Spleen Disease (Hemangiosarcoma, Hematoma)
It is not uncommon for us to encounter problems with the spleen. Sometimes it just enlarges without any major problems, sometimes it twists on itself, sometimes it ruptures and causes internal bleeding, and sometimes it becomes cancerous. A rupturing spleen is called a hematoma. Cancer of the spleen is called hemangiosarcoma (abbreviated as HSA).
In breeds that have a high incidence of splenic cancer we recommend yearly exams starting at 5 years of age, with blood panels, radiographs and ultrasounds. This will enable us to catch this problem early before complications start and it spreads, since the prognosis is poor in most cancerous spleens because they have already spread by the time of diagnosis.
Unfortunately, some pets, especially large breed dogs, will not show any symptoms until the spleen is huge and possibly rupturing. A rupturing spleen is a medical emergency requiring immediate veterinary care. These dogs can collapse and go into life-threatening shock.
The Long Beach Animal Hospital, staffed with emergency vets, is available until the evenings 7 days per week to help if your pet is having any problems, especially collapse, seizures, fractures, shock, pain, breathing hard, or bleeding.
Think of us as your Long Beach Animal Emergency Center to help when you need us for everything from minor problems to major a major emergency. We serve all of Los Angeles and Orange county with our Animal Emergency Center Long Beach, and are easily accessible to most everyone in southern California via Pacific Coast Hwy or the 405 freeway.
If you have an emergency that can be taken care of by us at the Animal Emergency Hospital Long Beach always call us first (562-434-9966) before coming. This way our veterinarians can advise you on what to do at home and so that our staff and doctor can prepare for your arrival. To learn more please read our Emergency Services page.
You can see pictures of the surgery to remove large spleens in the surgery section later in this page. After that, there is a link to another page where we remove a 14# spleen hematoma!
Graphic and bloody surgical photos are on this page
We will use some medical terms regarding the spleen:
- Extra medullary hematopoiesis – The making of red blood cells outside of the bone marrow
- Reticuloendothelial system – in regards to the spleen, it is the system that recycles red blood cells
- Anemia – a low amount of red blood cells or hemoglobin
- Thrombocytopenia – a decrease in thrombocytes, which are an important part of the clotting factors when there is bleeding.
- Hemoabdomen – free blood in the abdomen
- Splenomegaly – enlargement of the spleen as a result of any cause
- Splenectomy – removal of the spleen
- Hypersplenism- an enlarged spleen that is normal and not causing any problem
The spleen is an elongated and relatively flat organ that resides in the abdomen of mammals along the outer edge of the stomach. It has a tremendous blood supply that is closely attached to the blood supply supporting the stomach. It is the largest filter of blood in the body.
It has an outer capsule composed of smooth muscle and elastic fibers. The internal part of the spleen (called the parenchyma) has white pulp and red pulp. The white pulp is lymphatic tissue and the red pulp is part of the venous blood system. In between these pulps is elastic tissue that can fill up as needed.
A normal spleen in a cat
A normal spleen in a small dog
A swollen spleen in a medium sized dog
The blood supply to the spleen is closely adjoined to the stomach. You can see the dark vertical blood vessels in this photo as they enter fat between the stomach and a very enlarged and dark spleen in a semi-circle at the far right.
Let’s have a little comparative anatomy fun and show you what the spleen of an Iguana looks like during surgery to remove eggs from her. As you can see it is more cylindrical in shape compared to the elongate shape in mammals.
The spleen has many functions. The four primary ones are:
- Storage of cells
- Production of red blood cells
- Filtration of the bloodstream
- Production of cells for the immune system
Iron that has been recycled from old red blood cells is stored in the spleen where it awaits transport to the bone marrow.
Fortunately, the body can get by without a spleen in most cases, so if there is a serious problem, and all other factors are equal, we will remove it. We tend to remove only spleens that are cancerous, rupturing, or have a torsion.
Splenomegaly is a generalized term that simply means enlargement of the spleen. In some species, like ferrets, an enlarged spleen can be normal, and is called hypersplenism. A spleen can be enlarged diffusely or it might have nodules in certain areas.
There are many causes for an enlarged spleen. The most common and important are listed in more detail below. Some of the more uncommon ones are due to infectious agents (erlichiosis, babesia, hemobartonella), FIP, medications, and immune mediated diseases.
This spleen has splenomegaly in addition to numerous nodules
In this problem the spleen twists on itself, compromising the blood supply. When the spleen twists the blood keeps on pumping into it by the arterial system, but this same blood is not able to leave through the venous system, and the spleen becomes grossly engorged.
It can occur on its own, after excessive exercise, or due to trauma. It can occur in conjunction with Gastric Dilatation Volvulus (GDV), also known as bloat. We tend to see this torsion, along with GDV, in large and deep chested breeds.
If the torsion is chronic, there might be no symptoms at all, or there might be:
- poor appetite (anorexia)
- weight loss
- discolored urine
- vomiting- might be intermittent
- weight loss.
Examination of a pet with splenic torsion might reveal:
- pale mucous membranes (gums)
- rapid heart rate (tachycardia)
- painful abdomen
- a large mass in the abdomen upon palpation
- jaundice (icterus)
A blood panel might reveal:
- low platelets (thrombocytopenia)
- elevated white blood cells (leukocytosis),
- elevated liver enzyme tests,
- hemoglobin in the urine (hemoglobinuria)
This disease is diagnosed by imaging tests when the above symptoms are present. A radiograph might reveal a mass in the abdomen with the spleen abnormally located. Ultrasound can confirm the problem and give us an idea of its severity.
A splenic torsion is considered an emergency, so the treatment of choice is surgical removal after a pet has been stabilized by treating for shock. On the deep chested breeds we might even tack the stomach to the abdomen to help prevent potential GDV in the future.
Some splenic masses that are cancerous are classified as benign, meaning they do not generally spread (metastasize), and only take up extra space within the abdomen. Even though they do not spread, sometimes this extra space they take up can interfere with other organs.
Some benign cancerous masses include lipoma (fatty tumors), hemangioma (associated with vasculature), and plasmacytosis (infiltration of plasma cells throughout the splenic nodule or tissue in general). Unfortunately, when a spleen has cancer it commonly is the malignant version called hemangiosarcoma and not this benign version.
The most common malignant tumor in the spleen is the hemangiosarcoma (HSA). It is also called malignant hemangioendothelioma). The cause is not known. It can spread to many different organs, making it highly malignant:
HSA can also cause complications, such as disruption of the coagulation cascade which causes a mixture of abnormal clot formation as well as inability to control internal bleeding (known as disseminated intravascular coagulation, DIC).
Symptoms of HSA vary, and range from mild to severe. In extreme cases sudden blood loss can lead to sudden death.
These large nodules on this spleen are a malignant cancer called hemangiosarcoma
Another common type of malignant splenic cancer is lymphosarcoma, a type of cancer that can have a primary tumor in any other organ (i.e. lung, gastrointestinal tract, liver). Lymphosarcoma is one of the more common tumor types observed in the spleen of cats. Sometimes the tumor within the spleen is not even the primary tumor, but rather a single nodule or multiple nodules due to metastasis from a distant primary tumor.
Hematomas are one of the most common causes of an enlarged spleen in dogs, representing over 50% of splenomegaly cases. This type of splenic mass is basically an accumulation of pooled blood within the splenic tissue; many stop growing and are then resorbed after a period of time, but others grow exponentially and eventually rupture.
A ruptured hematoma originating from the spleen is an emergency, and often the pet experiences an acute collapsing episode followed by a significant loss of blood into the abdomen (hemoabdomen). You can see the surgery of a dog with an 8 pound hematoma later in this page
A spleen hematoma that has ruptured
Congestions of the spleen can occur from iatrogenic causes, which are those associated with administration of certain drugs (i.e. anesthetic agents or tranquilizers). Congestion can also occur due to increased blood pressure within the vasculature of the liver (known as portal hypertension), which can occur secondary to congestive heat failure among others.
The spleen can over-react to particular conditions, resulting in a disease process known as hyperplastic, or reactive, splenomegaly. A spleen can become reactive when there is excessive stimulation of the immune system from conditions such as immune-mediated disease, bacterial infections, tick-borne diseases, and many more.
This spleen has a laceration
Dogs, cats, and ferrets can get splenic diseases, although it is much more of a problem in dogs. Splenomegaly itself can occur in most any age due to the numerous causes of the condition. For instance, if the cause of splenic enlargement is infectious, then the pet may be quite young.
However, if the enlargement is cancerous, the pet tends to be middle aged (average 10 years in dogs). Due to the wide range of causes, there is no known gender predilection (males tend to be affected equally as often as females). Certain disease processes tend to be over-represented by specific breeds:
Splenic torsion tends to occur in large breed, deep-chested dogs:
Splenic tumors like HSA tend to occur in several breeds. It can be some common in some breeds that we recommend physical exams, blood work, abdominal radiographs, and especially abdominal ultrasounds, yearly in these dogs as they reach 5 years of age:
- German Shepherds
- Golden Retrievers
- Portugese Water Dogs
- English setters
- English pointers
- Great Danes
- Skye Terriers
- Bernese Mountain Dogs
In many cases, a patient with splenic disease has very little or no specific clinical signs. Observations made by owners at home might include non-specific indicators of illness:
- weight loss
- discolored urine
- abdominal distention
Upon palpation of the abdomen, significant abnormalities of the spleen can usually be detected, especially when a large mass is present within the cranial aspect of the abdomen (toward the chest). However, a mass or enlarged organ in the cranial abdomen cannot always be differentiated from a mass or enlargement of the liver.
In some cases, decreased pallor (pale gums) can be a sign of anemia or shock, which in combination with an abdominal mass can indicate a ruptured splenic mass or torsion. We confirm this with an ultrasound before surgery.
If the gums are pale, certain diseases of the spleen may lead to free blood in the abdomen, which can sometimes but not always be detected by palpation of a fluid wave.
Other generalized signs might include weakness, fever, dehydration, poor pulses, increased heart rate (tachycardia), increased bleeding at site of blood draw (due to coagulopathy), and/or increased size of peripheral lymph nodes.
The peripheral lymph nodes can be palpated. This dog is getting its submandibular lymph nodes checked. We have an In-Home Exam Page where we teach you how to check these lymph nodes on your own for early warning sign of disease. Next time you come to the hospital we can demonstrate how to find them on your pet.
Many lymph nodes are internal, and can be seen only with special imaging like ultrasound. This mesenteric lymph node. that lays within the small intestines, is being measured to determine if it is larger than normal. This enlargement could a sign that it is doing it job normally fighting inflammation or an infection. Unfortunately, it far too often is a sign of malignant cancer.
Some diagnostic tests which provide significant information include radiographs, blood work, ultrasonography, evaluation of the cells (cytology) through a fine-needle aspirate sample, and surgical exploration.
The arrow points to what a spleen looks like on a radiograph. It is enlarged, although a lobe of the liver can easily overlap the spleen and make the spleen look enlarged. So in this case, technically it’s called hepatosplenomegaly.
The arrow points to a normal spleen
Here is a dog with an enlarged spleen. Can you see it?
The red circle delineates the enlarged spleen.
L.I. – Large Intestine
Blood work (clinical chemistry and complete blood counts) is a crucial component for detection of compromised organ function. Splenic involvement might reveal anemia (decreased red blood cells), thrombocytopenia (decreased platelets for clotting), leukopenia (decreased white blood cells) and reticulocytosis (increased immature red blood cells to indicate that the body is trying to compensate for the loss of mature red blood cells).
This is a blood panel that might be seen with splenic disease, although many other diseases can also cause this type of blood panel. The primary problem in this blood panel is anemia.
Red blood cells (RBC), Hemoglobin (HGB), and Hematocrit (HCT) are all low in this dog
If abdominal fluid is present we can remove it and analyze it. This is called abdominocentesis. There is no guarantee this will make a diagnosis since many cancers, including HSA, might not be found in this fluid. If we take a radiograph and see fluid we might perform abdominocentesis to see if the fluid is blood. This helps us determine if there is a ruptured or bleeding spleen.
Tapping the abdomen allows us to see what kind of fluid is present and also to send it in for analysis. It is also therapeutic for the pet when the fluid causing distention of the abdomen is no longer pressing on sensitive internal organs.
Ultrasonography has revolutionized diagnosis in animals, and prevented many unnecessary exploratory surgeries (called celiotomies or laparotomies), while at the same time alerted us to the fact that we need to do immediate surgery. Keep in mind, our patients do not talk to us, and an enlarging tumor in the abdomen in one of us humanoids would be uncomfortable, and cause us to seek medical care long before we see a dog or cat with a tumor growing in the abdomen.
Ultrasonography of the abdomen is an important modality for diagnosis of splenic disease because of its sensitivity to changes of organ size, shape, location, and even texture. An ultrasonographic examination in combination with radiographs provides a comprehensive understanding of which organs are involved and often helps to narrow the possibilities down to a select few differentials.
We use ultrasound to confirm our suspicions of a splenic tumor based on the breed, history, exam findings, and blood panels and radiographs. Ultrasound confirms the diagnosis, lets us know if the spleen is already rupturing, tells us the size of the spleen, and if there are any other internal organ problems.
What an ultrasound of the spleen look like
Ultrasound of a different spleen
A splenic nodule
A typical ultrasound report on a dog with a cancerous spleen
A critical component of the ultrasonographic exam in HSA is echocardiography (evaluation of the heart). A key site of metastasis associated with hemangiosarcoma is the right atrium. HSA that has spread to the right atrium of the heart is a serious sign, and the prognosis is not good. This is important information if we are thinking of surgical removal of the spleen.
This ultrasound of the heart (echocardiogram) shows spread of the tumor to the right atrium, which is a poor prognosis
RV- Right ventricle
RA- Right atrium
Aspiration of the cells in an organ for cytological exam by a pathologist is an important part of most abdominal ultrasounds. It helps prevent an exploratory surgery, and can lead to a diagnosis in many cases. Cytologic evaluation of splenic problems is not always indicated and can sometimes be contraindicated depending on certain disease processes.
Certain cancers of the spleen, as well as hematomas ,may result in significant blood loss if stuck with a needle due their fragile nature. Even though the ultrasound guides the biopsy location, if the disease process only involves a small portion of the splenic tissue, or is sporadically located throughout, then a small needle-sized sample may not obtain the affected tissue at all.
We run a clotting panel on these patients before doing any ultrasound guided aspiration or biopsies to minimize any chance of internal bleeding from the needle.
This is a normal clotting panel. APTT is Activated Partial Thromboplastin Time
This tests the electrical activity of the heart. In some HSA’s there will be an arrhythmia that needs to be monitored closely during anesthesia for surgery.
This is an example of an arrhythmia
Histopathology is the analysis of the spleen microscopically by a pathologist after it is removed. This gives us our final diagnosis.
Surgery is a common treatment for splenic disease. Removal is called a splenectomy. If there is trauma or a problem in only a small part of the spleen, we might do a partial splenectomy since we always want to preserve as much function of the spleen as possible. This partial splenectomy is not common.
We do the surgery to remove the tumor, and if malignant add chemotherapy to help prevent spread after we do the surgery. Prior to surgery we do an ultrasound of the heart as already mentioned, and also take chest radiographs to check for spread of a tumor.
We also perform a clotting panel since blood loss is common in this surgery and we do not want post operative bleeding.
Unfortunately, survival time for dogs and cats with surgery alone HSA is only 1-3 months, with most dogs dying due to spread of the HSA to other organs, causing these organs to malfunction. This emphasizes the need for an early diagnosis in the breeds prone to this cancer.
Dogs that have surgery to remove the spleen, and that are also treated with chemotherapy, might survive up to 9 months. This depends on whether the tumor has spread, and again emphasizes the need for an early diagnosis. Dogs and cats have less side effects than people on chemotherapy, and their quality of life is high if this therapy is instituted immediately after surgery.
Dogs that are diagnosed at a young age, have had the HSA rupture prior to surgery, have evidence of spread to other organs when the splenectomy is performed, or have a more aggressive grade of tumor, do not tend to live 9 months after surgery.
The primary chemotherapy drug for HSA is Adriamycin (doxorubicin). It will slow the disease process, but it will not cure your pet of this disease. The doctors at the Veterinary Cancer Group in Tustin institute this therapy.
If a pet is anemic, or we anticipate significant blood loss during surgery, we will give a blood transfusion prior to surgery or during the procedure. Post operatively if a pet is not doing well we will give a blood transfusion also.
The first step in a blood transfusion is to do a crossmatch from recipient to donor to minimize the chance of a transfusion reaction. Dog’s have no iso-antibodies, so you can give a dog one transfusion with minimal risk of a reaction. Unless we have an emergency and time is of the essence, we prefer to test for a reaction.
The crossmatch involves a series of steps with tubes like these
A unit of whole blood
Pre-anesthetic preparation is important in every surgery we perform, no matter how routine, because surgery is not an area to cut corners. Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin.
Once our surgeon has reviewed all lab data, and has performed the pre-anesthetic physical exam, he starts his aseptic scub while our patient is being anesthetized
After scrubbing and gowning our surgeon opens the sterile instrument pack to make sure everything is in order and all instruments are sterile
While all of this is transpiring with our surgeon our patient is brought into the surgery suite and a final prep is performed. We want our surgeon waiting for her patient, not the other way around. All of this is to minimize anesthetic time.
When everything is to our satisfaction we will administer a sedative. This will calm her down and make the administration of the actual anesthetic, along with post operative recovery, much smoother. Many pets with Fentanyl patches do not need any additional sedative.
We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem. This machine monitors:
Carbon dioxide level
This is the screen we constantly monitor during surgery
The background noise you here in this video is the oxygen generator
In addition to our monitoring equipment, our nurse anesthetist stays “hands on” in monitoring important physiologic parameters like heart and respiratory rate and quality
She also checks something called Capillary Refill Time to make sure the heart is pumping enough oxygenated blood to the organs. When she presses on the gums to make them blanch white for a second, she measures how long it takes them to go back to their original pink color. It should be less than two seconds.
We have a detailed page on anesthesia to learn much more on how we anesthetize a wide variety of different species (like the duck below) at our hospital.
Modern anesthetics allows us to safely anesthetize high risk animals like this duck with a fractured wing. You can see her surgery in our Wildlife Care page.
A splenectomy is performed to treat and sometimes cure this problem. It is sometimes done as an emergency procedure if the spleen has ruptured and there is significant internal bleeding.
Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin.
To minimize anesthetic time we routinely have 2 doctors working as a team performing the splenectomy. They work together as a well orchestrated team.Our patient is under anesthesia and our surgeons are completing the draping process while our anesthetist is adjusting the surgical lights.
By working together early in the surgery we minimize anesthetic time
Special care is taken on entering the abdomen to minimize blood loss. There is minimal bleeding at this point as our surgeon gently dissects the sub Q (subcutaneous) tissue just under the skin.
As the surgery progresses we sometimes encounter significant bleeding from blood vessels in the sub Q fat and from muscles that are cut. All of them are clamped or cauterized before proceeding further. For a pet that might already be anemic this added blood loss is important to control, and it is stopped immediately.
When all bleeders are under control (called hemostasis) we enter the abdomen. We make our incision at a specific spot in the abdominal muscles called the linea alba. It is at this spot that there are minimal blood vessels. The linea also has strong tendinous attachments to the muscle, so when we sew it back together these tendons attachments have more holding ability than the abdominal muscles alone. This will prevent a hernia.
Our first view of the spleen once we have entered the abdomen. It is the round and reddish structure at the top of the abdominal opening and just to the left of our surgeon’s finger.
Our surgeon gently starts the process of bringing the spleen out of the incision with the of the assistant surgeon
A spleen that is not healthy is friable and can easily rupture when handled. Our surgeon has to gently coax it out to prevent this from happening.
Once it is finally exteriorized the problem is obvious. At this point we do not know if it is cancerous or not. We do know it is in the process of rupturing and glad we are getting it out now.
Now that we have it ready for removal we have to ligate its blood supply. As you remember from your surgical anatomy above the blood vessels to the spleen are closely related stomach. It is important to ligate the blood supply very close to the spleen so as not to compromise the blood supply to the stomach, leading to serious consequences.
This blood supply can be surrounded by fat. We have to isolate segments before we ligate.
In the center of this picture you can see one blood vessel that is already ligated. On the right our surgeon is in the process of ligating another blood vessel.
We have completed 3 ligations at this point, with many more to go
Our surgeons work simultaneously, each starting at a different end of the spleen, so they can complete this tedious part of the surgery sooner. It’s all about secure ligation of these blood vessels and minimal anesthetic time.
As part of the natural healing process there is a tissue in the abdomen called omentum. It is like a net, and surrounds an organ that might be diseased. For example, a ruptured intestine that is leaking intestinal fluid (extremely irritating to the abdomen and will cause a peritonitis), will have this net surround the intestine to wall off the leak.
In the case of this rupturing spleen the omentum covered the spleen to help prevent further blood loss. These are clots on the omentum from that. At this point in time during the surgery we cannot determine for sure if these are clots or spread of tumor. The report from the pathologist will tell us for sure. It turns out that this time they are clots.
When the spleen is completely removed we complete our exploratory surgery by checking the other internal organs, especially the liver. Once this check is complete we suture the muscle layer (the linea alba) closed. Again, we work as a team, with each surgeon (they are both lefties) suturing the linea until they meet in the center.
This is a long incision that is painful. At this point we also inject local anesthetic on the incision line so our patient awakens pain free. We also use our Therapy Laser on the incision for post operative pain.
Once we have finished suturing our patient, who is already on a pain patch (Duragesic or Fentanyl patch- which is removed in 3 days), is given an additional pain injection and carefully monitored post-operatively.
As part of the monitoring we perform a simple blood panel to make sure there was no problem with blood loss during surgery. If the blood loss is significant we will give a blood transfusion with the blood we have already set aside specifically for this patient.
Occasionally we come across a spleen that is so large it is hard to believe it can get this big. The following spleen was over 8 pounds, removed for a 65 pound labrador named Jake. Dr. P and Dr. R had to do this one together.
The size was obvious as soon as we entered the abdomen. Removing it was like delivering a baby! At this point in time we were not sure if it was a boy or a girl!
Dr. P is coaxing it out of the abdomen at the beginning of the surgery, being very careful not to rupture it
He had to be very gentle because it was quite delicate(friable) and already rupturing
Ligating the blood vessels to the spleen was more difficult than usual because of the size, scar tissue, and the omental tissue that covered the rupturing spleen
It turns out that this was a hematoma and the dog did fine for several more years. Lucky this spleen did not rupture before the surgery. Most likely, with a hematoma this large, death would have ensued rapidly.
As big as that one was, it is still not as big as this one, that weighed 14 pounds. Click on the X-Ray picture below to see the whole case from beginning to end, including the surgery.
That is 14# of tumor in one dog!
This is that 14# lighter labrador and his happy owner on his recheck exam two weeks later
After surgery we will consult with the oncologists at the Veterinary Cancer Group for further treatment Post Surgical Treatment
A successful outcome from surgery depends on what disease process is present and how long it has been present.
- Splenic Hematoma – good
- Splenic Torsion – good
- Hemangiosarcoma – guarded to poor
We routinely monitor our post-splenectomy HSA patients every few months with exams, blood panels, radiographs, and ultrasounds due to the highly malignant nature of this disease and the potential for metastasis (spread to other organs).