Splenectomy- non traumatic

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Splenectomy- non traumatic

• By
• Rajeev Suryavanshi

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Indications

• Trauma commonest
• Spontaneous rupture
• - Infect mono
• - Malaria
• Hypersplenism
• - H. spherocytosis
• - Elliptocytosis
• - ITP

• Neoplasia
• - Leukemia
• With other viscera
• - Total Gastrectomy
• - D. Pancreatectomy
• Others
• - Hydatid
• - abscess

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Infectious Mononucleosis

• Glandular fever
• 1920 article , John Hopkins Med bulletin
• Triad- fever, lymphadenopath, pharyngitis
• 80 Epstein Barr Virus
• Remaining majority CMV

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Syndrome consist of

• Fatigue, Fever, Splenomegaly, Adenopathy and
  Pharyngitis.
• Transmission - kissing
• Incubation 30 - 50 days
• Incidence 50/100,000 general population
• - 5000/100,000 Susceptible
  college students.
• Age 15 24 years.

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Virus and pathogenesis

• EBV- double stranded DNA virus.
• 2 stage pathogenesis-
• Stage1- virus infects oropharygeal
  epithelial cells.
• Stage 2- infectious virus invading
• B-lymphocytes, multiply.
• Circulating B cells cause involvement of
  Reticulo-endothelial system.

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Immune response

• Primary immune respons -
• NK cells
• CD4 Suppressor T Lymphocytes
• Target on infectious cells.
• Secondary immune response -
• CD8 T Lymphocytes for EBV

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Clinical Features

• Prodrome (3-5 days)
• - malaise, fatigue,
• headache, anorexia.
• Fever (mod high) grade, Chills /_
• Tender, symmetrical, lymphadenopathy usually
  cervical

• 60 -75 show Splenomegaly-2 weeks after illness.
• lt 30 Hepatomegaly
• 10 Jaundice
• Posterior palate petechiae.
• 10 Maculopapular rash

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Laboratory features

• CBC leukocytosis (10-20,000)
• Absolute lymphocytosis gt 50 in diff.
• Atypical Lymphocytosis gt 10
• (B cells with virus)
• Transient neutropenia
• Liver functions- increase in
  Aminotransferases, ALP,
• LDH and Bilirubin
  

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serology

• Test for Infectious mononucleosis related
  immunoglobulin M (IgM) heterophil antibodies.

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Differential diagnosis

• GABHS
• (Group A beta-Hemolytic pharyngitis).
• HIV
• Typhoid .

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Complications

• Upper air way obstruction.
• Spontaneous splenic rupture.
• Others-
• Cardio respiratory-
• Pneumonitis
• Myocarditis
• Pericarditis

• Hematological-
• Autoimmune anemia
• Thrombocytopenia.
• Hepatic
• Cholestatic jaundice
• Hepatic necrosis
• Neurological
• CN palsy
• Encephalitis

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Upper air way obstruction

• Cause Tonsillopharyngitis.
• Best use of corticosteroid in this situation.
• Timely use of steroids can prevent surgical
  intervention.
• Emergency tonsillectomy may be needed on
  occasion, if steroid fail to respond or
  uncontrolled bleeding from tonsil.

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Spontaneous splenic rupture

• Rate 1 in 1000 cases of infectious mono.
• Also seen in CMV, and Hep.A infection.
• Rupture seen lifting, walking, coughing,
  vomiting , defecating.
• Time of rupture 2-4 weeks, from start of
  illness.
• Capsule of spleen infiltrated by lymphocytes.

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Spontaneous splenic rupture

• Usual presentation
• - pain, left upper abdominal.
• - tenderness in LUQ
• - Kehrs sign.
• Diagnosis- CT scan / ultrasonography
• if patient is stable
• If unstable DPL / Surgical intervention.

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Management

• Supportive
• No specific therapy
• Rest and Fluids.
• Acetaminophen / Aspirin fever.
• Lozenges / Salt water gargles
• Antibiotics and Steroids are indicated in
  presence of complication.

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Steroid indication in infectious mononucleosis.

• Impending upper airway obstruction.
• Immune cytopenia
• Neurological complications
• Severe Hepatitis
• Myocarditis.
• Extreme fever

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Overwhelming post Splenectomy infection(OPSI)

• Infection due to encapsulated bacteria.
• 50 Strep. Pneumoniae.
• Other organisms-
• Haemophilius influenzae
• Neisseria meningitidis
• Incidence is 4 in post splenectomy patients
  without prophylaxis.
• Mortality is 50 of OPSI
• Highest risk in first 2 years after splenecotmy.

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Prevention of OPSI

• Antibiotic prophylaxis-
• penicillin or amoxicillin
• duration ? Life long
• for sure in kids up to 16 years of age.
• Immunization-
• Pneumococcal and Haemophilius
• given 2 weeks before elective surgery
• immediately post op for emergency cases.
• repeat every 5 -10 years.

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Return to play and work

• Individualize each patient.
• Recent recommendations for return to contact
  sports (3 weeks 3months)
• Practical guide is
• if patient feels well, LFT normal, suggest
  resuming light training as jogging , swimming
  usually after 4 weeks of illness.

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Thank you