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Surgery Lecture Notes, Books, MCQ and Good Articles

FR IDA Y , S EPT EMB ER 5, 2008 MedCosmos Medical Blogs

Spleen MCQ .All MedCosmos Series

1. As the functional anatomy of the spleen is divided into red pulp,

white pulp, and marginal zone, what function is incorporated into the
anatomy of the cortical zone that relates to infection control?
A. Filtration of red cells, encapsulated bacteria, and other foreign
material.
B. Red pulp for formation of red cells.
C. White pulp for its role in formation of granulocytes.
D. Gray areas, so formed because of the production of platelets.
E. Fibrous trabeculae.
Answer: A

DISCUSSION: The cortical networks described by Billroth are lined with

B-, T-, and other lymphocyte subpopulations. The open zones, called Labels
by some the cords of Billroth, serve as an anatomic microfilter as well
History Taking (6)
as a functional mechanism for removing foreign materials. For
example, immature red cells with retained nuclei are “pitted” by Important Eponyms (1)
these cords and removed from circulation. Pneumococcal and other MCQ : Breast (1)
bacteria (encapsulated and nonencapsulated) can be removed by the
MCQ : Cardiac Surgery (1)
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 MCQ : Cardiac Surgery (1)
spleen. The filter mechanism of the spleen, combined with this
immune capacity, is what is mainly lost in splenectomy that exposes MCQ : Endocrine (1)
the asplenic patient to overwhelming postsplenectomy sepsis MCQ : General Surgery (1)
syndrome (OPSS).
MCQ : Hernia-Acute Abdomen (1)
MCQ : Large Intenstine (1)
2. During the evolution of the understanding of hematologic diseases, MCQ : Liver-Pancreas (1)
the indications for splenectomy have changed. The most common
MCQ : NeuroSurgery (1)
indications for splenectomy are, in descending order of frequency:
A. Traumatic injury, immune thrombocytopenia, hypersplenism. MCQ : Oncology (1)
B. Immune thrombocytopenic purpura, traumatic injury, MCQ : Pediatric Surgery (1)
hypersplenism.
MCQ : Small Intenstine (1)
C. Hypersplenism, traumatic injury, immune thrombocytopenia.
D. Immune thrombocytopenia, hypersplenism, traumatic injury. MCQ : Spleen (1)
E. None of the above. MCQ : Stomach-Esophagus (1)
Answer: A
MCQ : Thoracic Surgery (1)

DISCUSSION: Over the years, the indications for splenectomy have MCQ : Thyroid Gland (1)
varied as better understanding and altered therapy for immune MCQ : Transplantation (1)
system diseases have occurred. Whereas in the past splenectomy was
MCQ : Trauma and Burns (1)
the available therapy for hypersplenism, better understanding of the
diseases causing hypersplenism (which is a syndrome) has allowed MCQ : Urology (1)
other therapies to emerge. Splenectomy, therefore, is less often MCQ : Vascular Surgery (1)
required for the treatment of hypersplenism associated with some
Surgery Books (7)
types of hematologic malignancies. Traumatic injury remains the
most common indication for splenectomy, although this situation may Surgery Lectures (1)
change as conservative management of splenic injuries continues to Surgery Must Read (1)
increase. Moreover, immune thrombocytopenia is increasing in
Surgery Pamphlets (2)
frequency and is definitively cured by splenectomy.

Blog Archive
▼ 2008 (48)
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 3. Useful methods for detection of splenic injury, in descending order ▼ 2008 (48)
of sensitivity, are: ▼ September (48)
A. Diagnostic peritoneal lavage. Paradoxical Aciduria
B. CT.
Thoracic Surgery MCQ
C. Ultrasonography.
D. Isotope scan. Cardiac Surgery MCQ
E. Magnetic resonance imaging (MRI). NeuroSurgery MCQ
Answer: B Urology MCQ
Pediatric Surgery MCQ
DISCUSSION: Diagnosis of splenic injury is most specifically made and
quantitated by CT. Diagnostic peritoneal lavage is useful for detecting Vascular Surgery MCQ
intra-abdominal bleeding, but not specific to splenic injury. Isotope Liver and Pancreas MCQ
scans are useful to a point but do not delineate the anatomy of the Large Intenstine MCQ
spleen that is injured. Classifications of splenic injury are currently
Stomach and Esophagus MCQ
being developed based on the images provided by CT scans and are
evolving into prospective decision trees for operation or conservative Hernia and Acute Abdomen
management. MCQ
Trauma and Burns MCQ
General Surgery MCQ
4. The following statements about splenosis are correct:
A. Autotransplantation of splenic tissue is an etiology. Thyroid Gland MCQ
B. May protect against OPSS. Small Intenstine MCQ
C. May over time be “born again” and regain some immune function. Oncology MCQ
D. May produce tuftsin and properdin.
Transplantation MCQ
E. All of the above.
Answer: E Enocrine Surgery MCQ
Breast MCQ
DISCUSSION: Splenosis or autotransplantation of splenic tissue, which Spleen MCQ
may follow splenic injury, can result in the return of some types of
Technical Basis Of Radiation
immune function. The “born again” spleen refers to the detection in
Therapy
blood samples of the opsonin tuftsin and properdin, which have been
Metastasis of Prostate Cancer
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 observed to occur in the occasional patient at a period of time remote Metastasis of Prostate Cancer
from splenic injury. The supposition is that as the splenic implants Schwartz Manual Surgery 8th
grow and multiply in time, they reach a critical mass whereby Edition
opsonins may be formed and presumably the implants can provide Bailey & Love's Short Practice
some of the host defense mechanisms that were lost with of Surgery
splenectomy.
Sabiston Textbook of Surgery
A History of Plastic Surgery
5. The following comments about immune thrombocytopenic purpura Endoscopic Surgery of
(ITP) are accurate: Potential anatomical spaces
A. Platelet count is low. 1000 Eponyms in Surgery
B. Circulating antiplatelet factor is present.
Sentinel Lymph Node
C. Antiplatelet factor is immunoglobulin G (IgG) antibody.
D. Purpura is directed against a platelet-associated antigen. History & Examination in
E. May be fatal. Rheumatoid Arthritis
F. All of the above. Varicose veins examination
Answer: A
Examination for a diabetic
foot
DISCUSSION: ITP is a disease characterized by low platelet counts and
Thyroid Examination
a bone marrow with proliferative megakaryocytes. The disease is
usually diagnosed by abnormal episodes of bleeding, which may occur Lump History & Examination
from trauma, menses, etc. The causative event by which sensitized Named Hernia
platelet-associated antibodies are developed is probably multiple. The
Deep Vein Thrombosis
effect of the platelet-associated antibodies, which is usually IgG, is
directed against a platelet-associated antigen and, when coating of Post Operative Fever
normal platelets occurs, results in the platelets being sequestered Staging of breast cancer
from the system by the reticuloendothelial system with resultant PERIPHERAL VASCULAR
thrombocytopenia. DISEASE History
Q-A Scrotal Swelling

6. ITP: Management of Differentiated

Thyroid Carcinoma
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 A. Is most common in men in their 20s. Thyroid Carcinoma
B. Is frequently cured in adults by corticosteroid administration. Top 100 Secrets in Surgery
C. Usually requires splenectomy in children. Burns
D. Is most common in the sixth decade of life.
Sister Mary Joseph Nodule
E. Is in remission in more than 80% of patients with splenectomy.
Answer: E DD of rectal bleeding
DD of scrotal swelling
DISCUSSION: ITP is characterized by a low platelet count and is
DD of breast lumps
definitively diagnosed by low platelet count in association with bone
marrow that shows thrombasthenia. Patients with this illness Lots of Surgery Pamphlets
experience abnormal bleeding during menstruation or nosebleeds or in
response to minor insults. Occasionally, a patient who bleeds
excessively after an auto accident is found to have undiagnosed ITP.
The usual therapy is initiated with prednisone, and some believe that
the prednisone response is predictive of success after splenectomy.
Approximately 80% of patients, however, require increasing doses of
steroids to maintain satisfactory platelet counts and ultimately
require splenectomy. Similarly, approximately 80% of patients achieve
normal platelet counts within 3 months after splenectomy, whereas
more than 90% are remitted from further bleeding episodes.

7. Splenectomy and perioperative therapy for ITP:

A. Follow successful steroid therapy.
B. Respond permanently to high-dose intravenous gamma globulin.
C. Are best preceded by polyvalent vaccines for Pneumococcus,
Haemophilus influenzae, and Neisseria meningitidis.
D. Cannot be done laparoscopically.
E. Are associated with splenomegaly.
Answer: C

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 8. Thrombotic thrombocytopenic purpura (TTP) is a syndrome
characterized by all of the following except:
A. Thrombocytopenia.
B. Microangiopathic hemolytic anemia.
C. Deposition of platelet microthrombi.
D. Fluctuating neurologic abnormalities.
E. Renal failure.
F. Afebrile.
Answer: F

DISCUSSION: This disease, sometimes called Moschcowitz's syndrome,

is characterized by thrombocytopenia, microangiopathy, chemolytic
anemia, fluctuating neurologic abnormalities, progressive renal
failure, and fever. Platelet deposits, with hyaline material composed
of aggregated platelets and fibrin, occur. The cause is unknown, and
the prognosis is very poor: survival is less than 10%. A combined
approach using antiplatelet drugs and corticosteroids can be effective
and sometimes has improved results if done with splenectomy.

9. Which of the following comments does not describe hypersplenism?

A. It may occur without underlying disease identification.
B. It may be secondary to many hematologic illnesses.
C. It is associated with work hypertrophy from immune response.
D. It requires evaluation of the myeloproliferation.
E. It is associated with antibodies against platelets.
Answer: E

DISCUSSION: Hypersplenism was described by Chauffard in 1907 and

initially was mostly associated with the syndrome in which a variety of
hematologic illnesses, ranging from sickle cell disease to the

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 leukemias, could be found to have improved circulating blood
elements if the spleen were removed. Diagnosis of these illnesses has
improved, and illnesses once classified as primary hypersplenism now
are frequently classified as secondary, as the primary mechanism
involved is known. The spleen may enlarge owing to differing
pathophysiologic mechanisms, but when it achieves a certain size, it
removes all of the main circulating cellular blood elements (red blood
cells, white blood cells, platelets). One element may be more deficient
than others.

10. Hyposplenism is a potentially lethal syndrome. Which of the

following statements is incorrect?
A. It is confirmed by isotope scan.
B. It is always associated with an atrophic spleen.
C. It may be associated with overwhelming post-splenectomy sepsis
syndrome (OPSS).
D. It is associated with thyrotoxicosis, corticosteroid administration,
and some contrast agents.
E. It may be associated with ulcerative colitis or sickle cell anemia.
Answer: B

11. Hodgkin's disease is a malignant lymphoma with four histologic

subtypes. Which of the following is not one of the subtypes?
A. Lymphocyte predominance.
B. Nodular sclerosis.
C. Mixed cellularity.
D. Lymphocyte depletion.
E. Leukocyte-lymphocyte dominance.
Answer: E

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 DISCUSSION: A variety of histologic conventions for the major
subtypes of Hodgkin's disease have been derived over the years. They
are useful in identifying the prognosis and predictions for morbidity
and mortality. The subtypes are further subdivided to provide more
precise association with therapeutic approaches, with identification
with various staging levels, etc.

12. Which of the following statements about lymphatic capillaries are

true?
A. These vessels have delicate tricuspid valves every 2 to 3 mm.
B. Lymphatic capillaries are more permeable than blood capillaries.
C. Lymphatic capillaries are less permeable than blood capillaries.
D. Lymphatic capillaries contain gaps large enough to admit particles
as large as lymphocytes.
Answer: CD

DISCUSSION: The transporting lymphatic vessels have valves but

lymphatic capillaries do not. The lymphatic capillaries will accept
particles including bacteria, red blood cells, and lymphocytes and
transport them to regional lymph nodes.

13. Which of the following forces do not promote the formation of

interstitial fluid?
A. Increased venous pressure.
B. Constrictive pericarditis.
C. Hypernatremia.
D. Hypoproteinemia.
Answer: C

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 DISCUSSION: Interstitial fluid production is a function of the
hydrostatic and colloid osmotic pressures across the capillary
membrane. Forces tending to increase interstitial fluid flux across the
capillary membrane include obstruction to outflow of the capillary due
to structural or functional obstruction in the venous system or
increase in venous pressure from any cause, reduction in osmotic
pressure due to hypoproteinemia, and increase in pore size due to
local mediators of inflammation.

14. The most frequent cause of primary lymphedema is:

A. A deficiency of transporting lymphatic channels.
B. Valvular incompetence in lymphatic channels.
C. Obstruction or removal of regional lymph nodes.
D. Thrombosis of lymphatic channels.
Answer: A

DISCUSSION: Primary lymphedema is most frequently due to

hypoplasia or aplasia of extremity transporting lymphatic channels.

15. Most patients with lymphedema can be managed by:

A. Pedicle transfer of lymphatic bearing tissue into the affected area.
B. Elevation, elastic support garments, and massage therapy or
mechanical pneumatic compression.
C. Lymphatic bypass using an autogenous vein graft.
D. Excision of hypertrophic scarred fibrotic skin and subcutaneous
tissue down to muscle fascia and coverage with split-thickness skin
grafts.
Answer: B

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 DISCUSSION: The vast majority of patients with mild to moderate
lymphedema can be managed with leg elevation and elastic support
garments, and some will require mechanical pneumatic compression
or massage therapy. Only patients with very severe deforming
elephantiasis require operative therapy.

16. Which statements about lymphangiomas are true?

A. Most lesions appear during puberty.
B. These lesions frequently respond to small doses of radiation
therapy.
C. The lesions usually grow slowly but may infiltrate local tissues.
D. Malignant transformation is frequent.
Answer: C

DISCUSSION: Lymphangiomas are congenital malformations of the

lymphatic vessels. Most appear at birth or during early infancy. The
lesions grow slowly and infiltrate local tissues, but actual malignant
degeneration is exceedingly rare. The lesions are not responsive to
radiation therapy.

17. The two primary causes of death from sickle cell disease in the
first decade of life are which of the following?

a. Sepsis
b. Splenic sequestration crisis
c. Acute chest syndrome
d. Heart failure
Answer: a, b

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 Sickle cell disease and thalassemia are the principal
hemoglobinopathies that cause clinically important disease. Clinical
symptoms are directly dependent upon the amount of HgbS present,
and this is variable. Patients who are homozygous for HgbS usually
have small sequential splenic infarcts as a result of microvascular
occlusion and the spleen usually becomes small, fibrotic, and
dysfunctional by the age of 5 years. Splenic sequestration crisis is a
cause of anemia that can be acute and life-threatening. Sepsis
associated with functional asplenia can be lethal as well. These are
the two primary causes of death in sickle cell disease during the first
decade of life.

18. The best therapy for a patient with thrombotic thrombocytopenic

purpura is which of the following:

a. Plasmapheresis
b. Corticosteroids
c. Splenectomy
d. Intravenous immune globulin
Answer: a

Thrombotic thrombocytopenic purpura (TPP) is a relatively rare

syndrome with no definitive diagnostic test or clinical characteristic.
The principal clinical features are thrombocytopenic purpura, fever,
microangiopathic hemolytic anemia, mental status changes, and renal
dysfunction. Treatment is generally focused on the removal of the
plasma constituents that lead to platelet aggregation. Plasmapheresis
is particularly effective and has decreased the 1-year mortality rate of
50% to 80% to about 10%. Splenectomy was initially proposed for TPP

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 but has been shown to have little benefit and instead is associated
with a considerable risk of postsplenectomy sepsis. Corticosteroids
and intravenous immune globulin are appropriate therapies for
immune thrombocytopenic purpura (ITP), but not TPP.

19. Which of the following statements regarding post splenectomy

sepsis are true?

a. The incidence in children is generally reported as less than 5%

b. Haemophilus influenzae, Streptococcus pneumoniae and Neiseria
meningitidis are the most common causative organisms
c. Autotransplantation techniques eliminate this risk
d. The mortality rate is now approximately 50%
e. The incidence in adults in approximately 1%
Answer: a, b, d, e

Postsplenectomy sepsis (PSS) refers to the increased risk of systemic

infection in patients who have undergone splenectomy. The incidence
of PSS in children is as high as 4% during a follow-up of nearly 10
years, and from 0.3% to 1.8% in adults during an 8-year follow-up. The
highest incidence of PSS is among those who have undergone
splenectomy for associated malignancies or who had an incidental
splenectomy during other surgical procedures in adulthood. In
children, the patients most at risk for PSS are those who have
undergone splenectomy for either congenital or acquired anemias. It
is important to remember that any patient who has undergone
splenectomy or who has hyposplenism is at risk for PSS.
The most common causative organisms are Streptococcus
pneumoniae, Haemophilus influenzae, and Neiseria meningitidis.
Other less common encapsulated organisms have also been identified.

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 In addition, organisms without classical polysaccharide cell walls can
occasionally produce overwhelming infection in postsplenectomy
patients. The mortality from PSS is approximately 50%. Splenic
autotransplantation has been proposed as an alternative means of
splenic preservation in patients whose spleens are too severely
injured for in situ repair. Splenic autotransplants do not appear to
have normal splenic function. Splenic autotransplants have diminished
ability to protect against PSS when compared to a normal spleen and
they have not been demonstrated to prevent post-splenectomy sepsis.

20. You are consulted regarding a 50-year old male with Laennec’s
cirrhosis, portal hypertension and hypersplenism. He has no history of
gastrointestinal bleeding. You would recommend which of the
following?

a. Splenectomy
b. Prophylactic sclerotherapy for esophageal varices
c. Portosystemic shunt
d. Observation
Answer: d

Patients with hypersplenism from portal hypertension usually present

with thrombocytopenia as the primary manifestation. The role of
splenectomy in such patients is controversial. Although splenectomy
may transiently increase the number of platelets in the peripheral
circulation, it generally does not improve survival. At the time of
surgery, these patients have considerable risk for massive bleeding
and subsequent complications related to hepatic dysfunction. These
latter complications include ascites, coagulopathy, and wound
complications. The severity of the underlying liver disease is the

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 determining factor for these patients. Some believe that splenectomy
is contraindicated in patients with portal hypertension. Indeed, the
perioperative risks are considerably greater than normal. This should
be considered as a last option, and even then with the realization that
the operative and preoperative morbidity and mortality are high.
In the absence of gastrointestinal bleeding, this particular patient has
no indication for either sclerotherapy or portosystemic shunting.

21. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an

abnormality of erythrocyte metabolism associated with hemolytic
anemia. Pharmocologic agents which induce hemolysis include which
of the following?

a. Acetylsalicylic acid
b. Vitamin E
c. Sulfamethoxazole
d. Desferrioxamine
e. Nitrofurantoin
Answer: a, c, e

Generally, G6PD deficiency is not clinically apparent; hemolytic

anemia occurs in most patients only after the consumption of certain
medications or exposure to specific chemicals. A partial list of
oxidizing agents known to induce acute hemolytic anemia in patients
with G6PD deficiency follows:
Acetylsalicylic acid (high dose)
Phenacetin
Nitrofurantoin
Sulfamethoxazole
Doxorubicin

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 Nalidixic acid
Acetanilid
Primaquine
Phenazopyridine
Methylene blue
Niridazole
Furazolidone
Fava beans
Splenectomy is rarely indicated in patients with G6PD deficiency.
Management generally is adequate simply by avoiding exposure to
precipitating agents. Vitamin E and desferrioxamine may be
therapeutic for G6PD deficient patients, presumably related to their
antioxidant activity.

22. Hypersplenism is associated with which of the following diseases?

a. Portal hypertension
b. Lymphoma
c. Mononucleosis
d. Systemic lupus erythematosus
e. Gaucher disease
Answer: a, b, c, d, e

Hypersplenism is not a specific disease but rather a physiologic state

characterized by splenomegaly, a decrease in circulating levels of
some blood cells or platelets, bone marrow hypertrophy in response to
the decrease in the circulating blood elements, and some degree of
improvement by splenectomy. Disease processes associated with
secondary hypersplenism include the following:
INCREASED VENOUS PRESSURE

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 Portal hypertension
Splenic vein thrombosis
Severe congestive heart failure
MALIGNANCY
Leukemias (especially chronic)
Lymphoma
CHRONIC INFLAMMATORY DISEASES
Felty syndrome
Systemic lupus erythematosus
Sarcoidosis
METABOLIC ABNORMALITIES
Amyloidosis
Gaucher disease
Niemann-Pick disease
INFECTION
Mononucleosis
Bacterial endocarditis
Parasites
Fungus
OTHER
Myelofibrosis with myeloid metaplasia
Polycythemia vera

23. A 40-year old woman with chronic immune thrombocytopenic

purpura (ITP) is refractory to corticosteroids. The approximate
likelihood she will benefit from a splenectomy is approximately which
of the following?

a. Less than 20%

b. 40%

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 c. 60%
d. 80%
Answer: c

Splenectomy remains the principal treatment for ITP. Platelet counts

rise to adequate levels in 60% to 80% of patients who undergo the
procedure. Ninety percent of patients who have had good responses
to corticosteroids have improved platelet counts after splenectomy.
Of patients who do not respond to corticosteroids, about 60% respond
to splenectomy. Splenectomy is effective by virtue of its ability to
remove the site of platelet destruction. Because the spleen is the site
of most platelet sequestration in ITP, splenectomy should eliminate
this source of platelet consumption. Furthermore, splenectomy
removes a significant source of antiplatelet IgG production.

24. Which of the following statements regarding splenic function in

humans are true?

a. The specific immune function of the spleen is principally related to

its antigen processing role
b. The spleen is the major site of synthesis of complement pathway
proteins
c. The spleen is more efficient than the liver at removing bacteria
with a high density of surface opsonins
d. The spleen serves as a principal source of nonspecific opsonins
Answer: a, d

Immune function of the spleen includes both nonspecific and specific

immune responses. Nonspecific immune function is largely
characterized by removal of particulate matter by the macrophages.

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 The spleen contains 25% of the fixed tissue macrophage population in
the body. The spleen is more efficient than the liver at removal of
incompletely opsonized bacteria. The liver is most effective at
removing bacteria with a high density of surface opsonins. The spleen
also serves as a principal source of nonspecific opsonins. These
include tuftsin, properidin, and fibronectin. Tuftsin stimulates
granulocyte and macrophage motility and phagocytosis. Properdin
activates the alternative pathway of the complement system, leading
to complement fixation. Both the activated complement complexes
and the complement products facilitate the destruction of the target
organism. Fibronectin is a macromolecule that appears to have
nonspecific stimulatory activity on the processes of fibrosis and
wound healing.
The specific immune functions of the spleen are principally related to
its antigen-processing role, and this is in turn dependent on its
unique anatomy and the circulation of lymphocytes into the spleen.
The liver, not the spleen, is the major site of synthesis of
complement pathway proteins.

Posted by MedCosmos at 5:30 PM

Labels: MCQ : Spleen

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