266 Historical Review Abordaje deEsplenomegalia Fig 1. Hippocrates examining the upper abdomen (possibly pal- pating the spleen?) of a patient. Photograph courtesy of Dr Barbara Bain, St Mary’s Hospital, London. golden age of lifeÕ (Stukeley, 1722; Fig 2). The prevailing view for many centuries was, however, one of gloomy and
Introducción • Se origina del mesodermo esplácnico a la 11ª SDG. • Peso: 50 - 250 gr. • Medidas: • Largo: 11 a 13 cm. • Ancho: 6 - 8 cm. • Espesor: 3 - 4 cm. • Situación: 9ª - 11ª costillas.TRATADO DE ANTOMÍA HUMANAEditorial Salval S.A. Tomo IVTestut. L. Latarget A
Introducción• Irrigación: • Arterial: tronco celíaco. • Venosa: forma la vena porta con la vena mesentérica inferior. • Linfática: hacia cadena esplénica.• Inervación: plexo solar.ANATOMÍA PARA ESTUDIANTESEditorial El Sevier Gray España 2005Richarch L. Drake
Funciones• Reservorio de Sangre.• Hematopoyética.• Hematodestructora.• Inmunológica.• De depósito. ANATOMÍA CON ORIENTACIÓN CLÍNICA Keith L. Moore, 4a edición Editorial Panamericana 2002
Exploración FísicaSíntomas y Signos Cardinales de las EnfHoracio Jinich, 5ª Ed.Manual Moderno, 2006.
Exploración Física Exactitud• Comparación vs US: • La palpación es más exacta en sujetos delgados. • E: 92%; VPP: 92%. • Percusión: S: 62%; E: 72%. • Combinación de resultados positivos: S: 46%; E: 97%.
Esplenomegalia• Deﬁnición “estándar de referencia”: peso mayor a 250 gr.• Clínicamente palpable: 16% muestran un tamaño normal.• Radiológica, US: • Longitud craneocaudal ≥13 cm. • Díametro AP ≥2/3 de la distancia entre la pared abdominal anterior y la posterior. • TC: Longitud ≥10cm. S: 81%; E: 90%. Splenomegaly: Investigation, diagnosis and management Determination of splenomegaly by CT: is there a place for a single measurement? Bezerra AS. A.L. Pozo et al. / Blood Reviews 23 (2009) 105–111 AJR Am J Roentgenol. 2005;184(5):1510
Splenomegaly in 2,505 Patients at a Large University Medical Center From 1913 to 1995 1963 to 1995: 449 Patients ROBERT A. OREILLY, MD, San Francisco, California WIM, August 1998-Vol No. 2 Splenomegaly was studied retrospectively at the University of California, San Francisco (UCSF), School -A WIM of Medicine in 301 patients from 1963 to 1995 and compared with the UCSF service of the San Fran- 169,Causas más comunes cisco General Hospital Medical Center (SFGH) in 148 patients from 1979 to 1994. The combined 449 patients were classified into several diagnostic groups and were studied by means of several clinical and laboratory associations. Hepatic disease in the percentage of patients at UCSF (with those at SFGH given in parentheses) was associated with splenomegaly in 290/o (41%), hematologic disease, 32% diseases, 10% (4%); USED (16%); infectious diseases, 16% (36%); congestive or inflammatoryABBREVIATIONSprimary IN TEXT splenic disease, 6% (1%); other, 5% (1%); and cause unknown, 2% (1%). Massive splenomegaly oc- curred in 27% of the patients of the combined series, particularly= acquired immunodeficiency syndrome AIDS in patients with hematologic dis- eases. The acquired immunodeficiency syndrome (AIDS) occurred in more than half of the patients with infectious diseases at SFGH and was four times more frequent chronic lymphocytic leukemia CLL = than in the patients at UCSF. The • Enfermedad hepática (cirrosis): 33 % CML = chronic myelocytic (chronic commonest diseases associated with splenomegaly were hematologic (lymphoma), hepatic leukemia liver disease), infectious diseases (AIDS and endocarditis), congestive (congestive heart failure), pri- HIV = human to the spleen). In 11 pa- mary splenic (splenic vein thrombosis), and other (malignancy not metastaticimmunodeficiency virus 1ITP = idiopathic thrombocytopenic tients with AIDS and massive splenomegaly, Mycobacterium avium complex occurred in 8 (73%). purpura Splenectomy was performed in 117 patients (26%), primarily for hematologic amelioration. I conclude PVT = choice vein thrombosis that for splenomegaly of unknown origin, the invasive procedure ofportal for patients with hemato- • Malignidad hematológica (linfoma) : 27% SFGH = San liver biopsy; and for infec- logic associations may be a bone marrow biopsy; for hepatic associations, a Francisco General Hospital Medi tious disease associations, a lymph node biopsy, before any SVT = splenic vein thrombosis consideration of a diagnostic splenectomy. (OReilly RA. Splenomegaly in 2,505 patients at a large university medical center from 1913 to 1995. 1963 to 1995: 449 patients. West j Med 1998; 169:88-97) UCSF = University of Califomia, San Francis • Infección (VIH, Endocarditis): 23%. spleen from a surgical procedure excised Splenomegaly presents a diagnostic challenge because nearly always it is due to another primary disorder. northern California. The centering of AIDS patients at the SFGH and to a lesser extent at UCSF allowed the assess- The only analyses from a developed country on ment of the development of AIDS on the diagnostic eval- total of 331 patients splenomegaly in general were two office-based studies coded having sp were uation of splenomegaly and massive splenomegaly. as • performed decades ago in which no diagnosis was estab- Congestión (ICC): 8%. UCSF for the lished in more than 25% of the patients.23 Only a single study of hospital-based patients in the United States has could been reported.4 Now, a second municipal hospital has 1963 1995; 30 medical Patients and Methods years be found. Therefore, the study was not to Patient Demographics remaining 301 patients. A total of 193 pati been studied, San Francisco General Hospital Medical Center (SFGH), which has been compared with and con- All hospital records at SFGH for patients of any age diag- coded having splenomegaly; 45 me trasted to a university medical center at the University of were nostically coded asas splenomegaly from 1979 through 1994 • Enfermedad propia del bazo (trombosis): 4 be found. Therefore, the st California, San Francisco (UCSF), School of Medicine (23%) could for about the same period. Infections with the human immunodeficiency virus (HIV) and with diseases related %. were reviewed retrospectively. Splenomegaly was defined not as an enlarged spleen determined by one of the following: palpable by at least two clinicians or noted on two written the remaining 148 patients. The to the acquired immunodeficiency syndrome (AIDS) are on observations, greater than 12 cm in length on radiologic prevalent in the young male homosexual community of imaging study, or more than 250 grams wet weight on an splenomegaly for these years at UCSF was • Otras o desconocidas: Departments ofJose,A.California.MD, ofSCalifornia, Francisco,CAfrom about 90,000 admissions, or 0.3%. the 5%.OReilly,University Bascom Valley Medical Center, San Reprint Robert From Medicine, requests to 751 San Stanford Ave, San Jose, School of Medicine; Medical 95128. Alto; University Center, Palo and the Santa Clara Clinical and Laboratory Features The detailed criteria for the analysis of th laboratory features of the patients are all first part of this study.5 Results
Esplenomegalia Masiva• El polo inferior se encuentra dentro de la pelvis o cruza la línea media hacia el hemiabdomen derecho. • Causas: •LMC •Mieloﬁbrosis, idopática o postpolicitémica •Enfermedad de Gaucher. •Linfoma (incluída Leucemia de células peludas) •Kala-azar •Síndrome tropical esplenomegálico •Talasemia mayor •SIDA con complejo Mycobacterium avium O’ReillyRA.Splenomegalyin2505patientsatalargeuniversitymedicalcentre from 1913 to 1995. 1963 to 1995:449 patients. West J Med 1998;169:88–97
Síntomas•Dolor en CSI•Sensación de plenitud postprandial precoz•Dolor referido a hombro ipsilateral•Dolor tipo pleurítico agudo + dolor en CSIsugiere absceso esplénico
including bone marrow, liver and rectal y of these patients remained well for over Table 2eem to be a group of individuals with benign Initial investigations in the patient with splenomegaly. prevalence is not clear. Abordajecauses of splenomegaly have now been stud- In most patients In selected patients (depending on clinical features) US hospital inpatients.11–13 The estimatedo 1995 was 0.3% of admissions and a diagno- Haematology Full blood count Direct antiglobulin test Inicial8%, but 12% required a diagnostic splenec- Peripheral blood ﬁlm Reticulocyte count ents with splenomegaly, haematological ESR Malaria blood ﬁlm16–66%, hepatic disease in 9–41%, infectious Clotting screen Haemoglobin electrophoresis/HPLC estive or inﬂammatory disease in 4–10% and Biochemistry e (e.g. storage disease) in 1–6%.11–13 Within Urea and electrolytes Serum ACE sorders, the most common diagnoses were Liver function tests Serum protein electrophoresis all splenomegaly), CML (8–29%), haemoglo- C-reactive protein Urine Bence Jones protein Bone biochemistry L (0–20%) and myeloﬁbrosis (9–16%). •Historia Clínica omegaly vary between hospitals in the sameences between developing and developed Serum LDH Vitamin B12, red cell folate Microbiologyre striking. 11–45% of massive splenomegaly Monospot test Peripheral blood cultures •Exploración opical Splenomegaly Syndrome of malarialis due to schistosomiasis.14 Serology: hepatitis B/C Sputum microscopy, culture and AAFB Mantoux test Física Immunology Serology: HIV, CMV, toxoplasmosis, brucella tient with splenomegaly Auto-antibodies incl. ANA Rheumatoid factor begins with a thorough history and exami- Radiology ay elicit symptoms of pressure effects from Ultrasound/CT abdomen Ultrasound abdomen with duplex-Doppler studiesuch as left hypochondrial discomfort or early Plain chest radiograph CT chest, abdomen and pelvis symptoms of cytopenias due to hypersplen- Transthoracic/transoesophageal echocardiogram prising splenomegaly; anaemia, leucopenia Bedsideenia; compensatory bone marrow hyperpla- Urine dipstick (protein,t after splenectomy (if performed). General blood)uch as fever, sweats, weight loss or lymphad- ESR: erythrocyte sedimentation rate; HPLC: high-performance liquid chromatog-matological, malignant, infectious or inﬂam- raphy; LDH: lactate dehydrogenase; ACE: angiotensin-converting enzyme; AAFB:horough systemic enquiry is essential to acid and alcohol-fast bacilli; and ANA: anti-nuclear antibodies.
Abordaje AdicionalEsplenectomía Why does my patient have Lymphadenopathy or splenomegaly? Motyckova & Steensma Hematol Oncol Clin N Am 26 (2012) 395–408 •Causa aún desconocida. •Crecimiento refreactario a tratamiento •Persistencia de síntomas. •Paliativa: mieloﬁbrosis, LCP. •Víalaparoscópica: complicaciones del 6-22%. Mortalidad 1.4%
Abordaje Adicional Biopsia•No recomendada actualmente.•Poca utilidad clínica. Why does my patient have Lymphadenopathy or splenomegaly? Motyckova & Steensma Hematol Oncol Clin N Am 26 (2012) 395–408