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APPROACH TO PATIENT WITH
SPLENOMEGALY
Thamer A. AL-TRAIKI
421000312
Normal Spleen
The median splenic weight in adults is about 150
grams. It is not usually palpable, but may be felt in
children, adolescents, and some adults, especially
those of asthenic build.
Patients with chronic obstructive pulmonary disease
and low diaphragms commonly have palpable spleens
The spleen is considered to be normal in size if
its length is <13 cm or its thickness is < or = 5
cm on ultrasound examination [J Gen Intern Med 1993; 8:69.]
In one study, 3% of college freshmen had palpable spleens;
an additional study showed that 5% of hospitalized patients
with normal spleens based on scan results were thought to
have palpable spleens by their physicians.
Palpable spleens are Not always abnormal.
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Enlarged Spleen
The spleen must be enlarged about 3 times to be
clinically palpable.
The enlarged spleen may be minimally ,moderate , or
massively enlarged.
A spleen which is only minimally enlarged will be quite
movable with respiration, and may be palpable only at
the end of inspiration. Using a light touch, with the
skin depressed under the left costal margin, a
minimally enlarged spleen can be felt as a rounded
edge with the consistency of normal liver, which slips
under the examiner's fingers at the end of inspiration
and back on expiration.
Massively Enlarged Spleen :
A spleen enlarged such that its lower pole is within the
pelvis, or which has crossed the midline into the right
lower or right upper abdominal quadrants.
2006 UpToDate
Causes of splenomegaly
1- Reticular endothelial hyperplasia
2- Gush of blood
3- Infiltration
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Symptoms
symptoms of an enlarged spleen may include one or
all of the following:
•Pain, a sense of fullness, or discomfort in the left upper quadrant
•Pain referred to the left shoulder
•Early satiety, due to encroachment on the adjacent stomach
Acute pleuritic-like pain and tenderness in the left
upper quadrant in the presence of fever suggests the
presence of perisplenitis or splenic abscess, most
likely due to infection originating elsewhere in the
body (eg, sepsis, bacterial endocarditis). The abscess
may be accompanied by infarction due to septic
emboli
Is this mass spleen or not ?
1- we can’t get above it.
2- anteriomedial notch
3- moves inferiomedial with inspiration
4- dull to percussion
5- not ballottable unless gross ascitis
Approach to patient with splenomegaly
Hx
Ex
Ix
Rx
Associated symptoms
•Febrile illness (infectious)
headache, dry cough, constipation , rash ,then diarrhea
night sweat , malaise ,cough , wt loss
travel hx
Associated symptoms
•Weight loss, constitutional symptoms (neoplastic)
•Pallor, dyspnea, bruising, and/or petechiae (hemolytic)
•History of liver disease (congestive)
•Pancreatitis
ON EXAMINATION
•Temperature
•Signs of cirrhosis (eg, jaundice, telangiectasias,
gynecomastia, caput medusa, ascites)
•Heart murmur (endocarditis, congestive failure)
•Jaundice
•Scleral icterus ( cirrhosis
•Petechiae (any cause of thrombocytopenia)
ON EXAMINATION
Associated hepatomegaly
Associated lymphadenopathy
Size of spleen
Massively Enlarged Spleen
•Chronic myelogenous leukemia
•Myelofibrosis, idiopathic or post-polycythemic
•Gaucher disease
•Lymphoma, usually indolent, including hairy cell leukemia
•Kala-azar (visceral leishmaniasis)
•Hyperreactive malarial splenomegaly syndrome
•Thalassemia major
•AIDS with Mycobacterium avium complex
Investigations
CBC and peripheral smear
Hb decrease in anemia while increase in polycythemia
WBC increases in infection , abscesses & leukemia
ESR increases in infection & malignancy
CBC and peripheral smear
•Neutropenia, anemia, and/or thrombocytopenia may be present,
as these formed elements can be trapped in an enlarged spleen,
giving the nonspecific picture termed "hypersplenism."
•The term hypersplenism describes some of the sequelae often
observed with splenomegaly.
•Criteria for a diagnosis of hypersplenism include the
following:
•Anemia, leukopenia, thrombocytopenia, or combinations
thereof, plus cellular bone marrow, splenomegaly, and
improvement after splenectomy
•Thrombocytopenia: Approximately 30% of the total platelet
mass exists as an exchangeable pool in the spleen. Increased
splenic platelet pooling is the primary cause of the
thrombocytopenia of hypersplenism. In patients with
hypersplenism, as much as 90% of the total platelet mass can be
found in the spleen. In hypersplenism, the platelet count is
usually 50,000-150,000/mL.
•Anemia: The etiology of the anemia observed in splenomegaly is
the result of sequestration and hemodilution.
•Leukopenia: Increased destruction or sequestration of leukocytes
causes the leukopenia observed in splenomegaly.
On occasion, invading organisms may be seen on the peripheral
smear, either free in the plasma as in overwhelming sepsis, or
within neutrophils or monocytes (bacteria, ehrlichiae) or red blood
cells as occurs with malaria
•In systemic lupus erythematosus, circulating LE cells can
occasionally be seen, while patients with neutropenia and
rheumatoid arthritis can have circulating large granular
lymphocytes
•The presence of increased numbers of abnormal cells in the
peripheral blood suggests the presence of a hematologic malignancy.
LFTs
U&E
Blood Culture
Stool Culture
Rheumatoid Factor
Paul-Bunnell test
Urine Culture
•Ultrasound: This is a noninvasive, highly sensitive, and specific
technique for the evaluation of spleen size.also may identify the cause
eg cyst
CT scan
CT scan is the study of choice for identification of inflammatory
changes.
CT scan is sensitive for detecting mass lesions,
infarcts, and cysts
Splenectomy or splenic aspirate/biopsy
In a series of 122 "diagnostic" splenectomies
performed for unexplained splenomegaly, splenic mass
lesion, or to accurately classify a lymphoproliferative
disorder detected but not further characterizable on
bone marrow or peripheral blood examination, the
most common pathologic diagnoses were :
•Lymphoma/leukemia — 57 percent
•Metastatic carcinoma/sarcoma — 11 percent
•Cyst/pseudocyst — 9 percent
•Benign/malignant vascular neoplasm — 7 percent
The spleen as a diagnostic specimen. Cancer 2001; 91:2001.
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History: The most common history is mild abdominal pain that is
vague in nature. Increased abdominal girth is less common. Early
satiety from gastric displacement occurs with massive splenomegaly.
Associated symptoms or signs may include the following:
•Febrile illness (infectious)
•Pallor, dyspnea, bruising, and/or petechiae (hemolytic process)
•History of liver disease (congestive)
•Weight loss, constitutional symptoms (neoplastic)
•Pancreatitis (splenic vein thrombosis)
•Alcoholism, hepatitis (cirrhosis)
The presence or absence of symptoms due to an
enlarged spleen depends on many factors, such as the
acuteness and nature of the underlying illness, as well
as the size of the spleen.
Thus, a minimally enlarged spleen secondary to an
acute viral infection may be quite tender, while a
markedly enlarged spleen in one of the chronic
myeloproliferative disorders (eg, polycythemia vera,
agnogenic myeloid metaplasia) may be totally
asymptomatic unless there is an episode of splenic
infarction.
The ability to palpate an enlarged spleen
depends upon several variables,
including:
1-The size of spleen
Minimally enlarged spleens may not be felt. In one study, all
spleens with an estimated weight (from scanning studies)
exceeding 300 grams were palpable, with the average estimated
weight of a palpable spleen being 285 grams[ Ann Clin Res 1974; 6 Suppl
15:1 ]. However some spleens weighing as much as 900 grams are
not palpable [ Am J Med 1972; 52:362.]
2- The body habitus of the patient. The spleen is easier to feel
in thin individuals and in those who do not have an increased
anterior-posterior thoracic diameter.
3- The skill of the examiner coupled with the ability of the
patient to cooperate during the examination.