Splenomegaly

Normal spleen
● The spleen is the largest lymphoid organ of the body. Under normal conditions,
the average weight of the spleen is about 150 gm in the adult
● Normally, the organ lies well protected by the 9th, 10th and 11th ribs in the
upper left quadrant. The surface of the spleen is covered by a layer of
peritoneum underneath which the organ is ensheathed by a thin capsule.
● From the capsule extend connective tissue trabeculae into the pulp of the
organ and serve as supportive network. Blood enters the spleen by the splenic
artery which divides into branches that penetrate the spleen via trabeculae.
● From the trabeculae arise small branches called central arterioles. Blood in
the central arterioles empties partly into splenic venules and from there into
splenic vein, but largely into vascular sinuses of the red pulp and thence into
the splenic venous system.
Grossly, the spleen consists of homogeneous, soft, dark red mass called the red
pulp and long oval grey-white nodules called the white pulp (malpighian bodies).

Microscopically, the red pulp consists of a network of thinwalled venous sinuses

and adjacent blood spaces. The blood spaces contain blood cells, lymphocytes
and macrophages and appear to be arranged in cords called splenic cords or
cords of Billroth. The white pulp is made up of lymphocytes surrounding an
eccentrically placed arteriole. The periarteriolar lymphocytes are mainly T-cells,
while at other places the lymphocytes have a germinal centre composed
principally of B-cells surrounded by densely packed lymphocytes.
The spleen is a lymphoreticular organ that performs at least the following four
functions:
1. Like other lymphoid tissues, it is an organ of the immune system where B and T
lymphocytes multiply and help in immune responses.
2. The spleen plays an active role in sequestering and removing normal and
abnormal blood cells.
3. The vasculature of the spleen plays a role in regulating portal blood flow.
4. Under pathologic conditions, the spleen may become the site of extramedullary
haematopoiesis. The spleen is rarely the primary site of disease. Being the largest
lymphoreticular organ, it is involved secondarily in a wide variety of systemic
disorders which manifest most commonly as splenic enlargement (splenomegaly)
described below.
Splenomegaly
Enlargement of the spleen termed splenomegaly, occurs in a wide variety of disorders
which increase the cellularity and vascularity of the organ. Many of the causes are
exaggerated forms of normal splenic function.
Splenic enlargement may occur as a result of one of the following pathophysiologic
mechanisms:
I. Infections
II. Disordered immunoregulation
III. Altered splenic blood flow
IV. Lymphohaematogenous malignancies
V. Diseases with abnormal erythrocytes
VI. Storage diseases
VII. Miscellaneous causes.
● The degree of splenomegaly varies with the disease entity:
● Mild enlargement (upto 5 cm) occurs in CVC of spleen in CHF, acute malaria,
typhoid fever, bacterial endocarditis, SLE, rheumatoid arthritis and
thalassaemia minor
● Moderate enlargement (upto umbilicus) occurs in hepatitis, cirrhosis,
lymphomas, infectious mononucleosis, haemolytic anaemia, splenic
abscesses and amyloidosis.
● Massive enlargement (below umbilicus) occurs in CML, myeloid metaplasia
with myelofibrosis, storage diseases, thalassaemia major, chronic malaria,
leishmaniasis and portal vein obstruction.
● Mild to moderate splenomegaly is usually symptomless, while a massively
enlarged spleen may cause dragging sensation in the left hypochondrium.
Spleen becomes palpable only when it is enlarged.
HYPERSPLENISM
The term hypersplenism is used for conditions which cause excessive removal of
erythrocytes, granulocytes or platelets from the circulation.
The mechanism for excessive removal could be due to increased sequestration of
cells in the spleen by altered splenic blood flow or by production of antibodies
against respective blood cells.
The criteria for hypersplenism are as under:
1. Splenomegaly.
2. Splenic destruction of one or more of the cell types in the peripheral blood
causing anaemia, leucopenia, thrombocytopenia, or pancytopenia.
3. Bone marrow cellularity is normal or hyperplastic.
4. Splenectomy is followed by improvement in the severity of blood cytopenia.
EFFECTS OF SPLENECTOMY
In view of the prominent role of normal spleen in sequestration of blood cells,
splenectomy in a normal individual is followed by significant haematologic
alterations. Induction of similar haematologic effects is made use in the treatment
of certain pathologic conditions.
For example, in autoimmune haemolytic anaemia or thrombocytopenia, the
respective blood cell counts are increased following splenectomy.
The blood changes following splenectomy are as under:
1. Red cells: There is appearance of target cells in the blood film. Howell-Jolly
bodies are present in the red cells as they are no longer cleared by the spleen.
Osmotic fragility test shows increased resistance to haemolysis. There may be
appearance of normoblasts.
2. White cells: There is leucocytosis reaching its peak in 12 days after
splenectomy. There is shift-to-left of the myeloid cells with appearance of some
myelocytes.
3. Platelets: Within hours after splenectomy, there is rise in platelet count upto 3-4
times normal.
Splenic rupture
The most common cause of splenic rupture or laceration is blunt trauma. The
trauma may be direct or indirect.
Nontraumatic or spontaneous rupture occurs in an enlarged spleen but almost
never in a normal spleen. In acute infections, the spleen can enlarge rapidly to 2 to
3 times its normal size causing acute splenic enlargement termed acute splenic
tumour e.g. in pneumonias, septicaemia, acute endocarditis etc.
Some of the other common causes of spontaneous splenic rupture are
splenomegaly due to chronic malaria, infectious mononucleosis, typhoid fever,
splenic abscess, thalassaemia and leukaemias.
Rupture of spleen is an acute surgical emergency due to rapid blood loss and
haemoperitoneum. Sometimes fragments of splenic tissue are autotransplanted
within the peritoneal cavity and grow into tiny spleens there (splenosis)
Thanku