Chapter 481 Hyposplenism, Splenic Trauma, and Splenectomy
Hyposplenism
Congenital absence of the spleen is associated with complex cyanotic heart defects, dextrocardia, bilateral trilobed lungs, and heterotopic abdominal organs (Ivemark syndrome; Chapter 425.11). Splenic function is usually normal in children with congenital polysplenia. Functional hyposplenism may occur in normal neonates, especially premature infants. Children with sickle cell hemoglobinopathies (Chapter 456.1) may have splenic hypofunction as early as 6 mo of age. Initially, this is caused by vascular obstruction, which can be reversed with red blood cell (RBC) transfusion or hydroxyurea. The spleen eventually autoinfarcts and becomes fibrotic and permanently nonfunctioning. Functional hyposplenism may also occur in malaria (Chapter 280), after irradiation to the left upper quadrant, and when the reticuloendothelial function of the spleen is overwhelmed (as in severe hemolytic anemia or metabolic storage disease). Splenic hypofunction has been reported occasionally in patients with vasculitis, nephritis, inflammatory bowel disease, celiac disease, Pearson syndrome, Fanconi anemia, and graft vs host disease.
Trauma
Injury to the spleen may occur with abdominal trauma. Small splenic capsular tears may cause abdominal or referred left shoulder pain as a result of diaphragmatic irritation by blood. Larger tears result in more severe blood loss, with similar pain and signs of hypovolemic shock. Previously enlarged spleens (as in patients with infectious mononucleosis) are more likely to rupture with minor trauma. CT scan with IV contrast is the best imaging modality to assess splenic trauma.
Treatment of a small capsular injury should include careful observation with attention to changes in vital signs or abdominal findings, serial hemoglobin determinations, and the availability of prompt surgical intervention if a patient’s condition deteriorates (Chapter 66
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