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GS54 General Surgery and Thoracic Surgery
Spleen
Toronto Notes 2019
Kehr’s Sign
Left shoulder pain due to diaphragmatic irritation from splenic rupture, worsens with inspiration
Spleen
Splenic Trauma
• typicallyfromblunttrauma(especiallyinpeoplewithsplenomegaly) • mostcommonintra-abdominalorganinjuryinblunttrauma
• mayhaveKehr’ssign
Treatment
• non-operative
■ in stable patients: extended bed rest with serial hematocrit levels, close monitoring for 3-5 d;
pediatric guidelines for days of bed rest is grade plus 1 (i.e. grade 3 splenic laceration requires 4 d of
bed rest)
■ hemostatic control
■ splenic artery embolization if patient stable and one of: active contrast extravasation, splenic
pseudoaneurysm, hemoperitoneum • operative
■ hemodynamically unstable patients with positive FAST will undergo operative surgical exploration
■ splenorrhaphy (suture of spleen) ± splenic wrapping with hemostatic mesh – if patient
hemodynamically stable, patient has stopped bleeding and laceration does not involve hilum
■ partial splenectomy, rarely performed due to risk of recurrent hemorrhage
■ total splenectomy if patient unstable or high-grade injury
Splenectomy
Indications
• splenictrauma(mostcommonreasonforsplenectomy),hereditaryspherocytosis,primary hypersplenism, chronic immune thrombocytopenic purpura (ITP), splenic vein thrombosis causing esophageal varices, splenic abscess, thrombotic thrombocytopenic purpura (TTP), and sickle cell disease
• doesnotbenefitallthrombocytopenicstates(e.g.infection,mostmalignanciesinvolvingthebone marrow, drugs/toxins)
• probabilityofcureofITPbysplenectomyis60-70%,maybepredictedbyresponsetoIVIG
Complications
• short-term
■ injury to surrounding structures (e.g. gastric wall, tail of pancreas) ■ post-operative thrombocytosis, leukocytosis
■ thrombosis of portal, splenic, or mesenteric veins
■ subphrenic abscess
• long-term
■ post-splenectomy sepsis (encapsulated organisms): 4% of splenectomized patients (highest risk in
those <16 yr)
◆ 50% mortality
◆ prophylaxis with vaccinations, ideally 2 wk pre- or post-operative (pneumococcal, H. influenzae,
and meningococcus)
◆ liberal use of penicillin especially in children <6 yr
■ splenosis: intra-abdominal “seeding” of splenic tissue during removal
Splenic Infarct
Pathophysiology
• splenicarteryocclusionoroxygen-deliveryinsufficiencyleadingtoparenchymalischemiaandnecrosis • canoccurinsicklecelldisease,thromboembolism,myelofibrosis,CML,hypercoagulablestates
• patientcanbeasymptomaticorcanhaveleftupperquadrantpain(70%),N/V,fever,chills,andKehr
sign
Treatment
• non-operative:closefollow-up,analgesia
• indicationsforsplenectomy:complicationssuchasrupture,abscess,persistentpseudocyst,bleeding,or
sepsis
Indication of Splenectomy
SHIRTS
Splenic abscess/splenomegaly Hereditary spherocytosis
Immune thrombocytopenic purpura Rupture of spleen
Thrombotic thrombocytopenic purpura Splenic vein thrombosis