Spleenomegaly.pptx

Spleen : Anatomy; Physiology;Classification;Etiology;Stepwise approach; Assosiated features; Investigation.

1. SPL E NOMEGALY : APPROACH By- FAHAD AHMAD RN-27 FINAL YEAR MBBS HIMSR

2. INTRODUCTION  Anatomy & Physiology  Classification  Etiology  Step-wise approach  Associated features  Investigations

3. ANATOMY develops from condensations of mesoderm in the dorsal mesogastrium. The weight of the normal adult spleen is 75–250 g. lies in the left hypochondrium between the gastric fundus and the left hemidiaphragm, with its long axis lying along the tenth rib. The hilum sits in the angle between the stomach and the kidney and is in contact with the tail of the pancreas.

4.  The lower pole extends no further than the mid-axillary line.  There is a notch on the inferolateral border, and this may be palpated when the spleen is enlarged.

5. Normal spleen  Normal size  12 cm length , 7 cm width  13cm craniocaudal diameter  Weight < 250gm  Located along- 9 th , 10 th ,11 th 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.  Splenomegaly : Spleen weight of 400-500gm  750 – 1000gm : prominent below costal margin  >1000gm : massive splenomegaly

7. EXAMINATION OF SPLEEN  INSPECTION : Fullness in LUQ that descends on inspiration  Situated behind 9 th , 10 th and 11 th ribs  Long axis along line of 10 th rib  Anteriorly extends upto mid axillary line  Posteriorly, the superior angle is 4cm lateral to D10 spine

8. PALPATION  BIMANUAL PALPATION  BALLOTMENT  PALPATION FROM ABOVE - MIDDLETON MANOUVRE

9. BIMANUAL PALPATION  1. Place left palm firmly over left costal margin posterolaterally and press it forward and medially.  Palpate spleen with right hand starting from right iliac fossa

10. BIMANUAL PALPATION  2. Turn patient to right lateral position  Palpate with right hand

11. MIDDLETON MANOUVRE  Stand on left side  Face foot end of patient  Hooked fingers of LEFT HAND placed under left costal margin  With right hand, pressure is exerted over posterolateral aspect of lower thorax

12. PERCUSSION  NIXONS METHOD  Right lateral decubitus  Start from posterior axillary line  Upper border of dullness normally 6-8cm above costal margin  >8cm dullness  splenic enlargement

13. PERCUSSION  CASTELLS METHOD  Supine position  Dull note over lowest ICS in Anterior axillary line on full inspiration indicate splenomegaly

14. PERCUSSION  TRAUBE’S SEMILUNAR SPACE  left sixth rib superiorly  left anterior axillary line laterally  left costal margin inferiorly  Dull note : splenomegaly

15. Differential diagnosis  Enlarged left kidney  Enlarged left lobe liver  Carcinoma stomach  Carcinoma splenic flexure colon  Omental mass  Malignancy tail of pancreas

16. splenomegaly Massive Moderate Mi l d beyond umblicus, crosses mid line >8cm below left costal margin and or >1000gm weight b/w costal margin & umblicus (4-8cm) just palpable (1-3cm)

17. MECHANISM of SPLENOMEGALY  1. Hyperplasia or hypertrophy  Reticuloendothelial hyperplasia  Immune hyperplasia in response to  A. systemic infection  B. immunological diseases  2. Passive congestion due to decreased blood flow  3. Infiltrative diseases

18. CAUSES OF SPLENOMEGALY  Inflammatory splenomegaly  Hyperplastic splenomegaly  Infectious splenomegaly  Congestive splenomegaly  Infiltrative splenomegaly INCREASED DEMAND FOR SPLENIC FUNCTION

19. 1. INCREASED DEMAND  A. RETICULOENDOTHELIAL SYSTEM HYPERPLASIA  Spherocytosis  Early sickle cell anemia  Ovalocytosis  Thalassemia major  Hemoglobinopathies  PNH  Pernicious anemia

20. INCREASED DEMAND  B. IMMUNE HYPERPLASIA Hi (i) Response to infection IMN, viral hepatitis,AIDS,CMV,IE,TB, stoplasmosis, Malaria,Bacterial sepsis,Cong syphilis, splenic abscess, Leishmaniasis, Trypanosmiasis, Ehrlichiosis  (ii) Disordered Immunoregulation RA (Felty syndrome), SLE, Collagen vascular diseases, AIHA,Immune thrombocytopenias, Drug reactions, Sarcoidosis, Interleukin2 therapy,Thyrotoxicosis  (iii) Extramedullary hematopoiesis : Myelofibrosis, Myelo infiltrative disorders, marrow damage by toxins,radiation.

21. 2. Abnormal splenic/portal blood flow  Cirrhosis  Hepatic vein obstruction  Portal vein obstruction  Cavernous transformation of portal vein  Splenic vein obstruction  Splenic artery aneurysm  Hepatic schistosomiasis  CHF  Hepatic echinococcosis  Portal hypertension

22. 3. Infiltration of Spleen deposits  Amyloidosis  Gaucher disease  Niemann Pick  Tangier disease  Hurlers syndrome, Other MPS  Hyperlipidemias  Intracellular or extracellular Leu k emias Benign and Malignant Infiltrations Lymphomas Hodgkins disease Myeloproliferative syndromes Angiosarcomas Metastasis ( MC= Melanoma) Eosinophilic Granuloma Histiocytosis X Hamartomas Hemangioma Splenic cysts

23. 4. Unknown Etiology  Idiopathic splenomegaly  Berylliosis  Iron deficiency anemia

24. MASSIVE SPLENOMEGALY (>1000GM or >8cm)  CML  CLL  Lymphoma  Hairy cell leukemia  Myelofibrosis with myeloid metaplasia  Chronic malaria  Kala - azar (Tropical Splenomegaly)  Sarcoidosis  Gaucher disease  AIHA  Diffuse splenic hemangiomatosis

25. Moderate splenomegaly(4-8cm)  Viral hepatitis  Cirrhosis  Lymphomas  Amyloidosis  Splenic abscess,infarct  Hemolytic anemias  IMN  Hemochromatosis  Polycythemias

26. Mild splenomegaly (1-3cm)  Acute malaria  Typhoid  kala-azar  Septicemias  SLE  Infective endocarditis  RA  Thalassemia Minor  Miliary TB  Leptospirosis  HIV  CCF

27. Step-wise approach to splenomegaly  History  Physical examination  Laboratory tests  Imaging  Specialised tests

28. H istory  Mild vague, abdominal pain.  Pain may be referred to the left shoulder.  Early satiety from gastric displacement occurs with massive splenomegaly.  Associated symptoms or signs  Febrile illness (infectious)  Pallor, dyspnea, bruising, and/or petechiae (hemolytic process)  History of liver disease (congestive)  Weight loss, constitutional symptoms (neoplastic)  Pancreatitis (splenic vein thrombosis)  Alcoholism, hepatitis (cirrhosis)

29. 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

30. 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

31. Lab investigations  CBC  Peripheral smear study  Reticulocyte count  Blood C/S  Serology (viral, parasitic)  LFT  Hb electrophoresis / coombs test  Coagulation profile  Amylase/lipase  AMA, Anti CCP, RA factor  Bone marrow analysis

32. Imaging  USG  CT scan sensitive & specific non-invasive etiology of splenomegaly liver size,heterogenecity splenic mets, abscess,calcf.,cysts retro peritoneal LN cranio caudal ln > 12 cm  Liver- spleen colloid scan- (RBC – Cr51,Tc99) hepatic steatosis, SOL, splenic functions PHT, colloid shift +  MRI/ Doppler USG portal / splenic vein thrombosis cavernomas

33. imaging  MRI scanliver hemangiomas hemochromatosis erlenmeyer flask sign (Gaucher)  PET scan Dx & staging of lymphomas determine metabolic cells in spleen

34. Specialised testing  Abdominal fat pad aspiration  JAK-2 mutation  Gene testing ( bcr-abl , C282Y)  Enzyme testing  Lymph node biopsy  FNAC spleen  Splenectomy  Liver biopsy