Clinical examination of spleen

This presentation gives general overview of different techniques of clinical examination of spleen.

1. C linical examination of spleen Jibran Mohsin Resident, Surgical Unit I SIMS/Services Hospital, Lahore

2. Outline Introduction Clinical examination Inspection Palpation Percussion Features of splenic mass

3. Introduction NORMAL SPLEEN palpable or not? NOT palpable clinically Only occasionally palpable in 1-3 % of New Guinea population (exception) Tip may be palpable in newborn up to 3 moths of age Size of NORMAL SPLEEN? 5 inches (length) x 3 inches (width) x 1 inches (thickness) i.e. 12 x 7 cm Enlarged if largest dimension > 14 cm (SRB’s clinical methods in surgery, 1 st edition, pg. 466)

4. Introduction WHEN CLINICALLY PALPABLE? Very variable axis and will become palpable with lesser degree of enlargement when almost vertical than when almost horizontal. (i.e. Palpable spleen always indicates splenomegaly OR normal spleen not palpable) Clinically palpable if…………………. Near/more than 2 times enlarged Bedside techniques: Methods of clinical examination,3 rd edition, pg. 156 ; A manual on clinical surgery, 10 edition, S. Das, pg. 491 2.5 times normal SRB’s clinical methods in surgery, 1 st edition, pg. 493 2-3 times normal Hutchison’s clinical methods, 22 nd edition, pg. 125 3 times normal Clinically oriented anatomy, Keith L. Moore, 5 th edition, pg. 285; Macleod’s Clinical examination,12 th edition, pg. 202; SRB’s clinical methods in surgery, 1 st edition, pg. 466

5. Introduction Direction of enlargement: Before clinically palpable Enlarges in superior and posterior direction Once palpable Appears/felt below tip of 10 th rib (beneath/under the left costal margin) Enlarges downwards, medially (inwards) and forwards towards umbilicus. ( LHC to RIF)

6. Introduction Grading of enlargement/ slpenomegaly Basis of Classification Largest dimension Distance from left costal margin Moderate splenomegaly 11-20 cm Tip enlargement (mild) 1-2 cm (up to 3 cm) Severe Splenomegaly > 20 cm Moderate enlargement 3-7 cm (3-8 cm) Marked(severe) enlargement 7 + cm (>8 cm)

7. CLINICAL EXAMINATION – SPLENOMEGALY (INSPECTION) a bulging mass may be seen emerging from under the Left costal margin extending diagonally towards the Right Lower Quadrant (RLQ)

8. CLINICAL EXAMINATION – SPLENOMEGALY (PALPATION) SUPINE POSITION (BEST POSITION for palpation _BAILEY ) Single (right) hand (press during expiration, keep steady during inspiration) (1 cm at a time between each breath) (breath deeply with open mouth) (feel splenic edge as it descends during inspiration)(release pressure during peak of inspiration) Classical method (RLQ/umbilicus/just below in RIF(diagonally)  LHC) Lateral aspect of index finger (parallel to left costal margin) (S. Das) Tip of middle/index fingers (fingers lying transversely across abdomen) (N. Browse, SRB, Macleod’s, Hutchison, Bedside , Bailey ) Feel costal margin along its length as position of tip is variable; medial to lateral direction Bimanual (support with left hand, palpate with right hand) Put left hand placed on left lower ribs. Slide skin downwards so that right hand gets an extra bit of skin to insinuate beneath the left costal margin. Place flat of left hand over the lowermost ribcage posterolaterally (restricting the expansion of left lower ribs on inspiration and concentrating more of the inspiratory movement into moving spleen downwards OR pulling ribcage forward) (Ask patient to relax back on to your left hand) Right hand placed beneath costal margin well out to left. Ask patient to breath in deeply. Press in deeply with fingers of right hand beneath the costal margin(medial – lateral), at same time exerting considerable pressure medially and downwards with left hand. Repeat this maneuver with right hand moving more medially beneath costal margin on each occasion. RIGHT LATERAL POSITION (left leg flexed at hip and knee ± place patient left hand on your right shoulder) Bimanual (support with left hand, palpate with right hand) STAND ON LEFT SIDE OF PATIENT (NOT recommended) Hook method (Supine position) From above, spleen may be continently palpable with 2 hands arching below the left costal margin while patient is asked to take deep breath in/out slowly. Hands moved further downwards and laterally with each expiration waiting for enlarged spleen to knock at fingers during inspiration when fingers are kept static. Hooking maneuver of Middleton (Middleton’s maneuver) (Right lateral position) Examiner stands on left side facing towards foot end. Keep left hand fingers hooked under left costal margin, exert pressure now posterolateral aspect of lower thorax using right hand. Place patient’s left fist under their left posterior chest Spleen felt at end of deep inspiration MISCELLANEOUS ( Dipping method- marked ascites ) ( maneuver of Bockus –jump up and down a few times in splanchnoptotic habitus)

9. CLINICAL EXAMINATION – SPLENOMEGALY (PERCUSSION) Percussion from RIF towards LHC like single handed palpation Percussion of Traube’s (semilunar)Space crescent-shaped space, encompassed by the lower edge of the  left lung , the anterior border of the  spleen , the left costal margin and the inferior margin of the  left lobe  of the  liver . Thus, its surface markings are respectively the left sixth  rib  superiorly, the left mid axillary line laterally, and the left costal margin inferiorly. With patient supine, percuss inferior to lung resonance to map out gastric tympany. Should be resonant on percussion (due to gastric bubble) Dullness indicates possible splenomegaly as stomach gets displaced. (False positive = full stomach/colon i.e. time since las meal , pleural effusion, pneumonia, obesity) Sensitivity 62 % and specificity 72 % Percussion by Castell’s method ( Donald O. Castell first described his sign in the 1967) With patient in supine position, percuss in the lowest Left intercostal space in the anterior axillary line (usually the 8th or 9th IC space – Castell’s point ) this space should remain resonant during full inspiration dullness on full inspiration indicates possible splenic enlargement (a positive Castell’s sign ) Most sensitive of all clinical signs Sensitivity 82 % and specificity 83 %. Interpretation and false positive = same as percussion of Traube’s space Percussion by Nixon’s method patient is first placed in the right lateral decubitus position. Percussion starts at the midpoint of the left costal margin and is continued upward perpendicular to the left costal margin. Normally, the level of dullness does not extend more than 8 cm above the costal margin and splenomegaly is diagnosed if the dullness extends beyond 8 cm. Ludwig Traube (1818 -1876) German physician (first described by his pupil in 1868)

10. Features of splenic mass Firm swelling Sharp/smooth rounded anterior border/edge with angular poles Dull to percussion over mass 1-2 notches often-though not invariably- felt in lower medial border/midway/ supero -medial along its leading edge. Not bimanually palpable thus not ballotable (i.e. can’t be pushed back and forth between the anterior and posterior hands – feels like patting a ball back and forth in a pool of water) Moves downwards on inspiration Can’t insinuate into space between left costal margin and spleen (Hook sign- hooking the left costal margin with fingers is not possible) Upper border can’t be felt (i.e. can’t ‘get above it’) Appearing beneath left subcostal margin in LHC/LUQ  RIF (enlarges downward and medially) No Bowel sounds over spleen

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