Spleen : Anatomy; Physiology;Classification;Etiology;Stepwise approach; Assosiated features; Investigation.

1. SPLENOMEGALY :
APPROACH
By-
FAHADAHMAD
RN-27
FINALYEARMBBSHIMSR

2. INTRODUCTION
Anatomy & Physiology
Classification
Etiology
Step-wise approach
Associated features
Investigations

3. ANATOMY
• develops from condensations of mesoderm in the dorsal
mesogastrium.
• The weight of the normal adult spleen is 75–250 g.
• lies in the left hypochondrium between the gastric
fundus and the left hemidiaphragm, with its long axis
lying along the tenth rib.
• The hilum sits in the angle between the stomach and the
kidney and is in contact with the tail of the pancreas.

4. The lower pole extends no further than the mid-axillaryline.
There is a notch on the inferolateral border, and this may be palpated
when the spleen is enlarged.

5. Normal spleen
Normal size
12 cm length , 7 cm width
13cm craniocaudal diameter
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

6. Splenomegaly : Spleen weight of 400-500gm
750 – 1000gm : prominent below costal margin
>1000gm : massive splenomegaly

8. EXAMINATION OF SPLEEN
INSPECTION :Fullness in LUQ that descends on inspiration
Situated behind 9th, 10th and 11th ribs
Long axis along line of 10th rib
Anteriorly extends upto mid axillaryline
Posteriorly, the superior angle is 4cm lateral to D10spine

9. PALPATION
BIMANUALPALPATION
BALLOTMENT
PALPATION FROMABOVE- MIDDLETON MANOUVRE

10. BIMANUAL PALPATION
1. Place left palm firmly over left costal margin posterolaterally and
press it forward and medially.
Palpate spleen with right hand starting from right iliacfossa

11. BIMANUAL PALPATION
2. Turn patient to right lateralposition
Palpate with right hand

12. MIDDLETON MANOUVRE
Stand on left side
Face foot end of patient
Hooked fingers of LEFTHAND placed
under left costal margin
With right hand, pressure isexerted
over posterolateral aspect of lower
thorax

13. PERCUSSION
NIXONSMETHOD
Right lateral decubitus
Start from posterior axillaryline
Upper border of dullness normally 6-8cm above costalmargin
>8cm dullness  splenic enlargement

14. PERCUSSION
CASTELLSMETHOD
Supine position
Dull note over lowest ICSin Anterior axillary line on full inspiration
indicate splenomegaly

15. PERCUSSION
TRAUBE’SSEMILUNAR SPACE
left sixth rib superiorly
left anterior axillary linelaterally
left costal margin inferiorly
Dull note :splenomegaly

16. Differential diagnosis
Enlarged left kidney
Enlarged left lobe liver
Carcinoma stomach
Carcinoma splenic flexure colon
Omental mass
Malignancy tail of pancreas

17. splenomegaly
Massive
Moderate
Mild
beyond umblicus, crosses mid line
>8cm below left costal margin and or >1000gm weight
b/w costal margin & umblicus
(4-8cm)
just palpable
(1-3cm)

18. MECHANISM of SPLENOMEGALY
1. Hyperplasia or hypertrophy
Reticuloendothelial hyperplasia
Immune hyperplasia in response to
A. systemic infection
B. immunological diseases
2. Passive congestion due to decreased blood flow
3. Infiltrative diseases

19. CAUSESOFSPLENOMEGALY
Inflammatory splenomegaly
Hyperplastic splenomegaly
Infectious splenomegaly
Congestive splenomegaly
Infiltrative splenomegaly
INCREASEDDEMAND FOR
SPLENIC FUNCTION

20. 1. INCREASED DEMAND
A. RETICULOENDOTHELIALSYSTEMHYPERPLASIA
Spherocytosis
Early sickle cellanemia
Ovalocytosis
Thalassemia major
Hemoglobinopathies
PNH
Pernicious anemia

21. INCREASED DEMAND
B.IMMUNE HYPERPLASIA
Hi
(i) Response to infection IMN, viral hepatitis,AIDS,CMV,IE,TB,
stoplasmosis, Malaria,Bacterial sepsis,Cong syphilis, splenic abscess,
Leishmaniasis, Trypanosmiasis, Ehrlichiosis
(ii) Disordered Immunoregulation RA(Felty syndrome), SLE,Collagen
vascular diseases,AIHA,Immune thrombocytopenias, Drug reactions,
Sarcoidosis, Interleukin2 therapy,Thyrotoxicosis
(iii) Extramedullary hematopoiesis : Myelofibrosis, Myeloinfiltrative
disorders, marrow damage by toxins,radiation.

22. 2. Abnormal splenic/portal blood flow
Cirrhosis
Hepatic vein obstruction
Portal vein obstruction
Cavernous transformation of portal vein
Splenic vein obstruction
Splenic artery aneurysm
Hepatic schistosomiasis
CHF
Hepatic echinococcosis
Portal hypertension

23. 3. Infiltration of Spleen
 deposits
 Amyloidosis
 Gaucher disease
 Niemann Pick
 Tangier disease
 Hurlers syndrome, Other
MPS
 Hyperlipidemias
Intracellular or extracellular
Leukemias
Benign and Malignant Infiltrations
Lymphomas
Hodgkins disease
Myeloproliferative syndromes
Angiosarcomas
Metastasis ( MC= Melanoma)
Eosinophilic Granuloma
Histiocytosis X
Hamartomas
Hemangioma
Splenic cysts

24. 4. Unknown Etiology
Idiopathic splenomegaly
Berylliosis
Iron deficiencyanemia

25. MASSIVE SPLENOMEGALY
(>1000GM or >8cm)
CML
CLL
Lymphoma
Hairy cell leukemia
Myelofibrosis with myeloid metaplasia
Chronic malaria
Kala - azar (Tropical Splenomegaly)
Sarcoidosis
Gaucher disease
AIHA
Diffuse splenic hemangiomatosis

26. Moderate splenomegaly(4-8cm)
Viral hepatitis
Cirrhosis
Lymphomas
Amyloidosis
Splenic abscess,infarct
Hemolytic anemias
IMN
Hemochromatosis
Polycythemias

27. Mild splenomegaly (1-3cm)
Acute malaria
Typhoid
kala-azar
Septicemias
SLE
Infective endocarditis
RA
Thalassemia Minor
Miliary TB
Leptospirosis
HIV
CCF

28. Step-wise approach to splenomegaly
History
Physical examination
Laboratory tests
Imaging
Specialised tests

29. History
Mild vague, abdominal pain.
Pain may be referred to the left shoulder.
Early satiety from gastric displacement occurs with massive splenomegaly.
Associated symptoms or signs
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)

30. 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 tissuedisorder
Leukopenia- felty’s syndrome, septicemia

31. 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

32. Lab investigations
CBC
Peripheral smear study
Reticulocyte count
Blood C/S
Serology (viral, parasitic)
LFT
Hb electrophoresis / coombs test
Coagulation profile
Amylase/lipase
AMA, Anti CCP
,RAfactor
Bone marrow analysis

33. Imaging
USG
CTscan
sensitive & specificnon-invasive
- etiology of splenomegaly
- liver size,heterogenecity
- splenic mets, abscess,calcf.,cysts
- retro peritoneal LN
- cranio caudal ln > 12cm
Liver- spleen colloid scan- (RBC–Cr51,Tc99)
- hepatic steatosis, SOL,splenic functions
- PHT,colloid shift +
MRI/ Doppler USG - portal / splenic veinthrombosis
- cavernomas

34. imaging
MRI scanliver hemangiomas
hemochromatosis
erlenmeyer flask sign (Gaucher)
PETscan Dx & staging of lymphomas
determine metabolic cells in spleen

35. Specialised testing
Abdominal fat pad aspiration
JAK-2 mutation
Gene testing (bcr-abl ,C282Y)
Enzyme testing
Lymph node biopsy
FNAC spleen
Splenectomy
Liver biopsy