approach to splenomegaly

1. APPROACH TO
SPLENOMEGALY
Dr.G.VENKATA RAMANA
HOD FAMILY MEDICINE
RDT HOSPITAL BATHALAPALLI

2. ANATOMY OF SPLEEN
 Location:
 left hypochondrium between the fundus of the stomach and
the diaphragm, behind the midaxillary line opposite the 9th,
10th, and 11th ribs.
 Its long axis lies parallel to the long axis of the 10th rib.
 Size, Shape, and Colour
 size -roughly corresponds to the fist of the subject
 wedge-shaped soft organ
 purple colour
 Measurements of the spleen
 Thickness: 1 inch.
 Breadth: 3 inches.
 Length: 5 inches.
 Weight: 7 oz

3. EXTERNAL FEATURES
 1. Two ends
 anterior
 posterior
 2. Three borders
 superior
 inferior
 intermediate
 3. Two surfaces
 diaphragmatic
 visceral

4. INTERNAL FEATURES
 Parenchyma is divided into
red and white pulp.
 Red pulp consists of venous
sinus and cords of
structures like blood cells,
macrophages and
mesenchymal cells.
 White pulp has a central
artery, which is surrounded
by splenic corpuscles or
Malpighian corpuscles
 cor puscles are formed by
lymphatic sheath containing
lymphocytes and
macrophages

5. ARTERIAL AND VENOUS SUPPLY
 ARTERIAL SUPPLY
 splenic artery, the largest
branch of the coeliac trunk
 tortuous to allow
movements of the spleen
 VENOUS DRAINAGE
 splenic vein
 Its tributaries
 1.Short gastric veins.
 2. Left gastroepiploic vein.
 3. Pancreatic veins.
 4. Inferior mesenteric vein
 It joins the superior
mesenteric vein to form the
portal vein

6.  LYMPHATIC DRAINAGE
 The splenic tissue proper has no lymphatics
 NERVE SUPPLY
 sympathetic fibres derived from the coeliac plexus.
 They supply blood vessels (vasomotor) and smooth
muscle fibres present in the trabeculae and capsule

7. FUNCTIONS OF SPLEEN
 Spleen is the largest lymphoid organ in the body
(hemolymphoid organ).
 To filter blood by removing worn-out RBCs and
microbial agents from the circulation.
 To manufacture RBCs in fetal life and lymphocytes
after birth.
 To provide immunity to the body by producing
immunoglobulin M (IgM) by plasma cells.
 To store RBCs and release them in circulation when
required.

8. EXAMINATION OF SPLEEN
 INSPECTION
 May reveal fullness in left upper quadrant that descends on
inspiration usually in massive spleenomegaly
 PALPATION
 To become palpable, spleen should have enlarged 2-3 times.
Direction of enlargement is towards right iliac fossa.
 Palpate from right iliac fossa to left hypochondrium
 Wait for one full phase of respiration
 At the height of inspiration, release the pressure on the
examining hand so that the finger tips slip over the lower pole
of spleen, confirming its presence and surface characteristics.
 If spleen is not palpable, move the examining hand upwards
after each inspiration until the finger tips are under the costal
margin.
 Repeat this process along the entire rib margin as the
position of the enlarging splenic tip is variable

9. SPLEEN PALPATION METHODS
 CLASSICAL METHOD
 Supine position
 Palpate from from right iliac fossa to left hypochondriac region
 Edge of the spleen may be felt on deep inspiration
 BIMANUAL METHOD
 Right lateral position
 One hand is placed over the left lower chest and the spleen is
palpated with the other hand
 HOOKING METHOD The patient is put in right lateral position
and the examiner stands on the left side and feels the spleen by
hooking his fingers over the left costal margin
 DIPPING METHOD This method is used when there is severe
ascites which may mask an enlarged spleen. The patient is put in
the supine position and the examiner palpates as in the classical
method except that he dips his fingers into the abdomen with
each palpation, so that the fluid is displaced temporarily to the
side. This facilitates palpation of the spleen

11. PERCUSSION
 Nixon’s method
 patient is placed on the right
side.
 Percussion begins at the
lower level of pulmonary
resonance in the posterior
axillary line and proceeds
diagonally along a
perpendicular line toward the
lower mid anterior costal
margin.
 The upper border of dullness
is normally 6-8 cm above the
costal margin.
 Dullness greater than 8 cm in
an adult is presumed to
indicate splenic enlargement

12. CASTELL’S METHOD
 With patient supine,
percussion in the lowest
intercostal space in the
anterior axillary (8th or
9th) produces a resonant
note if the spleen is
normal in size.
 This is true during
expiration or full
inspiration.
 A dull percussion note on
full inspiration suggests
splenomegaly

13. PERCUSSION OF TRAUBE’S SPACE
 Boundaries
 Superiorly- 6th rib
 Inferiorly-left costal
margin
 Laterally-left mid
axillary line
 If splenomegaly is
present-dull note is
heard in traube’s space

14. DIFFERENCES
 Sharp edge
 Notch present
 Cross midline
 Moves with respiration
 Cannot get above it
 Round edge
 No notch
 Not cross midline
 Not moves with
respiration
 Can get above it
Spleen kidney

15. CLASSIFICATION OF SPLENOMEGALY
 Massive -beyond
umbilicus,crosses
midline in to pelvis
 >8cm
 Moderate- between
costal margin and
umbilicus
 4-8cm
 Mild –just palpable
 1-3cm

16. HYPERSPLENISM
 Splenomegaly
 Pancytopenia
 Presence of hypercellular marrow
 Reversal with splenectomy

17. MECHANISM OF SPLENOMEGALY
 Reactive reticulo-endothelial hyperplasia
 Lymphoid hyperplasia
 Proliferation of lymphoma cells
 Infiltration by abnormal cells
 Extramedullary hematopoeisis
 Proliferation of macrophages due to RBC
destruction
 Vascular congestion

18. CAUSES OF SPLENOMEGALY
 Infection
 Viral – Hepatitis, infectious mononucleosis,
cytomegalovirus,HIV,EBV
 Bacterial – Salmonella, Brucella, tuberculosis
 Parasitic – Malaria, schistosomiasis, toxoplasmosis,
leishmaniasis
 Infective endocarditis
 Fungal

19.  Inflammation
 Sarcoid
 Serum sickness
 Systemic lupus erythematosus
 Rheumatoid arthritis (Felty syndrome)

20.  Infiltrative, nonmalignant
 Gaucher disease
 Niemann-Pick disease
 Amyloid
 Other lysosomal storage diseases (eg,
mucopolysaccharidoses)
 Langerhans cell histiocytosis
 Hemophagocytic lymphohistiocytosis
 Rosai-Dorfman disease

21.  Malignancy
 Lymphoma, usually indolent variants
 Acute and chronic leukemias
 Polycythemia vera
 Multiple myeloma and its variants
 Essential thrombocythemia
 Primary myelofibrosis
 Primary splenic tumors
 Metastatic solid tumors

22.  Congestive
 Cirrhosis
 Heart failure
 Thrombosis of portal, hepatic, or splenic veins
 Hematologic (hypersplenic) states
 Acute and chronic hemolytic anemias, all etiologies
 Sickle cell disease (children)
 Following use of recombinant human granulocyte
colony-stimulating factor

23. MASSIVE SPLENOMEGALY (>8CM, >1000GM)
 Chronic myeloid leukaemia
 Myeloid metaplasia
 Myelofibrosis
 Hairy cell leukaemia
 Gaucher’s disease
 Niemann-Pick disease
 Sarcoidosis
 Thalassaemia major
 Chronic malaria, Kala-azar ,Schistosomiasis
 Congenital syphilis
 Extrahepatic portal vein obstruction
 Diffuse splenic haemangiomatosis
 Lymphoma
 Polycythaemia

24. MODERATE SPLENOMEGALY 4-8CM
 Viral hepatitis
 Cirrhosis
 Lymphomas
 Leukaemias
 Infectious mononucleosis
 Haemolytic anaemias
 Splenic infarcts
 Splenic abscess
 Amyloidosis
 Haemochromatosis
 Polycythaemia.

25. MILD SPLENOMEGALY 1-3CM
 Congestive cardiac failure
 Acute malaria
 Typhoid
 Infective endocarditis
 Septicaemia
 Systemic lupus erythematosus
 Rheumatoid arthritis
 Thalassaemia minor
 Miliary tuberculosis
 Leptospirosis
 HIV

26. STEP WISE APPROACH TO SPLENOMEGALY
 History
 Physical examination
 Lab investigations
 Imaging
 Specialised testing

27. SYMPTOMS
 early satiety
 abdominal fullness or distention
 pain referred to the chest or left shoulder

31. LAB INVESTIGATIONS
 CBC and blood smear
 Immature or abnormal white blood cells (WBCs) –
Lymphoproliferative or myeloproliferative disorders
 Cytopenias – Liver disease with hypersplenism,
AIHA, ITP, Felty syndrome, or congenital disorders
(eg, hereditary hemolytic anemias)
 Teardrop cells – Myelofibrosis or thalassemia
 Spherocytes – AIHA or hereditary spherocytosis
 parasitic organisms may be seen on the blood
smear. Examples include Ehrlichia species in
WBCs; or Bartonella, Babesia or malarial
organisms in RBCs

32.  Blood culture
 Seology (viral,fungal,parasitic)
 HIV
 LFT
 Reticulocyte count
 Hb electrophoresis
 Direct coombs test
 RA factor,anti CCP
 ANA profile
 Coagulation profile
 a glucocerebrosidase assay on peripheral blood
leukocytes

33.  Bone marrow biopsySplenomegaly with
leukocytosis, abnormal lymphocytes, or immature
WBCs on the peripheral blood smear
 Splenomegaly with thrombocytosis or
erythrocytosis
 Lymph node biopsy Splenomegaly with
lymphadenopathy.
 Liver biopsyliver disease that requires liver biopsy
 Splenic biopsy may be used in cases of isolated
splenic lesions of unknown cause for which there is
no other tissue more amenable to biopsy or if
biopsies from other sites have been unrevealing

36. SPECIALISED TESTING
 JAK-2 mutation
 Gene testing (bcr-abl C282Y)
 Enzyme testing
 FNAB spleen

38. TROPICAL SPLENOMEGALY
 Massive splenomegaly
 Endemic areas of malaria,kala-azar
 IgM antibodies positive
 No parasite in blood
 Lymphocytic infiltration of splenic sinusoids
 Long term anti-malarials