splenomegaly and hypersplenism
TRANSCRIPT
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Splenomegaly and Hypersplenism
done by Anas M.kamel Hindawi5th year beirut arab university
salamtak workshop
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It lies in the left upper quadrant of the abdomen
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normal spleen 10 cm length ,150 gms
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Lies beneath 9 th to the 12 th rib
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lymphatic organ suspended within the greater omentum
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connected to stomach by gastrosplenic ligament ,and to the kidney by splenorenal
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Blood supply by splenic vesseleslymph drainage follow its bld supply
paraortic and caeliac Ln.s
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Spleen has only efferent lymph vessels
and caeliac symp. Supply along the art.
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white pulp
• Composed of malphigian corpuscles wich are :
• Lymphoid follicles “B lymphocytes”• Periarteriolar lymphoid sheath “T lymphocutes”
• macrophages
• Active immune response through humoral and
cell-mediated pathways.
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Red pulp
• Contains the cords of Billroth with fixed macrophages and sinusoids
• Mechanical filtration of RBC.s
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• Blood filtration; macrophages remove: Hematopoietic elements Intraerythrocytic parasites Encapsulated bacteria
• Enhancement of Ag trapping and processing in macrophages
• Reservoir for one third of the peripheral blood platelet pool and 10 % of RBC.s
• Pitting :howel jolly and heinz bodies removal from RBC.s
• Site for extramedullary hematopoiesis
Spleen functions
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90% of blood passing “300 ml/min “ thru the spleen moves in an open circulation :
from arteries to the cords to the sinusesthus spleen pulp pressure reflects
pressure of the portal system
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Hypersplenism
• Clinical syndrome characterized by :
• Splenic enlargment “splenomegaly”• Anaemia ,leukopenia and thrombocytopenia
• Compensatory bone marrow hyperplasia• Improvement after splenectomy
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splenomegaly
• Mild splenomegaly : largest dimension bt 12 and 20 cm ,400-500 g
• Severe splenomegaly : largest dimension more than 20 cm ,more than 1000 g
• If spleen below costal margin 750-1000 g
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Symptoms
• Pain
• Early satiety
• Heavy sensation in the left upper quadrant
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signs
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Inspection : fullness moved with resp. mov.
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Auscultation : venous hum or friction rub
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Bimanual examiaton (palpitation)
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• Supine flexed knees
• Lt hand at the costovertebral angle
• Rt hand feels the tip or notch of the spleen during resp.
• identify the lower edge of spleen by examining from Lt lower quadrant and the right lower quad.
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Percussion
• Nixon’s method
• Castel's sign
• Traube’s sign
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Nixon’s method
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Castell's sign• Patient is placed in the supine position
• Percussion in the lowest intercostal space in the anterior axillary line (eighth or ninth) produces a resonant note if the spleen is normal in size during either expiration or during full inspiration bcz of air in the stomach and colon
• A dull percussion note on full inspiration suggests splenomegaly
• Difficult in obese
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Traube’s sign
• The borders of Traube’s space are the sixth rib superiorly, the left midaxillary line laterally, and the left costal margin inferiorly
• Patient is supine with the left arm slightly abducted
• During normal breathing, this space is percussed from medial to lateral margins, yielding a normal resonant sound
• A dull percussion note suggests splenomegaly.
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How to differentiate in examination the kidney from the spleen
• Splenic notch• Can cross the midline• Can’t get above
• Moves with resp.• Splenic rub• No ballotable
• No notch• Can’t cross midline• May get above
• Not moves with resp.• No rub• ballotable
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Causes of splenomegaly
• Increased function
• Abnormal bld flow
• Infiltration
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Increased demand for splenic function
• Reticuloendothelial system hyperplasia (for removal of defective erythrocytes) as in :
• spherocytosis
• thalassemia • nutritional anaemia• Early sickle cell anaemia
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Increased demand…..ctd
• Immune hyperplasia
• Either in response to infection whether viral ,bacterial ,fungal or parazite
• Or disordered immunity as rehumatoid arthritis (felty’s syndrome),SLE ,collagen vascular ,drug reaction ,sarcoidosis ,thyrotoxicosis
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Increased demand…..ctd
• Extramedullary hematopoiesis as in myelofibrosis ,marrow damage by toxins or radiation ,marrow infiltration by tumour or leukemia or gausher disease
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Abnormal splenic or portal blood flow
• Cirrhosis
• Congestive Heart failure
• Hepativ vein obstruction either int. or ext.• Portal vein obstruction
• Splenic vein ostruction
• Hepatic schiztosomiasis
• Portal hypertension
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Infiltration of the spleen
• Intacel. Or extrcel. Infiltration
• Amylodosis• Gaicher disease
• Nimen pick disease
• hperlipidaemia
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Infiltration of……ctd
• Benign and malignant cellular infiltrations
• Leukemia (acute ,chronic ,lymphoid)• Hodgkin and NHL• Myeloproloferative• Angiosarcoma• Metastatic tumors• Haemangioma ,fibroma ,lymphangioma• Splenic cysts
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Diseases associated with massive splenomegaly
• Thalassemia• visceral leishmaniasis (Kala Azar)• schistosomiasis• Chronic myelogenous leukemia• Chronic lymphocytic leukemia• lymphomas• hairy cell leukemia• myelofibrosis• polycythemia vera• Gauchers disease• Niemann Pick disease• sarcoidosis• Autoimmune hemolytic anemia• Malaria
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Diagnostic Approach
• History and physical examination
• Laboratory and imaging studies
• Bone marrow biopsy in advanced• • suspected cases
• splenectomy
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Laboratory Tests
• Erythrocyte count
• If inc. polycythemia vera• If decr. Thalassemia major ,SLE ,cirrhosis
,portal HT
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Granulocyte counts may be
• Decrease as in felty’s syndrome ,congestive splenomegaly
• Increase in infections and inflam. Process also in myelofibrosis
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Platelet count
• Decrease in cong.splenomeg. ,myeloproliferative dis ,LSD
• Increase in polycythemia vera
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• SGPT ,SGOT
• PT ,pPT
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Imaging
• US
• CT
• MRI
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treatment
• Treat the underlying disorder. • Splenectomy is indicated in certain clinical
situations. • Symptom control in patients with massive
splenomegaly
• Disease control in patients with traumatic splenic rupture
• Correction of cytopenias in patients with hypersplenism or immune-mediated
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Multiple cysts
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Massive splenomegaly
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Normal spleen dimensions
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Spleen injury
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Pseudo cyst treated by percutanous drainage if child
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Splenomegaly compressing the stomach
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Spleen abcess
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• Bailey and loves’s short practice of surgery
• Cecil Textbook of medicine• Harrison’s principal of inernal medecine
17th edition
• Goljan pathology 2nd edition
References
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Thanks 4 u all my friendspeace