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A. Splenectomy is surgical removal of the spleen. Several nearby anatomic structures may be injured during splenectomy, including the gastric wall (stomach), if the short gastric arteries are compromised; the tail of the pancreas, if the caudal pancreatic arteries are compromised or during manipulation of the splenorenal ligament; and the left kidney, during manipulation of the splenorenal ligament. The most common complication

Gastrosplenic Ligament

Gastrosplenic ligament

• Short gastric arteries and veins

• Left gastroepiploic artery and vein

Splenorenal ligament

• Terminal branches of splenic artery

• Tributaries of splenic vein

Spleen And Gastrosplenic Ligament

Splenorenal ligament

• Terminal branches of splenic artery

• Tributaries of splenic vein

Gastrosplenic ligament

• Short gastric arteries and veins

• Left gastroepiploic artery and vein

Figure 11-1. (A) Arterial supply of the spleen. The splenic artery (S) is the largest branch of the celiac trunk. Al = anterior-inferior pancreaticoduodenal artery; AS = anterior-superior pancreaticoduodenal artery; CH = common hepatic artery; CP = caudal pancreatic arteries; DP = dorsal pancreatic artery; GD = gastroduodenal artery; GP = great pancreatic artery; LG = left gastric artery; LGE = left gastroepiploic artery; PI = posterior-inferior pancreaticoduodenal artery; PS = posterior-superior pancreaticoduodenal artery; RGE = right gastroepiploic artery; SG = short gastric arteries; SMA = superior mesenteric artery; TB = terminal branches of the splenic artery. (B) Visceral surface of the spleen. The gastrosplenic ligament and splenorenal ligament are shown, along with the structures they contain. C = colon depression; G = gastric depression; R = renal depression. (A adapted with permission from Ernest WA: NMS Anatomy, 2nd ed. Media, PA, Harwal Publishing, 1990, p 213; B adapted with permission from Moore KL: Clinically Oriented Anatomy, 3rd ed. Baltimore, Williams & Wilkins, 1992, p 175.)

of splenectomy is atelectasis (collapse) of the left lower lobe of the lung. Thrombocytosis (i.e, increased number of platelets within the blood) is common postoperatively; anticoagulation therapy may be necessary to prevent spontaneous thrombosis. Abnormal RBCs with bizarre shapes, some of which contain Howell-Jolly bodies (nuclear remnants), are found in the blood postoperatively.

B. Overwhelming postsplenectomy sepsis. After splenectomy, patients (especially children) are at great risk for bacterial septicemia because of decreased opsonic production, decreased IgM levels, and decreased clearance of bacteria from the blood. The pathogens most commonly involved are Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. Patients with sickle cell anemia usually undergo "autosplenectomy" because of multiple infarcts caused by stagnation of abnormal RBCs. Therefore, these patients are prime targets for postsplenectomy sepsis. Clinical signs include: influenza-like symptoms that progress to high fever, shock, and death.

C. Hypersplenism is increased splenic function (i.e., not to be confused with splenomegaly, which is increased splenic size). Clinical findings include: anemia, leading to pallor and fatigue; leukopenia, leading to increased susceptibility to infection; thrombocytopenia, leading to easy bruising and nosebleeds; and a compensatory increase in bone marrow activity. Hypersplenism may be caused by hematopoietic disorders (e.g., hereditary spherocytosis, thalassemia) or immune disorders (e.g., immune thrombocytopenic purpura).

1. Hereditary spherocytosis is a genetic hematopoietic disease characterized by a deficiency in the spectrin protein that helps to stabilize the RBC membrane and usually is caused by a mutation in the gene for ankyrin. Hereditary spherocytosis results in anisocytosis (variation in the size of RBCs) and spherocytes with no central pallor zone. Clinical signs include: anemia, fatigue, jaundice, pigmented gallstones, and splenomegaly. Treatment is splenectomy.

2. Immune thrombocytopenic purpura is an immune disorder in which circulating antibodies (IgG) directed against platelet-associated antigen cause rapid destruction of platelets. Clinical signs include: low platelet count, easy bruising, petechiae, mucosal bleeding, menorrhagia, and increased megakaryocyte count. Treatment includes: steroid (e.g., prednisone) administration, platelet transfusions, and plasmapheresis. Splenectomy is recommended if steroid administration is ineffective.

D. Splenic vein thrombosis most commonly is associated with pancreatitis. Clinical signs include: gastric varices and upper gastrointestinal bleeding.

III. RADIOLOGY. Anteroposterior barium radiograph of splenomegaly, computed tomographic (CT) scan of traumatic spleen rupture, aortogram of traumatic spleen rupture, and CT scan of traumatic spleen rupture (Figure 11-2).

Nuclear Scan Splenic Rupture

Figure 11-2. (A) Anteroposterior barium radiograph showing an enlarged spleen (splenomegaly). The lateral wall of the stomach (S) is indented {arrow), indicating an enlarged spleen. Compare this radiograph with Figure 9-1B, where the lateral contour of the stomach is preserved because the spleen is of normal size. Splenomegaly commonly is found in patients with liver cirrhosis or portal hypertension and right-sided heart failure. (B) CT scan of a traumatic spleen rupture. The spleen is the organ that is most commonly injured in car accidents (the liver is a close second). Note the splenic rupture or laceration (arrowhead) and the intrasplenic hematoma (arrow). Clinical signs of splenic rupture are hypotension, pain in the left hypochondriac region, and Kerr sign (referred pain to the left shoulder). In addition to trauma, splenic rupture is associated with infectious mononucleosis, malaria, and sepsis. (C) Aortogram of a traumatic spleen rupture. Note the large globular areas of extravasated contrast material (arrows). (D) CT scan of a traumatic spleen rupture. Note the large subcapsular hematoma (arrowheads), which appears as a crescentic mass conforming to the shape of the spleen (S). Balance sign is the presence of a palpable, tender, enlarged mass in the left hypochondriac region due to a subcapsular hematoma.[A adapted with permission from Freedman M: Clinical Imaging: An Introduction to the Role of Imaging in Clinical Practice. New York, Churchill Livingstone, 1988, p 339; B adapted with permission from Levy RC, Hawkins H, Barsan WG: Radiology in Emergency Medicine. St. Louis, CV Mosby, 1986, p 192; C adapted and D reprinted with permission from Kohler RE: Spleen. In Lee JKT, Sagel SS, Stanley RJ (eds): Computed Body Tomography. New York, Raven Press, 1983.]

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Responses

  • forbes craig
    What veins and arteries are located by the body of the pancreas?
    7 years ago
  • neftalem
    How to visualize gastroepiploic?
    7 years ago

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