APPROACH TO PATIENT WITH SPLENOMEGALY

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APPROACH TO PATIENT WITH SPLENOMEGALY
Thamer A. AL-TRAIKI
421000312
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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 lt13 cm or its thickness is lt or
  5 cm on ultrasound examination
J Gen Intern Med 1993 869.
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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.
http//www.emedicine.com/med/topic2156.htm
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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.
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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
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Causes of splenomegaly
1- Reticular endothelial hyperplasia
2- Gush of blood
3- Infiltration
http//www.utdol.com/application/search.asp
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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
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Is this mass spleen or not ?
1- we cant get above it.
2- anteriomedial notch
3- moves inferiomedial with inspiration
4- dull to percussion
5- not ballottable unless gross ascitis
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Approach to patient with splenomegaly
Hx
Ex
Ix
Rx
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Associated symptoms

• Febrile illness (infectious)

headache, dry cough, constipation , rash ,then
diarrhea night sweat , malaise ,cough , wt
loss travel hx
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Associated symptoms

• Weight loss, constitutional symptoms (neoplastic)

• Pallor, dyspnea, bruising, and/or petechiae
  (hemolytic)

• History of liver disease (congestive)

• Pancreatitis

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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)

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ON EXAMINATION
Associated hepatomegaly
Associated lymphadenopathy
Size of spleen
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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

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Investigations
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CBC and peripheral smear
Hb decrease in anemia while increase in
polycythemia
WBC increases in infection , abscesses leukemia
ESR increases in infection malignancy
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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

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• 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.

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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
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• In systemic lupus erythematosus, circulating LE
  cells can occasionally be seen, while patients
  with neutropenia and rheumatoid arthritis can
  have circulating large granular lymphocytes

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• The presence of increased numbers of abnormal
  cells in the peripheral blood suggests the
  presence of a hematologic malignancy.

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LFTs
UE
Blood Culture
Stool Culture
Rheumatoid Factor
Paul-Bunnell test
Urine Culture
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• 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
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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
912001.
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Thank You
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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)

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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.
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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 151
. However some spleens weighing as much as 900
grams are not palpable Am J Med 1972 52362.
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• 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.