Clinical Cases - Stomach & Spleen

A 42-year-old business executive was admitted to the hospital after visiting the emergency room complaining of severe epigastric pain and pain over her right shoulder. She had a history of gastric ulcer which had been treated previously with medication, but on questioning, she admitted that she had been so busy recently that she had forgotten to refill her prescription and had not taken her medication in some time. As a result of the history and physical findings, the physician suspected that she was suffering from a perforated gastric ulcer. Gastroscopy was performed which confirmed the diagnosis. When the surgeon examined the patient's stomach during the surgery, she found a small perforation on the posterior aspect of the body of the stomach near the lesser curvature. The perforation was repaired and, in addition, a vagotomy was performed. During the vagotomy, the surgeon found it necessary to cut the left gastric artery and ligate it.

Questions to consider:
  1. What structures are at risk for damage by gastric juices if a perforation like the one described above occurs?
    Any structure located posterior to the stomach could be damaged by gastric juices leaking from a perforated ulcer on the posterior wall of the stomach. These organs would include the pancreas, the left suprarenal gland, the upper part of the left kidney, the diaphragm, the splenic artery, and its branches, and maybe the spleen. Erosion of the wall of the splenic artery is of particular concern because it could lead to severe internal hemorrhage and rapid exsanguination.
  2. Why did the patient experience pain over her shoulder as well as in her abdomen?
    The shoulder pain was likely referred pain that occurred due to irritation of the diaphragm by gastric juices. The diaphragm is innervated by the phrenic nerves which arise from cervical nerves 3, 4, and 5. These cervical nerves also contain nerves that innervate the shoulder region; thus, the shoulder is a common location for referred pain from the diaphragm.
  3. What is a vagotomy and why was it performed?
    A vagotomy involves severing some or all of the branches of the anterior and posterior vagal trunks. In severe cases of gastric ulcer, this procedure is sometimes performed to reduce the acid secretion of the stomach, which is stimulated, in part, by parasympathetic innervation provided by the vagus nerves. A partial gastrectomy, which involves removing the antrum of the stomach, may also be performed for this purpose.
  4. Since the left gastric artery had to be ligated during the surgery, how will the stomach obtain an adequate blood supply?
    If the left gastric artery is occluded due to surgical ligation or some other event, collateral circulation from the right gastric artery (a branch of the proper hepatic artery), right gastroomental artery (a branch of the gastroduodenal artery), and the left gastroomental and short gastric arteries (branches of the splenic artery) is usually adequate to compensate for loss of flow through the left gastric artery.
  5. Variations in the arteries of the celiac trunk are quite common, and thus are of particular interest to surgeons working in this area. Suppose the common hepatic artery originated from the left gastric artery in this case (an uncommon, but possible, variation) and the surgeon had to ligate the left gastric artery proximal to the bifurcation. How would this affect blood flow to the stomach? to other organs?
    The anatomic variation described in this question is probably quite rare, but if the common hepatic artery did originate from the left gastric artery and the left gastric were ligated, the only blood flow to the stomach would be through the left gastroomental artery from the splenic artery (unless there was retrograde flow into the gastroduodenal artery from the superior mesenteric artery, which we will learn later). This may not be sufficient for the stomach's survival. In addition, critical blood flow to the liver, gall bladder, duodenum, and pancreas would be interrupted, leading to the death of the patient unless blood flow was promptly restored.

A twenty-six year old female presents to your Emergency Room after a motor vehicle accident. The patient reports that she was a pedestrian on South University Avenue and while crossing the street was struck by a car. The patient's only complaints are abdominal tenderness and left shoulder pain. On physical exam you note that her vital signs are: blood pressure (BP) 90/60, heart rate (HR) 110, and respiratory rate (RR) 12. Her abdomen is tender on palpation of the left upper quadrant, with a faint tire mark over that area; in addition you detect crepitus (indicating fractured ribs) over the 9th,10th, and 11th ribs on the left side. You order a CBC which demonstrates an increased white blood count and a decreased hematocrit. You perform a diagnostic peritoneal lavage (DPL) and order a CT . The DPL has a bloody drainage (through which you cannot read a newspaper) and CT confirms a complete splenic rupture and fractured ribs. The patient is taken to the O.R. for a splenectomy , and a pneumococcal vaccine is delivered to the patient.

Questions to consider:
  1. What overlying structures protect the spleen?
    Ribs 9, 10, and 11 lie over the region of the spleen; the spleen cannot normally be felt on deep palpation below the costal margin, unless significantly enlarged .
  2. What other structures lie within this quadrant and are at risk for injury?
    Stomach, splenic flexure of the colon, tail of the pancreas, left kidney, and suprarenal gland, as well as the spleen.
  3. What is the major arterial supply of the spleen ? What other major branches arise from this artery?
    The splenic artery, a branch of the celiac trunk, is the major arterial blood source to the spleen. The branches of the splenic artery include the left gastro-omental, and the short gastric arteries.
  4. What is the major vein that drains the spleen, and what is its course?
    The splenic vein drains the spleen. It leaves the hilum of the spleen to join the inferior mesenteric vein, which then joins the superior mesenteric vein to form the portal vein.
  5. What are the signs and symptoms of acute splenic rupture?
    Hypotension, left upper quadrant pain, peritoneal irritation, and referred pain to the left shoulder.