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Splenomegaly : Examination techniques and Clinical Approach

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ANATOMY OF SPLEEN

Histologically:

FUNCTIONS OF SPLEEN

Spleen is the largest lymphoid organ organ and serves following functions –
  1. Red pulp: Removal of senescent and defective RBCs (mechanism: hypoxia, low pH and low glucose)
  2. White pulp: Synthesis of antibodies
  3. Removal of antibody-coated bacteria and anti-body coated blood cells from circulation
  4. Extramedullary hematopoiesis
  5. Blood pooling

An increase in these normal functions may result in splenomegaly

EXAMINATION OF SPLEEN

1. Palpation:

If history suggest splenomegaly but is not palpable: Roll the patient on to the right lateral position with flexion of left hip and knee and examine as before.

Splenomegaly: Abnormal enlargement of Spleen

If ascites is gross: Use dipping method to palpate the spleen

2. Percussion:

Castell’s sign: With the patient supine, percussion in the lowest intercostal space in the anterior axillary line (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.

MECHANISMS OF SPLENOMEGALY

1. Work hypertrophy

2. Infiltration

3. Passive congestion

CAUSES OF SPLENOMEGALY

Mnemonic: CHIMPS

  1. Congestive: Portal hypertension (Cirrhosis, Hepatic/Splenic/Portal vein occlusion), Cardiac (CHF, Constrictive pericarditis)
  2. Hematologic: Neoplastic (Lymphomas, Leukemias, Myeloproliferative disorders), Non-neoplastic (Megaloblastic anemia, Hemoglobinopathies, Autoimmune hemolytic anemias)
  3. Infective: Subacute Bacterial Endocarditis (SBE), Brucellosis, TB, Salmonella, Septic shock, Infectious mononucleosis, Hepatitis, Cytomegalovirus (CMV), Histoplasmosis, Malaria, Leishmaniasis, Schistosomiasis, Trypanosomiasis
  4. Inflammatory: Felty’s syndrome, SLE, Rheumatoid arthritis, Sarcoidosis
  5. Metabolic-infiltrative: Gaucher’s disease, Niemann-Pick’s syndrome, Amyloidosis
  6. Miscellaneous: Cyst, abscess, cavernous hemangiomas
  7. Primary hypersplenism: Dacie’s syndrome (Splenomegaly of unknown cause + Pancytopenia)
  8. Splenic cyst or hamartoma

Felty’s syndrome: A triad of Rheumatoid arthritis, Splenomegaly and Neutropenia

Hypersplenism: It is the splenic hyperactivity with increased blood cell destruction. Diagnostic criteria are:

Banti’s disease: Congestive splenomegaly with hypersplenism occuring in cirrhosis and portal hypertension

CLINICAL APPROACH TO SPLENOMEGALY

A) History:

1. Suggestive of splenomegaly:

2. Suggestive of associated disease:

B) Physical examination:

1. Inspection: Fullness in LUQ that descends on inspiration (massive splenomegaly)

2. Palpation: Spleen is not normally palpable (palpable when 2-3 times enlarged). Enlargement takes place in a superior and posterior direction before it becomes palpable subcostally. A palpable spleen must be reported in following points:

A palpable spleen is distinguished from palpable left kidney mass by:

Normal sized spleen may be palpable in:

3. Auscultation: Venous hum or a friction rub may be heard

4. Percussion: Palpation is confirmed by dullness as spleen is dull to percussion

5. Other relevant findings in Physical Examination:

a. Skin:

b. Lymphadenopathy:

c. Fever

d. Eyes and ENT

e. Cardiac examination:

f. Extremities:

g. Abnormal neurological examination:

Differential diagnosis of splenomegaly:

  1. Enlarged left kidney
  2. Enlarged left lobe of liver
  3. Carcinoma of stomach
  4. Carcinoma of splenic flexure of colon
  5. Omental mass (TB or malignancy)
  6. Malignancy of tail of pancreas
  7. Ovarian tumor in females

C) Grading of Splenomegaly Based on Degree of Enlargement

1. Massive (>8cm or >5 fingers):

Tropical Splenomegaly Syndrome or Hyperactive Malarial Splenomegaly (HMS)

An idiopathic splenomegaly affecting malnourished children and adult ♀ in malaria-endemic regions eg. New Guinea, Africa, which may be a defective immune response to P malariae

2. Moderate (4-8cm or 2-4 fingers):

3. Mild (<4cm or <2 fingers):

D) Lab Investigations:

1. Initial investigations:

2. Additional investigations: Based on disease suspected by clinical and/or initial laboratory findings

3. Bone marrow aspiration and biopsy

4. Lymph node biopsy

5. Splenic biopsy

6. Liver biopsy

7. Lung or Skin biopsy

E) Imaging:

1. To evaluate splenomegaly

2. Confirming suspected diagnosis

Investigations should be based on disease suspected by clinical and/or initial laboratory findings

SPLENECTOMY

1. Indications:

Causes of Splenic rupture

2. Problems after splenectomy:

Causes of Asplenism or Hyposplenism

3. Prophylaxis for Post-splenectomy infection:

4. Post splenectomy hematological features:

Sources:

  1. Harrison’s Principle of Medicine 16th Edition
  2. Davidson’s Principle and Practice of Medicine 20th Edition
  3. Bedside Clinics in Medicine Part I by Arup Kumar Kundu
  4. Kumar and Clarke’s Clinical Medicine 6th Edition
  5. Assessment of Splenomegaly – BMJ Best Practices

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