SPLENOMEGALY- INTEGRATED

APPROACH TO DIAGNOSIS
CANDIDATE: DR. SARATH MENON.R
DIVISION OF GASTROENTEROLOGY
MGM MEDICAL COLLEGE,INDORE
INTRODUCTION
 Definition & symptoms

 Classification

 Hypersplenism

 Etiology

 Step-wise approach

 Associated features

 Investigations
 Galen –source of
black “black bile‟ or
 “melancholia”
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
FUNCTIONS

 Quality control over RBC – culling & pitting

 Synthesis of antibodies

 Removal of antibody coated bacteria & RBC

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
TRAUBE‟S SPACE
BIMANUAL PALPATION
DIFFERENCES

spleen kidney

 Sharp edge  Round edge

 Notch –med border  No notch

 Cross midline  Not cross midline

 Moves with  Not moves with resp.

respiration
 Cannot get above it  Can get above it
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)
HYPERSLENISM

 Splenomegaly

 Pancytopenia

 Presence of hypercellular marrow

 Reversal with splenectomy

SYMPTOMS OF SPLENOMEGALY
 Pain

 Early satiety

 Feeling of heaviness in LUQ

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
CAUSES OF SPLENOMEGALY
 Infective

 Hyperplastic

 Congestive

 Infiltration
INFECTIVE

 Acute & subacute- IMN, infective endocarditis,

severe pyogenic inf.
Viral hepatitis,CMV,AIDS
 Chronic - TB,syphilis,brucellosis

 Tropical splenomegaly

 Malaria,kala azar, trypanosomiasis

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
HYPERPLASTIC

 Extramedullary hemopoeisis- myeloprolif.d/s

- marrow damage
- marrow infiltration

 Reticulo endothelial hyperplasia –(abn.RBC)

- sickle cell d/s,spherocytosis,Hbnopathies,
thalassemia major,PNH
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
DISORDERED IMMUNOREGULATION
 Felty‟s syndrome- RA+ splenomegaly+leucopenia

 Systemic lupus erythromatosis

 Collagen vascular diseases

 Sarcoidosis

 Immune thrombocytopenia
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

MODERATE SPLENOMEGALY(4-8CM)
 Cirrhosis
 Lymphomas„

 Amyloid

 Splenic abscess,infarct

 Hemolytic anemias

 IMN
MILD SPLENOMEGALY (1-3CM)
 Acute infective conditons
 Acute malaria,tyhoid,kala-azar,septicemias
STEP-WISE APPROACH TO SPLENOMEGALY
 History
 Physical examination

 Laboratory testings

 Imaging

 Specialised testing
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

HISTORY …..CONT
 Jaundice
 High risk sexual behavior (AIDS)

 Past medical history

 Drugs
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
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

 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
IMAGING

 MRI scan- liver hemangiomas

hemochromatosis
erlenmeyer flask sign(Gaucher)
 PET scan - Dx & staging of lymphomas

- determine metabolic cells in spleen

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
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

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

SUMMARY

 Splenomegaly – major physical finding

 Step wise approach- history,physical exam

 Look for associated features

 Lab investigation & Imaging

 Search for etiology & treat