INTEGRATED APPROACH TO SPLENOMEGALY

1. SPLENOMEGALY- INTEGRATED
APPROACH TO DIAGNOSIS
CANDIDATE: DR. SARATH MENON.R
DIVISION OF GASTROENTEROLOGY
MGM MEDICAL COLLEGE,INDORE

2. INTRODUCTION
 Definition & symptoms
 Classification
 Hypersplenism
 Etiology
 Step-wise approach
 Associated features
 Investigations

3.  Galen –source of
black “black bile‟ or
 “melancholia”

4. 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

6. FUNCTIONS
 Quality control over RBC – culling & pitting
 Synthesis of antibodies
 Removal of antibody coated bacteria & RBC

7. 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

10. TRAUBE‟S SPACE

11. BIMANUAL PALPATION

12. DIFFERENCES
 Sharp edge
 Notch –med border
 Cross midline
 Moves with
respiration
 Cannot get above it
 Round edge
 No notch
 Not cross midline
 Not moves with resp.
 Can get above it
spleen kidney

13. 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)

14. HYPERSLENISM
 Splenomegaly
 Pancytopenia
 Presence of hypercellular marrow
 Reversal with splenectomy

15. SYMPTOMS OF SPLENOMEGALY
 Pain
 Early satiety
 Feeling of heaviness in LUQ

16. 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

17. CAUSES OF SPLENOMEGALY
 Infective
 Hyperplastic
 Congestive
 Infiltration

18. INFECTIVE
 Acute & subacute- IMN, infective endocarditis,
severe pyogenic inf.
Viral hepatitis,CMV,AIDS
 Chronic - TB,syphilis,brucellosis
 Tropical splenomegaly
 Malaria,kala azar, trypanosomiasis

19. 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

20. HYPERPLASTIC
 Extramedullary hemopoeisis- myeloprolif.d/s
- marrow damage
- marrow infiltration
 Reticulo endothelial hyperplasia –(abn.RBC)
- sickle cell d/s,spherocytosis,Hbnopathies,
thalassemia major,PNH

21. 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

22. DISORDERED IMMUNOREGULATION
 Felty‟s syndrome- RA+ splenomegaly+leucopenia
 Systemic lupus erythromatosis
 Collagen vascular diseases
 Sarcoidosis
 Immune thrombocytopenia

23. 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

24. MODERATE SPLENOMEGALY(4-8CM)
 Cirrhosis
 Lymphomas„
 Amyloid
 Splenic abscess,infarct
 Hemolytic anemias
 IMN

25. MILD SPLENOMEGALY (1-3CM)
 Acute infective conditons
 Acute malaria,tyhoid,kala-azar,septicemias

26. STEP-WISE APPROACH TO SPLENOMEGALY
 History
 Physical examination
 Laboratory testings
 Imaging
 Specialised testing

27. 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

28. HISTORY …..CONT
 Jaundice
 High risk sexual behavior (AIDS)
 Past medical history
 Drugs

29. 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

30. 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

31. 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

32. IMAGING
 MRI scan- liver hemangiomas
hemochromatosis
erlenmeyer flask sign(Gaucher)
 PET scan - Dx & staging of lymphomas
- determine metabolic cells in spleen

33. 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

34. 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

35. 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

36. SUMMARY
 Splenomegaly – major physical finding
 Step wise approach- history,physical exam
 Look for associated features
 Lab investigation & Imaging
 Search for etiology & treat