Splenomegaly
Because it occurs with various disorders and in up to 5% of normal adults, splenomegaly — an enlarged spleen — isn’t a diagnostic sign by itself. Usually, however, it points to infection, trauma, or a hepatic, autoimmune, neoplastic, or hematologic disorder.
Because the spleen functions as the body’s largest lymph node, splenomegaly can result from any process that triggers lymphadenopathy. For example, it may reflect reactive hyperplasia (a response to infection or inflammation), proliferation or infiltration of neoplastic cells, extramedullary hemopoiesis, phagocytic cell proliferation, increased blood cell destruction, or vascular congestion associated with portal hypertension.
Splenomegaly may be detected by light palpation under the left costal margin. (See How to palpate for splenomegaly.) However, because this technique isn’t always advisable or effective, splenomegaly may need to be confirmed by a computed tomography or radionuclide scan.
Emergency Actions
If the patient has a history of abdominal or thoracic trauma, don’t palpate the abdomen because this may aggravate internal bleeding. Instead, examine the patient for left-upper-quadrant pain and signs of shock, such as tachycardia and tachypnea. If you detect these signs, suspect splenic rupture. Insert an I.V. line for emergency fluid and blood replacement, and administer oxygen. Also, catheterize the patient to evaluate urine output, and begin cardiac monitoring. Prepare the patient for possible surgery.
History
Begin by exploring associated signs and symptoms. Ask the patient if he has been unusually tired lately. Does he frequently have colds, sore throats, or other infections? Does he bruise easily? Ask about left-upper-quadrant pain, abdominal fullness, and early satiety.
Physical assessment
Complete an abdominal assessment. Examine the patient’s skin for pallor and ecchymoses. Palpate his axillae, groin, and neck for lymphadenopathy.
Medical causes
Cirrhosis
About one-third of patients with advanced cirrhosis develop moderate to marked splenomegaly. Among other late findings are jaundice, hepatomegaly, leg edema, hematemesis, and ascites. Signs of hepatic encephalopathy — such as asterixis, fetor hepaticus, slurred speech, and decreased level of consciousness that may progress to coma — are also common. Besides jaundice, skin effects may include severe pruritus, poor tissue turgor, spider angiomas, palmar erythema, pallor, and signs of bleeding tendencies. Endocrine effects may include menstrual irregularities or testicular atrophy, gynecomastia, and loss of chest and axillary hair. The patient may also develop fever and right-upper-abdominal pain that’s aggravated by sitting up or leaning forward.
Endocarditis (subacute infective)
Endocarditis usually causes an enlarged, but nontender, spleen. Its classic sign, however, is a suddenly changing murmur or the discovery of a new murmur in the presence of fever. Other features include anorexia, pallor, weakness, fever, night sweats, fatigue, tachycardia, weight loss, arthralgia, petechiae, hematuria and, in chronic cases, clubbing. If embolization occurs, the patient may develop chest, abdominal, or limb pain; paralysis; hematuria; and blindness. Endocarditis may produce Osler’s nodes (tender, raised, subcutaneous lesions on the fingers or toes), Roth’s spots (hemorrhagic areas with white centers on the retina), and Janeway lesions (purplish macules on the palms or soles).
Hepatitis
Splenomegaly may occur with hepatitis. More characteristic findings include dark urine, clay-colored stools, anorexia, malaise, pruritus, hepatomegaly, vomiting, jaundice, and fatigue.
Histoplasmosis
Acute disseminated histoplasmosis commonly produces splenomegaly and hepatomegaly. It may also cause lymphadenopathy, jaundice, fever, anorexia, emaciation, and signs and symptoms of anemia, such as weakness, fatigue, pallor, and malaise. Occasionally, the patient’s tongue, palate, epiglottis, and larynx become ulcerated, resulting in pain, hoarseness, and dysphagia.
CULTURAL CUE:Histoplasmosis occurs worldwide, especially in the temperate areas of Asia, Africa, Europe, and North and South America. In the United States, it’s most prevalent in the central and eastern states, especially in the Mississippi and Ohio River Valleys.
Hypersplenism (primary)
With hypersplenism, splenomegaly accompanies signs of pancytopenia — anemia, neutropenia, or thrombocytopenia. If the patient has anemia, findings may include weakness, fatigue, malaise, and pallor. If he has severe neutropenia, frequent bacterial infections are likely. If he has severe thrombocytopenia, easy bruising or spontaneous, widespread hemorrhage may occur. The patient also experiences left-sided abdominal pain, and a feeling of fullness after eating a small amount of food.
Leukemia
Moderate to severe splenomegaly is an early sign of acute and chronic leukemia. With chronic granulocytic leukemia, splenomegaly is sometimes painful. Accompanying it may be hepatomegaly, lymphadenopathy, fatigue, malaise, pallor, fever, gum swelling, bleeding tendencies, weight loss, anorexia, and abdominal, bone, and joint pain. At times, acute leukemia also causes dyspnea, tachycardia, and palpitations. With advanced disease, the patient may display confusion, headache, vomiting, seizures, papilledema, and nuchal rigidity.
Lymphoma
Moderate to massive splenomegaly is a late sign of lymphoma and may be accompanied by hepatomegaly, painless lymphadenopathy, scaly dermatitis with pruritus, night sweats, fever, fatigue, weight loss, and malaise. Scaly rashes and pruritus may develop.
Mononucleosis (infectious)
A common sign of mononucleosis, splenomegaly is most pronounced during the second and third weeks of illness. Typically, it’s accompanied by a triad of signs and symptoms: sore throat, cervical lymphadenopathy, and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Occasionally, hepatomegaly, jaundice, and a maculopapular rash may also occur.
Pancreatic cancer
Pancreatic cancer may cause moderate to severe splenomegaly if tumor growth compresses the splenic vein. Other characteristic findings include abdominal or back pain, anorexia, nausea and vomiting, weight loss, GI bleeding, jaundice, pruritus, skin lesions, emotional lability, weakness, and fatigue. Palpation may reveal a tender abdominal mass and hepatomegaly; auscultation reveals a bruit in the periumbilical area and left upper quadrant.
Polycythemia vera
Late in polycythemia vera, the spleen may become markedly enlarged, resulting in easy satiety, abdominal fullness, and left-upper-quadrant or pleuritic chest pain. Signs and symptoms accompanying splenomegaly are widespread and numerous. The patient may exhibit deep, purplish red oral mucous membranes, headache, dyspnea, dizziness, vertigo, weakness, and fatigue. He may also develop finger and toe paresthesia, impaired mentation, tinnitus, blurred or double vision, scotoma, increased blood pressure, and intermittent claudication. Other signs and symptoms include pruritus, urticaria, ruddy cyanosis, epigastric distress, weight loss, hepatomegaly, and bleeding tendencies.
Splenic rupture
Splenomegaly may result from massive hemorrhage with splenic rupture. The patient may also experience left-upper-quadrant pain, abdominal rigidity, and Kehr’s sign. Signs and symptoms of shock may also occur.
Special considerations
Prepare the patient for diagnostic studies, such as a complete blood count, blood cultures, and radionuclide and computed tomography scans of the spleen.
Pediatric pointers
In addition to the causes of splenomegaly previously described, children may develop splenomegaly in histiocytic disorders, congenital hemolytic anemia, Gaucher’s disease, Niemann-Pick disease, hereditary spherocytosis, sickle cell disease, or beta-thalassemia (Cooley’s anemia). Splenic abscess is the most common cause of splenomegaly in immunocompromised children.
Patient counseling
Teach the patient about the disease process and his treatment options. Explain the importance of avoiding infection. Discuss the need for compliance with prescribed therapy and regular follow-up appointments.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Swollen spleen
Read excerpts from these other book chapters related to Swollen spleen:
Medical Books Excerpts
- Hepatomegaly
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Splenomegaly
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Hepatomegaly
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Splenomegaly
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Splenomegaly
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Hepatomegaly
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Splenomegaly
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Swollen spleen
» Next page: Hepatomegaly (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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