Spleen

Central role:

- Regulating the immune system

- Influencing metabolic and endocrine functions

Anatomy:

An encapsulated mass of vascular and lymphatic tissue

The largest RES organ

9-11th ribs

4 impressions

ligamentous attachments

Related to pancreatic tail

Blood supply

Embryonic anomaly:

Accessary spleen

Functions:

Removal of RBCs ,WBCs and Platelets

Extramedullary hemopoeisis

Recycling Iron

Immunological (T and B cell lymphocytes )

Splenomegaly:

Weight 500 gms

Average 15 cm

Massive,

> 1 Kgm

> 15 cm

Imaging studies:

- USS

- CT …….Trauma scoring

- MRI

- Angiography (embolization)

Indications for splenectomy:

The commonest is trauma

For elective ,the commonest is ITP

1. Benign disorders:

Hereditary spherocytosis

G6PD deficiency

Auto immune hemolytic disease

Sickle cell disease

Thalassemia

Indications foe splenectomy…..continued 2. Malignant diseases: WBCs disorders Hodgkins disease Non Hodgkins lymphoma Chronic lymphocytic lukemia Myeloproliferative disorders Acute myeloid lukemia Essential thrombocytopenia Polycythemia

Indications for splenectomy…..continued

3. Others:

3a. Infections:

Infectious mononucleosis

EB virus

CMV

( spontaneous rupture )

3b. Abscess

3c. Cysts:

Parasitic

Traumatic

Dermoid

3d. Tumors:

Primary (Sarcoma)

Metastatic

Indications for splenectomy…..continued

3e. Storage diseases:

Gauchers disease

Niemann-Pick disease

3f. Splenic artery aneurysm

3g. Portal H.T

3h. Feltys syndrome

3i. Wandering spleen

Preoperative considerations:

Patient Education

Overwhelming sepsis

Splenic vein thrombosis

Vaccinations:

Encapsulated pathogens

More with hematological and malignant disorders

More in children

Greatest risk, 1st 2 years

Timing

The Liver

The largest organ (1500 Gm)

Two lobes

8 segments

Protected by rib cage

Fibrous capsule (Glissons )

8 ligaments

Foramen of Winslow

Dual supply Hepatic artery 25%

Portal vein 75%

Portosystemic anastomosis

Physiology:

Storage Proteins ( AA)

Glucose (Glycogen)

Fat (Cholesterol)

Production All plasma proteins

All coagulation factors

Secretion Detoxification

Bile:

I litre per day

Bilirubin metabolism

Composition: water

Organic molecules:

Bile pigments

Bile salts

Phospholipids (Lecithin)

Cholesterol

Enterohepatic circulation

Jaundice:

Bilirubin more than 2.5 – 3 mgs/dl

Causes:

Prehepatic

Intrahepatic,

Gilberts syndrome

Crigler-Najjar syndrome

Dubin-Johnson syndrome

Posthepatic…..extrinsic or intrinsic obstruction of the biliary tree

Imaging:

- USS

- CT

- MRI

- PET

- Angiography

Liver cirrhosis:

The final sequela of chronic hepatic insult

Morphology Micronodular

Macronodular

Liver Cirrhosis …..continued

Etiology:

Viral hepatitis

Autoimmune hepatitis

Drug induced

Cholestasis

Metabolic Hemochromatosis

Wilsons disease

Hepatic vein outflow obstruction

Budd chiari syndrome

Congestive cardiac failure

Constrictive pericarditis

Portal Hypertension:

Portal venous system contributes

75% of the blood supply

72% of the Oxygen

Normal pressure 5-10 mmHg

Portal HT ……continued

Etiology:

1. Presinusoidal

Extrahepatic

Splenic vein thrombosis

Splenomegaly

Splenic A-V fistula

Intrahepatic

Schistosomiasis

Congenital hepatic fibrosis

Idiopathic portal fibrosis

Myeloproliferative disorders

Sarcoid

Portal HT etiology……continued 2. Sinusoidal Intrahepatic cirrhosis 3. Post sinusoidal Intrahepatic Vascular occlusive disease Posthepatic Budd Chiari CCF IVC web Constrictive pericarditis

Varices:

30% of patients with compensated cirrhosis

60% of patients with decompensated cirrhosis

1/3 of all patients with varices will experience variceal bleeding

Each episode 20-30% mortality if untreated

70% of patients who survive the initial episode will experience recurrent haemorrhage within 2 years

Prevention of variceal bleeding:

Non selective Beta blockers

Prophylactic endoscopic suveillance and band ligation

Acute Vareceal Bleeding:

Admission to ICU

Careful blood replacement

FFP

Platelets

Antibiotics

Vasopressin

Luminal tamponade Blackmore-Sengstaken tube

TIPS

Surgery:

Shunting Portocaval

Mesocaval

Distal lienorenal (Warren)

Non shunting Sigiura

Liver transplant

Budd Chiari syndrome:

Congestive Hepatopathy

Primary Thrombosis

Secondary Compresion

Liver Abscess:

Pyogenic

Amebic

Hydatid Disease:

70% in the liver

May be silent

May become infected or may rupture

Diagnosis:

ELISA 80% Positive (Weinburg)

Casoni

Eosinophilia 30%

Imaging

Hydatid disease ……continued

Treatment:

Albendazole

Mebendazole

Surgery

E.multilocularis (in the west )

Ascariases:

Retrograde locomotion into the bile ducts

Treatment:

Piperazine citrate

Albendazole

Mebendazole

ERCP

• Schistosomiasis:

• Perisinosoidal portal HT

• Education

• Hygiene

• Praziquantel Single dose 40-70 mg/kilo wt.

•

Liver Cysts:

Congenital

Benign cystadenoma

Polycystic liver disease

Caroli’s disease Biliary lithiasis 33%

Cholangitis

Biliary abscesses

Cholangiocarcinoma 7%

Benign Liver Lesions:

1. Cysts Primary ( congenital)

Secondary (traumatic)

Seromas

Bilomas

2. Hemangiomas

3. Adenoma

Females

OCP

Significant risk of rupture

Risk of malignant transformation to HCC

Benign Liver Lesions…….continued

4. Focal nodular hyperplasia

Malignant Liver tumors:

1. Primary

1a. From liver cells (HCC) Hepatocellular carcinoma

1b. From bile ducts (CC) Cholangiocarcinoma

Malignant Liver Tumors ……continued

HCC:

The 5th common malignancy

High fatality

Risk factors Viral hepatitis

Alcoholic cirrhosis

Hemochromatosis

Aflatoxin

Malignant liver Lesions…….continued

Cholangiocarcinoma

An adenocarcinoma of the biliary tree

Peripheral ( intrahepatic)

Central(extrahepatic)

Distal

Proximal(hilar) Klatskin tumor

Questions ?