1. Ziyad Al-Magwashi Abdulaziz Bayounis Meshari Al-Meshari
L.U.Q Pain & Masses
Ziyad Al-Magwashi
Abdulaziz Bayounis
Meshari Al-Meshari

2. LUQ Objectives Structures in LUQ Organs Not to Miss The Spleen Anatomy
Splenomegaly
Hemolytic Anemias
Tumors
Abscess
Trauma
Splenectomy

3. Case 1
Ahmed is a 45-year-old translator coming from Kenya recently. He comes to the ED because he is bothered by pain in his upper abdomen, mostly on the left side. You learn that he lived on his family’s farm in Kenya. What structures lie in the left upper quadrant of the abdomen? Hint: 10

5. Structures in the LUQ ? Spleen Stomach Left Kidney
Left suprarenal gland
Jejunum and proximal ileum
Left colic (splenic flexure)
Transverse colon: left half
Descending colon: superior part

6. Case 1 Continued…
You order a full work-up for Ahmed and find that he has marked eosinophilia. What other tests do you want to request?

7. CT scan showing hydatid cyst in left lobe of liver

8. Case 2
Sami is 59-year-old 30 pack year smoker who has recently lost 15 kg, and has a cough with blood tinged sputum. However, he mainly complains to you about the discomfort he feels in his left upper abdomen, which on palpation feels hard and nodular. Given the history, what is the most likely cause of this man’s abdominal masses? Hint: Strong suspicion of lung cancer.

9. CT scan showing metastatic liver cancer

10. LUQ…
1… Do not forget the left lobe of the liver.

11. Case 3
Sarah is 30-year-old overweight woman who has a history of gallstones. She is brought by her husband to the ED because she feels like there is a “painful bump on her stomach”. She mentions that she had an episode of severe pain that felt like “it was stabbing right through me to my back” a month ago but did not seek any help because she does not like hospitals. On palpation you feel a firm mass with an indistinct lower border that is resonant to percussion. Taking into account one of the complication of gallstones and her previous attach of abdominal pain, what is a possible diagnosis? Hint: Hx of stabbing pain radiating to the back.

12. CT scan showing pseudocyst at tail of pancreas

13. LUQ…
2… Do not forget body and tail of pancreas.

14. Question
A patient with suspected carcinoma of the stomach. What do you expect to find on palpation?
Nothing.
Do not expect to feel a mass in a patient with carcinoma of the stomach.
Browse’s Introduction To The Symptoms And Sings Of Surgical Disease, 4th Edition, P 425

15. Abdulaziz Bayounis Meshari Al-Meshari
The Spleen
Abdulaziz Bayounis
Meshari Al-Meshari

16. Anatomy of Spleen The largest lymphoid organ in the body.
Located in LUQ behind 9th, 10th and 11th ribs.
Weighs about g.
Varies in size and shape between people, but commonly fist-shaped, purple, and 4 in long.
It lies with it’s long axis along the line of the 10th rib and has an anterior notch.
Because the spleen is protected by the rib cage (lying behind the 9th, 10th and 11th ribs) we cannot easily palpate it unless it is abnormally enlarged.

17. Splenic Blood Supply The spleen receives its blood supply from:
 Splenic artery (largest branch of celiac artery)
 Short gastric arteries (gastroepiploic arteries)
The splenic vein carries blood from the spleen then it communicate with SMV to form portal vein.
The nerves accompany the Splenic artery and are derived from the Celiac plexus.
The hilum of the spleen is related to the pancreatic tail.

19. Functions of Spleen
The spleen plays multiple supporting roles in the body:
Filter: Phagocytosis of old and abnormal red blood cells.
Stores platelets (1/3 of platelets stored in spleen).
Immune: Produce antibodies (IgM) and Opsonin.
Reservoir: Contains about 8% of red blood cell mass.
Hematopoiesis: in fetal life and hematological disorders.

20. Splenomegaly
Remember: An enlarged spleen needs to be enlarged about 3 times its size to be palpated below the left costal margin.
An enlarged spleen may reach the right iliac fossa.

21. Splenomegaly - Causes

22. MASSIVE Splenomegaly
Cross midline extending into the right iliac fossa.
Most important causes:
1) Hematological Chronic myeloid leukemia
Myelofibrosis
2) Infections Malaria
Schistosomiasis
Visceral lishmaniasis
3) Others Tropical splenomegaly
Lysosomal storage diseases
(Gaucher’s & Nieman-Pick disease)

23. Approaching SPLENOMEGALY
History:
Fever, malaise, anorexia, foreign travel or with in an immigrant population infections
Weight loss, malaise, night sweats, pruritis and tendency to bleed malignancy
Anemia, fatigue, jaundice, gallstones and family Hx of similar symptoms hemolytic anemia
Neurological problems, mental retardation, skeletal deformities storage diseases

24. Physical examination:
Pyrexia , Rashes, tenderness, lymphadenopathy , jaundice infections
lymphadenopathy, bruise, scratch marks, cachexia malignancy
Jaundice, purpura, bony deformities, growth retardation hemolytic anemia
Palmer erythema, spider nevi, gynecomastia, ascitis, bruises, jaundice cirrhosis “portal hypertension”

25. Investigations: CBC , ESR , BLOOD FILM ± bone marrow biopsy
Urea & electrolytes
Liver function tests
Specific tests for infections and rheumatic diseases
U/S
CT scan

26. Hereditary spherocytosis:
Hemolytic Anemias
Hereditary spherocytosis:
Autosomal dominant inheritance.
The most common congenital hemolytic anemia.
The red cell membrane lacks the necessary protein assembly (spectrin & ankyrin)
decrease cellular plasticity with membrane loss  the RBCs are small, dense, & deformed haemolysis (by the spleen)

27. Hemolytic Anemia (Cont.)
Clinically:
hemolytic anemia, splenomegaly, jaundice is almost always present.
Periodic exacerbation (follows viral infections).
Due to haemolysis 85% patients will form pigmented gall stones.
Lab:
Anemia, high bilirubin (indirect), spherocytes seen on blood smear, reticulocyt count increased.
Coombs test negative.
Large spleen  risk of traumatic rupture.

28. Hemolytic Anemia (Cont.)
Treatment:
Splenectomy is the sole treatment for hereditary spherocytosis, associated gall stones  cholecystectomy
Splenectomy should be delayed in children until age of 6 years – why not earlier or later?
 To minimize risk of post-splenectomy infection, but before gallstones have time to form.

29. Spherocytes on Blood Film

30. Sickle Cell Disease Autosomal recessive inheritance
Due to replacement of normal hemoglobin A ( Hb-A) by sickle hemoglobin Hb-S (valine instead of glutamic acid in the 6th position of the Beta chain of globin).
Patients well have sickled shaped RBCs.
Those RBCs well be destroyed by the spleen causing splenomegaly (splenic sequestration).
Splenic microinfarcts lead to auto infarction.

31. Sickle Cell Disease (Cont.)
Diagnosis confirmed by electrophoresis (more than 80% of hemoglobin is Hb-S ).
Complications include pigment gall stones formation.
Management:
Prevent crisis (avoiding hypoxia, dehydration, etc),
Vaccinations (against pneumococcal and haemophilus influenza),
Hydroxyurea, folic acid (sever hemolysis), & exchange transfusion to reduce the frequency of crisis or as a prophylaxis before pregnancy or surgery.

32. Sickle Cell

33. SC Haemoglobin Electrophoresis

34. Thalassemia
Autosomal recessive inheritance more in the Mediterranean population.
These hereditary hemolytic anemia’s result from a hemoglobin underproduction.
Beta Thalasemia is the most common type.
Hemoglobin electrophoresis in Thalasemia major reveals absence of hemoglobin A and an increase in hemoglobin F.
Treatment includes blood transfusions, iron chelation and splenectomy.

36. Idiopathic thrombocytopenic purpura (ITP)
ITP is the condition of having a low platelet count (thrombocytopenia) of no known cause (idiopathic).
Most causes appear to be related to antibodies against platelets (IgG antiplatalets).
Often ITP is asymptomatic, however a low platelet count can lead to visible symptoms, such as purpura, petechiae, bleeding gums, ecchymoses and more seriously bleeding diathesis from GI tract.

37. ITP (Cont.)
Acute ITP (AITP) usually seen in children following viral infection.
Chronic ITP usually affect adults (usually idiopathic but may occur with autoimmune disorders, e.g. SLE, thyroid disease, CLL and HIV).

38. ITP Treatment Steroids. Intravenous immunoglobulin (I.V. IgG).
Medical therapy is the 1st line (steroids& IVIG)
If failed Splenectomy (most patients well respond 70%).
Intravenous Anti-D.
5. Platelet transfusion (reserved for intracranial or extreme hemorrhage).

39. Autoimmune Hemolytic Anemia
Is an acquired hemolytic anemia resulting from antibodies that are produced by the body against its own red cells.
Distinguishing feature is a positive direct Coombs test this identifies antibodies on the red cell surface.
Usually after 50 years, female to male 2;1, acute onset.
The type of antibody attached to the red cell determines the mechanism of hemolysis.
Divided by their optimal binding Tempreture:
Warm AIHA (37˚C) IgG mediated.
Cold AIHA (<4˚C) IgM mediated.

40. AHA (Cont.) Causes: Idiopathic Warm AHA: Idiopathic (40-50% of cases)
Secondary to drugs, connective tissue disease (warm antibodies, may benefit from splenectomy)
Cold AHA: infections( EBV, Mycoplasma pneumonia)  The hemolysis occurs intravascularly & not in within the spleen.
Drugs: Penicillin, cephalothin, streptomycin, methyldopa, quinidine, aspirin, phenacetin and several sulfonamides.
Physical Findings:
Pallor, jaundice and splenomegaly are the main physical findings.

41. AHA Treatment
Directed towards the hemolytic anemia and any underlying disease:
Blood transfusion, steroids are the primary Rx.
Splenectomy in Warm AIHA not responsive to medical Rx or requiring Large steroid doses.

42. Splenic Tumors
Benign and malignant infiltration: 1. Leukemia's (acute, chronic, lymphoid & myeloid) 2. Lymphomas(Hodgkins and non-hodgkins) 3. Myeloproliferative disorders 4. Metastatic tumors(commonly from lung breast and melanoma) 5. Histiocytosis X 6. Hemangioma, lymphangioma 7. Splenic cysts 8. Hamartomas 9. Eosinophilic granuloma

43. Splenic Abscess
Splenic abscess is rare - it should be suspected when there is progressive splenic enlargement and is associate with bacteraemia and abscess formation at other sites
Causes:
Bacterial Streptococcus, Staphylococcus, Enterococcus (predominant in most reports).
Fungal -Candida
Unusual flora -Burkholderia pseudomallei actinomycotic and mycobacterial abscesses, most typically seen in immunosuppressed patients.

44. Splenic Abscess (CT Scan)

45. Splenic Abscess (Cont.)
Patient usually present with:
Fever (>90%)
Abdominal pain (>60%) typically occurs suddenly, with a punctum maximum in the left hypochondrium (>39%)
Pleuritic chest pain around the left lung base (>15%) is aggravated by coughing or forced expiration.
General malaise

46. Splenic Abscess Treatment
Medical therapy: Start antibiotics immediately after taking blood cultures (antifungal if fungus suspected).
Surgical Therapy:
Percutaneous drainage:
Percutaneous drainage is indicated for easily accessible uniloculated or biloculated abscesses with otherwise favorable features, as described previously, and also for surgical patients at very high risk who cannot tolerate general anesthesia or surgery.
The procedure includes a risk of iatrogenic injury of the spleen, colon (splenic flexure), stomach, left kidney, and diaphragm.
2. Splenectomy.

47. Splenic Abscess Treatment (Cont.)
Open drainage: Open drainage is used when the abscess cannot be drained percutaneously. Depending on the location of the abscess, 1 of 3 access routes can be employed:
Transpleural: Usually requires resection of the 12th rib in the posterior axillary line and drainage of the abscess through the diaphragm
Abdominal extraperitoneal :Accesses the abscess through the lateral abdominal wall and between the peritoneum and the flat abdominal muscles
Retroperitoneal : Used when the abscess extends to the flank

48. Splenic Vein Thrombosis - Case
A 23-year-old man with episodes of hematemesis and hematochezia was admitted to ED with clinical signs of anemia and splenomegaly.
Lab results showed hematocrit, 22.2%; hemoglobin, 7.5 g/dL; international normalized ration (INR), Results of his liver function tests, as well as the rest of his biochemical examinations, were within normal limits.
An emergency endoscopy performed showed enlarged bleeding gastric varices but no esophageal varices  This led us to consider that the enlarged varices may be secondary to splenic vein thrombosis.
Ultrasound and CT scan revealed his enlarged spleen and an engorged splenic artery with a diameter of 1 cm, and a fusiform dilated splenic vein measuring 5 × 6 × 9 cm.
Daniel Paramythiotis, et al. Massive variceal bleeding secondary to splenic vein thrombosis successfully treated with splenic artery embolization: a case report. Journal of Medical Case Reports 2010, 4:139

49. CT Scan Showing Enlarged Spleen

50. Splenic Vein Thrombosis
Sinistral portal hypertension (SPH) is a clinical syndrome of gastric variceal hemorrhage in the setting of splenic vein thrombosis (SVT), mostly due to pancreatic pathology.
Unlike patients with generalized portal hypertension, most patients with SVT are usually asymptomatic and have a normal hepatic function.
Bleeding from gastric varices (GVs) is generally more severe than from esophageal varices, although it occurs less frequently.

51. SVT (Cont.)
Treatment:
Splenectomy is considered the treatment of choice for splenic vein thrombosis complicated by variceal hemorrhage or hypersplenism (symptomatic).

52. Splenic Trauma Most common organ injured in blunt trauma “MTA”.
Rarely injures by penetrating tumor
Signs & symptoms:
LUQ bruising
Shoulder pain “Kehr’s sign”
LUQ mass “balance’s sign”
Gastric bubble displacement

53. Splenic Trauma (Cont.)
Initial diagnostic procedures in an unstable patient is DPL , US “FAST = focused assessment with sonar for trauma”
In a stable patient CT scan
LAPAROTOMY
Management goals:
Resuscitation
Salvage in hematomas and simple lacerations is the primary goal; suture lacerations, ligate splenic vessels.
If above failed or severe rupture causing instability splenectomy is indicated.

54. Splenic Trauma (Cont.) Indications for Non-operative Management:
Hemodynamically stable
<2 units transfused
No increasing hematoma size when followed by U/S
Stable Hb estimations
Note: Keep in mind! There is a risk of delayed rupture of hematomas so observe patient 7-10 days

55. Splenectomy

57. Indications of Splenectomy
Trauma (usually blunt but it could be penetrating)
Cysts.
Congenital Hemolytic anemia:
Hereditary spherocytosis(most common)
Hereditary elliptocytosis
Thalasemia
Auto-immune
ITP
Auto-immune hemolytic anemia

58. Indications (Cont.) 5. For Symptom relief, such as: Hypersplenism
Splenic Vein thrombosis
Infectious mononucleosis
6. Hematologic malignancies
Hairy cell leukemia
Hodgkin’s lymphoma
7. TTP
8. Splenic artery aneurysm
9. Splenic abscess
10. Ectopic spleen

59. Complications of Splenectomy
Immediately postoperative:
Peripheral Blood changes
Leukocytosis
Thrombocytosis
Presence of Howell-Jolly bodies
Hemorrhage
Atelectasis (left lower lobe, most common)
Subphrenic Abscess or hematoma
Pancreatitis or pancreatic fistula (as a result from parenchymal manipulation)

60. Complications (Cont.) B. Postsplenoectomy Sepsis
Overwhelming sepsis usually with encapsulated Organism:
Pneumococcus or Haemophilus
In 4.25% of splenectomized Pt.
Fatal 50% of the time
Vaccinations for Streptococcus pneumoniae and H.influenze should be given to all splenectomized Pt. , more effective if given days before surgery.
Prophylactic Penicillin given to <18 y.o children.