Which of the following is the most common etiology of splenic cysts worldwide?
Splenic cysts are rare lesions. The most common etiology for splenic cysts worldwide is parasitic infestation, particularly echinococcal. Symptomatic parasitic cysts are best treated with splenectomy, though selected cases may be amenable to percutaneous aspiration, instillation of protoscolicidal agent, and reaspiration. Nonparasitic cysts most commonly result from trauma and are called pseudocysts; however, dermoid, epidermoid, and epithelial cysts have been reported as well. The treatment of nonparasitic cysts depends on whether or not they produce symptoms. Asymptomatic nonparasitic cysts may be observed with close ultrasound follow-up to exclude significant expansion. Patients should be advised of the risk of cyst rupture with even minor abdominal trauma if they elect non operative management for large cysts. Small symptomatic nonparasitic cysts may be excised with splenic preservation, and large symptomatic nonparasitic cysts may be unroofed. Both of these operations may be performed laparoscopically.
Which of the following is an indication for surgical treatment of a splenic aneurysm?
Although rare, splenic artery aneurysm (SAA) is the most common visceral artery aneurysm. Women are four times more likely to be affected than men. The aneurysm usually arises in the middle to distal portion of the splenic artery. The risk of rupture is between 3% and 9%; however, once rupture occurs, mortality is substantial (35-50%). According to a recent series, mortality is significantly higher in patients with underlying portal hypertension (>50%) than in those without it ( 17% ). SAA is particularly worrisome when discovered during pregnancy, as rupture imparts a high risk of mortality to both mother (70%) and fetus (95%). Most patients are asymptomatic and seek medical attention based on an incidental radiographic finding. About 20% of patients with SAA have symptoms of left upper quadrant pain. Indications for treatment include presence of symptoms, pregnancy, intention to become pregnant, and pseudoaneurysms associated with inflammatory processes. For asymptomatic patients, size greater than 2 em constitutes an indication for surgery. Aneurysm resection or ligation alone is acceptable for amenable lesions in the mid-splenic artery, but distal lesions in close proximity to the splenic hilum should be treated with concomitant splenectomy. An excellent prognosis follows elective treatment. Splenic artery embolization has been used to treat SAA, but painful splenic infarction and abscess may follow.
A 45-year-old man presents to the emergency department with emesis of bright red blood. Laboratory results include HGB 10 g/dL, HCT 30%, platelets 300,000/mm3, international normalized ratio (INR) 1.0, aspartate transaminase (AST) 30 U/L, alanine transaminase (ALT) 45 U/L, and albumin 4.0 g/dL. After appropriate resuscitation he undergoes esophagogastroduodenoscopy (EGD) which is notable for gastric varices. What is the appropriate treatment for his condition?
While portal hypertension is most commonly a result of cirrhosis it can result from other causes such as splenic vein thrombosis. Patients with splenic vein thrombosis can present with bleeding from gastric varices in the setting of normal liver function test results. These patients also often have a history of pancreatic disease. Portal hypertension secondary to splenic vein thrombosis is potentially curable with splenectomy.
Which of the following is NOT part of the triad seen with Felty syndrome?
The triad of rheumatoid arthritis (RA), splenomegaly, and neutropenia is called Felty syndrome. It exists in approximately 3% of all patients with RA, two-thirds of which are women. Immune complexes coat the surface ofWBCs, leading to their sequestration and clearance in the spleen with subsequent neutropenia. This neutropenia (<2000/mm3) increases the risk for recurrent infections and often drives the decision for splenectomy. The size of the spleen is variable, from nonpalpable in 5 to 10% of patients, to massive enlargement in others. The spleen in Felty syndrome is four times heavier than normal. Corticosteroids, hematopoietic growth factors, methotrexate, and splenectomy have all been used to treat the neutropenia of Felty syndrome. Responses to splenectomy have been excellent, with over 80% of patients showing a durable increase in WBC count. More than one-half of patients who had infections prior to surgery did not have any infections after splenectomy. Besides symptomatic neutropenia, other indications for splenectomy include transfusiondependent anemia and profound thrombocytopenia.
Which of the following is the most effective prevention strategy against OPSI?
Asplenic patients have an increased susceptibility to infection for the remainder of their lives and although the overall lifetime risk of OPSI is low the consequences can be devastating. Patients undergoing splenectomy for hematologic or malignant indications have a greater risk of OPSI than patients undergoing splenectomy for trauma or iatrogenic injury, and OPSI is more common in children than adults. Providers need to have a high index of suspicion when evaluating asplenic patients for possible infection. Patient education and vaccinations against encapsulated pathogens is the mainstay of preventative therapy. Patients should be vaccinated 2 weeks prior to elective splenectomy in order to optimize antigen recognition and processing. If splenectomy is performed emergently vaccinations are given postoperatively with an attempt to delay administration for 2 weeks to avoid the transient immunosuppression associated with surgery. There is little evidence supporting efficacy of prophylactic antibiotics in asplenic patients and vaccination remains the most effective prevention strategy.