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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 ?