Splenomegaly

splenomegaly- methods of examination
differential diagnosis of spleen
massive splenomegaly
percussion

1. Splenomegaly DR TANIYA PRUTHI

2. Introduction Reticuloendothelial organ Origin in dorsal mesogastrium at about 5 th week. Attached to stomach through gastrolienal ligament and to kidney via lienorenal ligament Originates in series of hillocks If hillocks fail to unify, it will produce accessory spleen seen in 20%.

3. Functions Quality check over the red blood cells by removing senescent and defective rbcs from the circulation in the red pulp Synthesis of antibodies in white pulp Removal of antibody coated rbc or bacteria from circulation Has a role in portal circulation

4. Anatomical details It has a white and red pulp Major blood flows into the central arterioles Through it will enter into cords and sinuses but will find its way back into circulation. Old and damaged rbcs are less deformable so they stay back in the cords where they are destroyed and components are recycled. Normal human spleen does not store rbc and contract in response to sympathetic stimulation Contain one third of total body platelets and marginated neutrophil s

5. Spleen weighs <250grams Entirely fits within the rib cage On ultrasound-max cepahlo -caudal diameter is 13cm Not palpable normally

6. Invasion of R bc by malarial parasite Image showing howell jolly body Denatured haemoglobin in the rbc

7. Adaptive function Clear bacteria from the circulation Generate immune response against the pathogen Extramedullary hematopiesis

8. Clinical approach Common symptoms seen are pain and heaviness in the left upper quadrant . Causes of pain are- 1)Acute swelling of the spleen and stretching of the capsule 3)Infarction 2) Inflammation of the capsule 4)Sickle cell crises Rupture of spleen itself can be painless

9. Physical examination On inspection -fullness in the left upper quadrant which descends with inspiration seen in massive splenomegaly For palpation- 1)Bimanual palpation 2) ballotment 3)Palpation from above( middleton maneuvre )

10. Bimanual palpation Patient is supine and knee flexed Left hand stretches the skin over the lower rib cage Right hand fingertips are used to palpate tip of spleen while patients inspires slowly and smoothly

11. For percussion three methods can be used Nixons method- Patient is placed on the right side Follow posterior axillary line percussion begins at lower level of pulmonary resonance and proceed diagonally along prependicular line towards the lower midanterior costal margin Upper border of dullness is 6-8cm above the costal margin Dullness of >8cm suggests splenomegaly

12. Castells method- patient is supine Follow the anterior axillary line Percuss In the lowest intercostal space Usually produces resonant sound If spleen is enlarged, in full expiration produces dull note.

13. 3)Percussion of traube’s semilunar space Traube’s space boundaries are Superiorly –sixth rib Inferiorly left costal margin Laterally-left mid axillary line Patient lies supine with left arm slightly abducted During normal breathing ,space is percussed from medial to lateral producing resonant sound If splenomegaly is present-dull note can be heard

14. Ausculatation Venous hum or friction rub

15. Differential diagnosis

16. Laboratory testing Cbc Peripheral smear study Reticulocyte count Blood c/s Serology Lft Coombs test Coagulation profile Bone marrow analysis

17. imaging Ultrasound- sensitive and non invasive CT scan -can detect splenic mets,abcess,cyst,retroperitoneal lyph node Mri / doppler ultrasound -portal and splenic vein thrombosis PET scan -for diagnosis and staging of lymphomas

18. Ultrasound showing spleen

19. Management Treat the underlying cause Follow up the patient for any increase in size If causing complications-remove the spleen known as splenectomy To reduce risk of infections after surgery- Vaccinations before and after surgery includes-pneumococcal vaccine,hemophilus influenza type b vaccine, meningococcal vaccine .

20. Thank you!!!