Splenomegaly
Audrey Paulman
The spleen is an encapsulated reticuloendothelial organ in the left upper quadrant of the abdomen with two basic functions: (a) the white pulp makes humoral antibodies, B and T lymphocytes, and plasma cells; and (b) the red pulp scavenges unneeded matter from the blood, including such items as Howell-Jolly bodies, bacteria, and aging blood cells.
Approach
Most cases of splenomegaly are caused by familial or acquired needs for increased scavenger activity, disease process infiltrating the spleen, abnormal blood flow, or infectious disease.
History
A. Presentation. The most common symptom of splenomegaly is a heaviness in the left upper quadrant of the abdomen. The patient may have pain believed to be caused by stretching of the splenic capsule. However, splenomegaly can be entirely asymptomatic. Even rupture of the spleen by trauma or disease process can be without pain.
A history of fevers, night sweats, pain, and fatigue might lead to an infectious cause, whereas alcohol abuse and a history of liver or heart failure would be important in splenomegaly caused by abnormal blood flow.
B. Family history may give clues to inherited red blood cell disorders and inherited disorders of metabolism.
Physical examination
The diagnosis of splenomegaly is made by palpation of a mass in the left upper quadrant. Harrison’s Textbook of Medicine cites that a spleen is palpable in 3% of normal college freshmen, whereas in tropical countries, the incidence of splenomegaly may reach 60% (1). Percussion is also used to delineate the size of the spleen. Percussion is only approximately 60% accurate in most studies, with palpation about 50% accurate. To palpate the spleen, the patient is in the supine position with the knees flexed to decrease abdominal muscle tone. Begin the examination by palpating the right lower quadrant and move upward across the abdomen as the patient breathes in deeply. Beginning the examination low in the abdomen, allows the lower edge of a markedly enlarged spleen to be detected.
Testing
A. Diagnostic imaging. The most accurate methods of determining spleen size include nuclear scans, computed tomography (CT) scan, and ultrasound. Ultrasound offers the most sensitivity and specificity, with the widest availability at the lowest cost. Magnetic resonance imaging has an advantage over CT scan in that it allows for delineating the blood flow patterns that cause congestion in the spleen. None of the methods are reliable in determining the underlying cause of splenomegaly.
B. Clinical laboratory tests. Most of the laboratory tests used in splenomegaly are those used to delineate other systemic disease processes (2–4). A complete blood count with peripheral smear will identify many of the hematologic diseases that cause splenomegaly. These include elevated white blood cell levels associated with leukemias, spherocytes in spherocytosis, and anemias. A bone marrow biopsy may show increased production of those cells that are low in the peripheral blood, leading to the diagnosis of hypersplenism. Also, the biopsy may show lymphocyte infiltration, increased myeloid elements, blast cells, fibrosis, abnormal staining in disease processes (e.g., amyloidosis), and macrophages in storage-related diseases (2).
Studies such as 51CR-labeled red blood cell count, platelet survival, and splenic survival studies help to determine if the spleen is sequestering an abnormal number of cells.
Diagnostic assessment
A. The diseases that are associated with splenomegaly include:
1. Infectious diseases. Infectious mononucleosis, bacterial endocarditis, tuberculosis, sarcoidosis, acquired immune deficiency syndrome, cytomegalovirus infection, hepatitis, splenic abscess, histoplasmosis, and tropical diseases.
2. Inflammatory diseases. Connective tissue disease, Felty’s syndrome, and serum sickness.
3. Abnormal blood flow. Cirrhosis; hepatic, splenic, or portal vein obstruction; and portal hypertension.
4. Storage diseases. Gaucher’s disease, Nieman–Pick disease, and Hand-Schuller-Christian disease.
5. Infiltrative disease. Leukemia, lymphoma, and Hodgkin’s disease.
6. Chronic anemia. Spherocytosis, sickle cell disease, and thalassemia.
B. Hypersplenism occurs when the size and activity of the spleen interfere with normal cells in the peripheral blood and increased bone marrow production of these cells. The treatment of hypersplenism is reversal of the underlying cause or splenectomy. Splenectomy can be performed by a laparoscopic technique. Preoperative pneumococcal vaccine should be considered for patients undergoing splenectomy.
References
1. Fauci A, Braunwald E, Isselbacher K, et al., eds. Harrison’s principles of internal medicine, 14th ed. New York: McGraw-Hill, 1998:347–350.
2. Nelson W, Behrman R, Kliegman R, Arvin A, eds. Nelson textbook of pediatrics, 15th ed. Philadelphia: WB Saunders, 1996:1439.
3. Rakel R. Saunders manual of medical practice. Philadelphia: WB Saunders, 1996:610.
4. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician 1998;58(6):1313–1320.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Swollen spleen
» Next page: Hepatomegaly (Field Guide to Bedside Diagnosis)
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