(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.
: ; ;
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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
White cell-related indications
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
White cell-related indications
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
Bone marro-related indications
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
Bone marro-related indications
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
Bone marro-related indications
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
Bone marro-related indications
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
Bone marro-related indications
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
Bone marro-related indications
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