/3rd of the splenic abscess are solitary in adults
 
 
 
Q5 Which of the following is not true regarding splenorrhaphy (Repairing of Spleen)
a) Use of Argon Beam coagulator is superior to other techniques.
b) Grade II and III injuries can be managed by suture repair
c) At least One third of the spleen should be preserved to maintain immunological function.
d) Mesh wrapping is recommended for Grade IV injuries
 
 
 Q6 OPSI is commonest in splenectomy done for
a) Thalassemia
b) Trauma
c) Hereditary Spherocytosis
d)ITP
 
 
 Q7 Which of the following is not true regarding wandering spleen?
a) The spleen is attached to a long vascular pedicle without the usual mesenteric attachments.
b) Torsion and infarction of the spleen are common complications
c) There is congenital atresia of the dorsal mesogastrium in children
d) Splenectomy is required in all cases
Q8.What is true about splenic abscess

a) Most of the abscess in spleen occur through local spread such as from kidneys, colon

b) Unilocular splenic abscess has a high mortality rate more than 50%
c) Splenomegaly is typically seen in splenic abscess
d) In one third of adults splenic abscess is multilocular
 
 
What is Hypersplenism                 MCH Questions                       USMLE
 
 
 
 
Answers
 
1 d
Splenectomy is indicated for NHL patients with massive splenomegaly leading to abdominal pain, early satiety, and fullness. It may also be indicated for patients who develop anemia, neutropenia, and thrombocytopenia associated with hypersplenism. Splenectomy may also be instrumental in the diagnosis and staging of patients with isolated splenic disease.
2. b
Pseudocyst of the spleen are 4 times more common than the true cysts. Pseudocyst spleen is mostly acquired after trauma.
 
True cysts of the spleen are lined by a layer of epithelium. True cysts like columnar lined cyst of spleen are rare. The epithelial cells are rich in CEA (Carcino embryonic Antigen) and CA19- 9 but they are benign. Management is required if the cyst is more than 8 cm or causing symptoms.
 
Classification of Splenic cysts
True Cyst- Congenital, epidermoid, or epithelial cysts. Or Parasitic and non parasitic
Pseudocyst
 
Splenic cysts are most common in the 2nd and 3rd decade of life, although they have been noted in all age groups, including infants. An asymptomatic painless abdominal mass is the presenting feature in approximately 30% to 45% of cases.
 
Treatment options include
Pseudocyst- Aspirations, Catheter drainage, Partial splenectomy, Splenectomy or a recent technique of partial splenic decapsulization (marsupilization)
 
3) a
Indication of splenectomy (removal of spleen) in ITP are
1.ITP has been  diagnosed for 6 weeks, still platelet count is less than 10000 with or without bleeding.
2. ITP diagnosed for 3 months with platelet count of less than 30000
 
4. c
Abscess of spleen  result from haematogenous spread from foci such as  endocarditis, osteomyelitis and IV drug abuse. It also results from spread from surrounding structures like colon and kidneys.
Both gram positive and gram negative organisms are responsible.
Splenomegaly is present in only a minority of patients. In adults 2/3rd of splenic abscess are solitary where as in children only 1/3rd are solitary.
 
5. a
Argon beam coagulator and other superficial coagulation devices are generallt preferred to the conventional techniques but studies have not shown a definite superiority.
In grade II and III injuries pledget suturing is advised .
Grade IV injuries are mangaed with polygalactin mesh.
Advantage of splenorrhaphy over splenectomy are
1. Immunological competence
2. Prevention of Left Subphrenic abscess.
 
6. a
One consistent observation is that the risk for OPSI is greater after splenectomy for malignancy or hematologic disease than for trauma
S. pneumoniae is the most frequently involved organism in OPSI and is estimated to be responsible for between 50% and 90% of cases. Other organisms involved in OPSI include Haemophilus influenzae, Neisseria meningitidis, Streptococcus species and other pneumococcal species, Salmonella species, and Capnocytophaga canimorsus
 
7. d
 
A “wandering spleen” occurs when the spleen is attached only by a long, loose vascular pedicle without the usual peritoneal attachments. Wandering spleen in children arise from congenital atresia of the dorsal mesogastrium. When found in women between 20 and 40 years of age, wandering spleens result from an acquired tissue laxity associated with pregnancy.
The condition is complicated by acute torsion around the vascular pedicle, which manifests with acute abdominal pain, fever, vomiting, acute pancreatitis, and gastric compression. Without detorsion, splenic infarction and gangrene ensue. Chronic torsion typically causes venous congestion and splenomegaly. In children without splenic infarction, the procedure of choice is splenopexy, suturing the spleen to the diaphragm, abdominal wall, or omentum.
Splenectomy is preferred in adults
8.d

Haematogenous route is the most common route for acquiring splenic abscess (70%). Risk factors inculde polycythemia vera, malignancies, IV drugs etc. Unilocular splenic abscess has mortality rates of 15-20% and multiloculated abscess about 80%. Typical symptoms are fever, pain abdomen, pleuritic chest pain. Splenomegaly is uncommon. In 1/3rd adults abscess is multilocular.

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Splenic Vein Thrombosis
 
Isolated thrombosis of the splenic vein is a rare but important cause of Upper GI bleeding. It leads to the formation of isolated gastric varices and is an easily treatable cause of Upper GI bleeding
 
Etiology
Chronic pancreatitis due to perivenous inflamation, stagnation and thrombosis
Pancreatic Carcinoma
Portal Hypertension
Renal disorders
Inflammatory diorders
 
Pathophysiology
 
Obstruction of the splenic vein outflow leads to formation of collaterals along the short gastric and gastro epiploic veins resulting in the formation of fundal gastric varices
Esophageal varices are also formed because of increased blood flow to the coronary vein
Vaices form in only 50% of the patients
Splenomegaly is a common finding
Diagnosis
Endoscopy
Endoscopic Ultrasound
Late Phase Celiac Angiography
 
Natural History of Splenic Vein thrombosis
Most cases are asymptomatic and require no treatment
Incidence of splenic vein thrombosis in patients with chronic pancreatitis is 13%
 
Treatment
If there is no bleeding patients can be followed up
After one episode of index bleed, splenectomy is the treatment of choice.Splenectomy removes the arterial inflow and venous outflow
If the Patient is Cirrhotic splenectomy should be avoided because it may lead to portal hypertension and preclude future liver transplantaion
 
 
 
Sarin's Classification of gastric Varices
Type I Gastroesophageal varices (GOV) are in continuity with the esophageal varices 2-5 cm below the Gastroesophheal junction
Type II Gastroesophageal varices (GOVII) re in continuity with esophageal varices in the fundus and cardia
 
Type I Isolated Gastric Varices (IGVI) Fundus of stomach in absence of esophageal varices
Type II Isolated varices (IGVII) in antrum or pylorus in the absence of eophgeal varices
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