Approach to splenomegaly


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Approach to splenomegaly

  2. 2. INTRODUCTION  Definition & symptoms  Classification  Hypersplenism  Etiology  Step-wise approach  Associated features  Investigations
  3. 3.  Galen –source of black “black bile‟ or  “melancholia”
  4. 4. NORMAL SPLEEN  Normal size – 12 cm length , 7 cm width (radionuclide scan) -13cm craniocaudal diamtr (USG)  weight- < 250gm  Located along- 9th, 10th,11th ribs mid-axillary  Spleen should be twice the size to be PALPABLE  Palpable spleens are not always ABNORMAL  3% normal population has palpable spleen
  5. 5. FUNCTIONS  Quality control over RBC – culling & pitting  Synthesis of antibodies  Removal of antibody coated bacteria & RBC
  6. 6. EXAMINATION OF SPLEEN  Inspection  Percussion – nixon method - rt.lateral ducubitus, > 8cm - castells method supine,lower ICS ,full exp & insp splenomegaly=dullness - traubes sign supine,6th rib,costal margin, anterior axill. line splenomegaly= dullness  Palpation - bimanual method,hooking maneuver
  9. 9. DIFFERENCES  Sharp edge  Notch –med border  Cross midline  Moves with respiration  Cannot get above it  Round edge  No notch  Not cross midline  Not moves with resp.  Can get above it spleen kidney
  10. 10. SPLENOMEGALY  Mild,moderate,massive  Massive - beyond umblicus, crosses mid line into pelvis (>8cm)  Moderate- b/w costal margin & umblicus (4-8cm)  Mild - just palpable (1-3cm)
  11. 11. HYPERSLENISM  Splenomegaly  Pancytopenia  Presence of hypercellular marrow  Reversal with splenectomy
  12. 12. SYMPTOMS OF SPLENOMEGALY  Pain  Early satiety  Feeling of heaviness in LUQ
  13. 13. MECHANISM OF SPENOMEGALY  Reactive Reticulo-endothelial hyperplasia  Lymphoid hyperplasia  Proliferation of lymphoma cells  Infiltration by abnormal cells  Extramedullary hemopoeisis  Proliferation of macrophages d/t RBC destruction  Vascular congestion
  14. 14. CAUSES OF SPLENOMEGALY  Infective  Hyperplastic  Congestive  Infiltration
  15. 15. INFECTIVE  Acute & subacute- IMN, infective endocarditis, severe pyogenic inf. Viral hepatitis,CMV,AIDS  Chronic - TB,syphilis,brucellosis  Tropical splenomegaly  Malaria,kala azar, trypanosomiasis
  16. 16. CONGESTIVE  Intra hepatic obst.portal hypertension - cirrhosis,biliary cirrhosis,hemochromatosis - primary sclerosing cholangitis  Extra-hepatic portal hypertension - venous malf,thrombosis,stenosis - ext.occlusion of portal,splenic vein  Chronic passive congestion of cardiac origin
  17. 17. HYPERPLASTIC  Extramedullary hemopoeisis- myeloprolif.d/s - marrow damage - marrow infiltration  Reticulo endothelial hyperplasia –(abn.RBC) - sickle cell d/s,spherocytosis,Hbnopathies, thalassemia major,PNH
  18. 18. INFILTRATIVE  Malignant infiltration- CML,lymphoblastic - lymhomas, MPD, - angiosarcoma,tumors - metastasis (melanoma)  benign - - storage d/s –Gaucher‟s,Neiman-pick - amyloidosis - hurler‟s syndrome,MPS - cysts,fibromas,hemangiomas,hamartomas -Eosnophilic granulomas
  19. 19. DISORDERED IMMUNOREGULATION  Felty‟s syndrome- RA+ splenomegaly+leucopenia  Systemic lupus erythromatosis  Collagen vascular diseases  Sarcoidosis  Immune thrombocytopenia
  20. 20. MASSIVE SPLENOMEGALY (>8CM >1000GM)  Myeloproliferative disorder  Chronic malaria,kala-azar (trop. Splenomegaly)  Storage disorders  Thalassemia major  Sarcoidosis  Hairy cell leukemia  Gaucher disease  Diffuse splenic hemangiomatosis
  21. 21. MODERATE SPLENOMEGALY(4-8CM)  Cirrhosis  Lymphomas„  Amyloid  Splenic abscess,infarct  Hemolytic anemias  IMN
  22. 22. MILD SPLENOMEGALY (1-3CM)  Acute infective conditons  Acute malaria,tyhoid,kala-azar,septicemias
  23. 23. STEP-WISE APPROACH TO SPLENOMEGALY  History  Physical examination  Laboratory testings  Imaging  Specialised testing
  24. 24. HISTORY  Age ,gender  Race  h/o recent infections like malaria  Fever,weight loss,sweating (lymphomas,infections)  Pruritis  Abnormal bleeding/bruising  Joint pain  h/o alcholism  h/o trauma  h/o neonatal umblical sepsis  Residence & travel abroad
  25. 25. HISTORY …..CONT  Jaundice  High risk sexual behavior (AIDS)  Past medical history  Drugs
  26. 26. PHYSICAL EXAMINATION  Size of the spleen  Hepatomegaly  Lymphadenopathy  Fever  Icterus  Bruising,petechiae  Oral & supf.sepsis  Stigmata of liver disease  Stigmata of RA/SLE  Splinter hemorrhage,retinal hemorrhage  Cardiac murmurs
  27. 27. LAB INVESTIGATIONS  CBC  Blood smear  Retic count  Blood C/S  Serology (fungal,viral,parasitic)  LFT  Hb electropheresis/ coombs test  Coag.profile  Amylase/lipase  AMA, Anti CCP,RA factor  Bone marrow analysis
  28. 28. IMAGING  USG- sensitive & specific non-invasive  CT scan – etiology of splenomegaly - liver size,heterogenecity - splenic mets, abscess,calcf.,cysts - retro peritoneal LN - craniocaudal ln > 10 cm  Liver- spleen colloid scan- (RBC –Cr51,Tc99) - hepatic steatosis,SOL,splenic functions - PHT,colloid shift +  MRI/ Doppler usg- portal/splenic vein thrombosis - cavernomas
  29. 29. IMAGING  MRI scan- liver hemangiomas hemochromatosis erlenmeyer flask sign(Gaucher)  PET scan - Dx & staging of lymphomas - determine metabolic cells in spleen
  30. 30. SPECIALISED TESTING  Abd.fat pad aspiration  JAK-2 mutation  Gene testing(bcr-abl ,C282Y)  Enzyme testing  Lymph node biopsy  FNAB spleen  Splenectomy  Lung or skin biopsy  Liver biopsy
  31. 31. SPECIAL SITUATIONS ASSOCIATED WITH SPLENOMEGALY  Fever- typhoid,malaria,kalaazar, infect.endocarditis, leukemia,lymphoma  Tender spleen- rupture,abscess,infarct  a/c illness+ anemia- AIHA,leukemia  Fever + LN- IMN,leukemia,lymhomas,SLE,sarcoid  Anemia- hemolytic anemia,hemoglobinopathies  Jaundice – cirrhosis,hemolytic anemia  Pulsatile spleen- aneurysm  High ESR- connective tissue disorder  Leukopenia- felty‟s syndrome,septicemia
  32. 32. TROPICAL SPLENOMEGALY (HMS)  Massive splenomegaly  Endemic areas of malaria,kala-azar  IgM antibodies +  No parasite in blood  Lymhocytic infiltration of splenic sinusoids  Long term anti-malarials
  33. 33. SUMMARY  Splenomegaly – major physical finding  Step wise approach- history,physical exam  Look for associated features  Lab investigation & Imaging  Search for etiology & treat