SU28.10-12 | Hepatobiliary and Splenic Surgery — Assignment

CLINICAL SCENARIO

A 42-year-old man is admitted to the surgical ward following a road traffic collision in which he struck his left side against the handlebars of a motorbike. He complains of left upper quadrant pain radiating to the left shoulder tip. On arrival his pulse is 118/min and blood pressure 96/64 mmHg; there is tenderness and guarding in the left upper quadrant and bruising over the lower left ribs. He is given intravenous fluids and stabilises transiently. Two days later, while still an inpatient, a different patient on the ward — a 58-year-old man with cirrhosis from chronic hepatitis B — is found to have a 5 cm liver lesion on a surveillance scan, prompting the team to review the spectrum of focal liver disease. You are the intern asked to prepare a structured account integrating the trauma case and the focal liver lesion for the morning teaching round.

1. Applied anatomy of the spleen and the basis of splenic injury

Describe the position of the spleen relative to the left lower ribs and its blood supply, and explain why blunt left-sided trauma so commonly injures it and why injury produces left shoulder-tip pain.

Guidance: Locate the spleen under ribs 9-11; name Kehr's sign and the diaphragmatic/phrenic basis of referred shoulder pain. Note the fragile, highly vascular parenchyma.

2. Assessment and management of the splenic injury

Explain how you would assess this patient (ATLS principles, role of haemodynamic stability versus CT grade) and justify your management decision, contrasting non-operative management with splenectomy.

Guidance: Make explicit that stability — not the AAST CT grade — leads the decision. State when angioembolisation and when laparotomy/splenectomy are indicated.

3. Post-splenectomy sepsis prophylaxis

Assume this patient ultimately requires splenectomy. Describe the risk of overwhelming post-splenectomy infection (OPSI), the organisms involved, and the prophylaxis required, contrasting the vaccination timing for elective versus emergency splenectomy.

Guidance: Name the encapsulated organisms (pneumococcus, meningococcus, Hib). Emergency case → vaccinate post-op (~2 weeks); contrast with the elective ≥2-weeks-before rule and explain WHY each timing is chosen. Add penicillin prophylaxis and an alert card.

4. The focal liver lesion: differential and investigation

For the cirrhotic patient with a 5 cm liver lesion, construct a differential diagnosis of focal liver lesions (HCC, amoebic abscess, pyogenic abscess, hydatid cyst) and outline the investigations that distinguish them.

Guidance: Tie HCC to cirrhosis/AFP and dynamic CT (arterial enhancement, washout). Contrast amoebic (anchovy-sauce, metronidazole) vs pyogenic (gut/biliary source) abscess; flag the cystic-lesion-is-hydatid-until-proven-otherwise rule and the danger of blind aspiration.

5. Principles of management of the focal liver lesion

Outline the principles of management for each diagnosis you listed, emphasising the contrasting medical-versus-surgical logic and the safety reflexes (no blind aspiration of a cystic lesion; albendazole + PAIR for hydatid).

Guidance: Explain why amoebic abscess is medical, when to drain, why hydatid needs albendazole cover + PAIR/surgery, and the role of Couinaud anatomy in HCC resection (future liver remnant).