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SPLENOMEGALY- INTEGRATED
APPROACH TO DIAGNOSIS
CANDIDATE: DR. SARATH MENON.R
DIVISION OF GASTROENTEROLOGY
MGM MEDICAL COLLEGE,INDORE
INTRODUCTION
 Definition & symptoms
 Classification
 Hypersplenism
 Etiology
 Step-wise approach
 Associated features
 Investigations
 Galen –source of
black “black bile‟ or
 “melancholia”
NORMAL SPLEEN
 Normal size – 12 cm length , 7 cm width
(radionuclide scan)
-13cm craniocaudal diamtr (USG)
 weight- < 250gm
 Located along- 9th, 10th,11th ribs mid-axillary
 Spleen should be twice the size to be PALPABLE
 Palpable spleens are not always ABNORMAL
 3% normal population has palpable spleen
Approach to splenomegaly
FUNCTIONS
 Quality control over RBC – culling & pitting
 Synthesis of antibodies
 Removal of antibody coated bacteria & RBC
EXAMINATION OF SPLEEN
 Inspection
 Percussion – nixon method
- rt.lateral ducubitus, > 8cm
- castells method
supine,lower ICS ,full exp & insp
splenomegaly=dullness
- traubes sign
supine,6th rib,costal margin,
anterior axill. line
splenomegaly= dullness
 Palpation - bimanual method,hooking maneuver
Approach to splenomegaly
Approach to splenomegaly
TRAUBE‟S SPACE
BIMANUAL PALPATION
DIFFERENCES
 Sharp edge
 Notch –med border
 Cross midline
 Moves with
respiration
 Cannot get above it
 Round edge
 No notch
 Not cross midline
 Not moves with resp.
 Can get above it
spleen kidney
SPLENOMEGALY
 Mild,moderate,massive
 Massive - beyond umblicus, crosses mid line
into pelvis
(>8cm)
 Moderate- b/w costal margin & umblicus
(4-8cm)
 Mild - just palpable
(1-3cm)
HYPERSLENISM
 Splenomegaly
 Pancytopenia
 Presence of hypercellular marrow
 Reversal with splenectomy
SYMPTOMS OF SPLENOMEGALY
 Pain
 Early satiety
 Feeling of heaviness in LUQ
MECHANISM OF SPENOMEGALY
 Reactive Reticulo-endothelial hyperplasia
 Lymphoid hyperplasia
 Proliferation of lymphoma cells
 Infiltration by abnormal cells
 Extramedullary hemopoeisis
 Proliferation of macrophages d/t RBC
destruction
 Vascular congestion
CAUSES OF SPLENOMEGALY
 Infective
 Hyperplastic
 Congestive
 Infiltration
INFECTIVE
 Acute & subacute- IMN, infective endocarditis,
severe pyogenic inf.
Viral hepatitis,CMV,AIDS
 Chronic - TB,syphilis,brucellosis
 Tropical splenomegaly
 Malaria,kala azar, trypanosomiasis
CONGESTIVE
 Intra hepatic obst.portal hypertension
- cirrhosis,biliary cirrhosis,hemochromatosis
- primary sclerosing cholangitis
 Extra-hepatic portal hypertension
- venous malf,thrombosis,stenosis
- ext.occlusion of portal,splenic vein
 Chronic passive congestion of cardiac origin
HYPERPLASTIC
 Extramedullary hemopoeisis- myeloprolif.d/s
- marrow damage
- marrow infiltration
 Reticulo endothelial hyperplasia –(abn.RBC)
- sickle cell d/s,spherocytosis,Hbnopathies,
thalassemia major,PNH
INFILTRATIVE
 Malignant infiltration- CML,lymphoblastic
- lymhomas, MPD,
- angiosarcoma,tumors
- metastasis (melanoma)
 benign -
- storage d/s –Gaucher‟s,Neiman-pick
- amyloidosis
- hurler‟s syndrome,MPS
- cysts,fibromas,hemangiomas,hamartomas
-Eosnophilic granulomas
DISORDERED IMMUNOREGULATION
 Felty‟s syndrome- RA+ splenomegaly+leucopenia
 Systemic lupus erythromatosis
 Collagen vascular diseases
 Sarcoidosis
 Immune thrombocytopenia
MASSIVE SPLENOMEGALY (>8CM
>1000GM)
 Myeloproliferative disorder
 Chronic malaria,kala-azar (trop. Splenomegaly)
 Storage disorders
 Thalassemia major
 Sarcoidosis
 Hairy cell leukemia
 Gaucher disease
 Diffuse splenic hemangiomatosis
MODERATE SPLENOMEGALY(4-8CM)
 Cirrhosis
 Lymphomas„
 Amyloid
 Splenic abscess,infarct
 Hemolytic anemias
 IMN
MILD SPLENOMEGALY (1-3CM)
 Acute infective conditons
 Acute malaria,tyhoid,kala-azar,septicemias
STEP-WISE APPROACH TO SPLENOMEGALY
 History
 Physical examination
 Laboratory testings
 Imaging
 Specialised testing
HISTORY
 Age ,gender
 Race
 h/o recent infections like malaria
 Fever,weight loss,sweating (lymphomas,infections)
 Pruritis
 Abnormal bleeding/bruising
 Joint pain
 h/o alcholism
 h/o trauma
 h/o neonatal umblical sepsis
 Residence & travel abroad
HISTORY …..CONT
 Jaundice
 High risk sexual behavior (AIDS)
 Past medical history
 Drugs
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
LAB INVESTIGATIONS
 CBC
 Blood smear
 Retic count
 Blood C/S
 Serology (fungal,viral,parasitic)
 LFT
 Hb electropheresis/ coombs test
 Coag.profile
 Amylase/lipase
 AMA, Anti CCP,RA factor
 Bone marrow analysis
IMAGING
 USG- sensitive & specific non-invasive
 CT scan – etiology of splenomegaly
- liver size,heterogenecity
- splenic mets, abscess,calcf.,cysts
- retro peritoneal LN
- craniocaudal ln > 10 cm
 Liver- spleen colloid scan- (RBC –Cr51,Tc99)
- hepatic steatosis,SOL,splenic functions
- PHT,colloid shift +
 MRI/ Doppler usg- portal/splenic vein thrombosis
- cavernomas
IMAGING
 MRI scan- liver hemangiomas
hemochromatosis
erlenmeyer flask sign(Gaucher)
 PET scan - Dx & staging of lymphomas
- determine metabolic cells in spleen
SPECIALISED TESTING
 Abd.fat pad aspiration
 JAK-2 mutation
 Gene testing(bcr-abl ,C282Y)
 Enzyme testing
 Lymph node biopsy
 FNAB spleen
 Splenectomy
 Lung or skin biopsy
 Liver biopsy
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
TROPICAL SPLENOMEGALY (HMS)
 Massive splenomegaly
 Endemic areas of malaria,kala-azar
 IgM antibodies +
 No parasite in blood
 Lymhocytic infiltration of splenic sinusoids
 Long term anti-malarials
SUMMARY
 Splenomegaly – major physical finding
 Step wise approach- history,physical exam
 Look for associated features
 Lab investigation & Imaging
 Search for etiology & treat
Approach to splenomegaly

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Approach to splenomegaly

  • 1. SPLENOMEGALY- INTEGRATED APPROACH TO DIAGNOSIS CANDIDATE: DR. SARATH MENON.R DIVISION OF GASTROENTEROLOGY MGM MEDICAL COLLEGE,INDORE
  • 2. INTRODUCTION  Definition & symptoms  Classification  Hypersplenism  Etiology  Step-wise approach  Associated features  Investigations
  • 3.  Galen –source of black “black bile‟ or  “melancholia”
  • 4. NORMAL SPLEEN  Normal size – 12 cm length , 7 cm width (radionuclide scan) -13cm craniocaudal diamtr (USG)  weight- < 250gm  Located along- 9th, 10th,11th 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. FUNCTIONS  Quality control over RBC – culling & pitting  Synthesis of antibodies  Removal of antibody coated bacteria & RBC
  • 7. EXAMINATION OF SPLEEN  Inspection  Percussion – nixon method - rt.lateral ducubitus, > 8cm - castells method supine,lower ICS ,full exp & insp splenomegaly=dullness - traubes sign supine,6th rib,costal margin, anterior axill. line splenomegaly= dullness  Palpation - bimanual method,hooking maneuver
  • 12. DIFFERENCES  Sharp edge  Notch –med border  Cross midline  Moves with respiration  Cannot get above it  Round edge  No notch  Not cross midline  Not moves with resp.  Can get above it spleen kidney
  • 13. SPLENOMEGALY  Mild,moderate,massive  Massive - beyond umblicus, crosses mid line into pelvis (>8cm)  Moderate- b/w costal margin & umblicus (4-8cm)  Mild - just palpable (1-3cm)
  • 14. HYPERSLENISM  Splenomegaly  Pancytopenia  Presence of hypercellular marrow  Reversal with splenectomy
  • 15. SYMPTOMS OF SPLENOMEGALY  Pain  Early satiety  Feeling of heaviness in LUQ
  • 16. MECHANISM OF SPENOMEGALY  Reactive Reticulo-endothelial hyperplasia  Lymphoid hyperplasia  Proliferation of lymphoma cells  Infiltration by abnormal cells  Extramedullary hemopoeisis  Proliferation of macrophages d/t RBC destruction  Vascular congestion
  • 17. CAUSES OF SPLENOMEGALY  Infective  Hyperplastic  Congestive  Infiltration
  • 18. INFECTIVE  Acute & subacute- IMN, infective endocarditis, severe pyogenic inf. Viral hepatitis,CMV,AIDS  Chronic - TB,syphilis,brucellosis  Tropical splenomegaly  Malaria,kala azar, trypanosomiasis
  • 19. CONGESTIVE  Intra hepatic obst.portal hypertension - cirrhosis,biliary cirrhosis,hemochromatosis - primary sclerosing cholangitis  Extra-hepatic portal hypertension - venous malf,thrombosis,stenosis - ext.occlusion of portal,splenic vein  Chronic passive congestion of cardiac origin
  • 20. HYPERPLASTIC  Extramedullary hemopoeisis- myeloprolif.d/s - marrow damage - marrow infiltration  Reticulo endothelial hyperplasia –(abn.RBC) - sickle cell d/s,spherocytosis,Hbnopathies, thalassemia major,PNH
  • 21. INFILTRATIVE  Malignant infiltration- CML,lymphoblastic - lymhomas, MPD, - angiosarcoma,tumors - metastasis (melanoma)  benign - - storage d/s –Gaucher‟s,Neiman-pick - amyloidosis - hurler‟s syndrome,MPS - cysts,fibromas,hemangiomas,hamartomas -Eosnophilic granulomas
  • 22. DISORDERED IMMUNOREGULATION  Felty‟s syndrome- RA+ splenomegaly+leucopenia  Systemic lupus erythromatosis  Collagen vascular diseases  Sarcoidosis  Immune thrombocytopenia
  • 23. MASSIVE SPLENOMEGALY (>8CM >1000GM)  Myeloproliferative disorder  Chronic malaria,kala-azar (trop. Splenomegaly)  Storage disorders  Thalassemia major  Sarcoidosis  Hairy cell leukemia  Gaucher disease  Diffuse splenic hemangiomatosis
  • 24. MODERATE SPLENOMEGALY(4-8CM)  Cirrhosis  Lymphomas„  Amyloid  Splenic abscess,infarct  Hemolytic anemias  IMN
  • 25. MILD SPLENOMEGALY (1-3CM)  Acute infective conditons  Acute malaria,tyhoid,kala-azar,septicemias
  • 26. STEP-WISE APPROACH TO SPLENOMEGALY  History  Physical examination  Laboratory testings  Imaging  Specialised testing
  • 27. HISTORY  Age ,gender  Race  h/o recent infections like malaria  Fever,weight loss,sweating (lymphomas,infections)  Pruritis  Abnormal bleeding/bruising  Joint pain  h/o alcholism  h/o trauma  h/o neonatal umblical sepsis  Residence & travel abroad
  • 28. HISTORY …..CONT  Jaundice  High risk sexual behavior (AIDS)  Past medical history  Drugs
  • 29. 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
  • 30. LAB INVESTIGATIONS  CBC  Blood smear  Retic count  Blood C/S  Serology (fungal,viral,parasitic)  LFT  Hb electropheresis/ coombs test  Coag.profile  Amylase/lipase  AMA, Anti CCP,RA factor  Bone marrow analysis
  • 31. IMAGING  USG- sensitive & specific non-invasive  CT scan – etiology of splenomegaly - liver size,heterogenecity - splenic mets, abscess,calcf.,cysts - retro peritoneal LN - craniocaudal ln > 10 cm  Liver- spleen colloid scan- (RBC –Cr51,Tc99) - hepatic steatosis,SOL,splenic functions - PHT,colloid shift +  MRI/ Doppler usg- portal/splenic vein thrombosis - cavernomas
  • 32. IMAGING  MRI scan- liver hemangiomas hemochromatosis erlenmeyer flask sign(Gaucher)  PET scan - Dx & staging of lymphomas - determine metabolic cells in spleen
  • 33. SPECIALISED TESTING  Abd.fat pad aspiration  JAK-2 mutation  Gene testing(bcr-abl ,C282Y)  Enzyme testing  Lymph node biopsy  FNAB spleen  Splenectomy  Lung or skin biopsy  Liver biopsy
  • 34. 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
  • 35. TROPICAL SPLENOMEGALY (HMS)  Massive splenomegaly  Endemic areas of malaria,kala-azar  IgM antibodies +  No parasite in blood  Lymhocytic infiltration of splenic sinusoids  Long term anti-malarials
  • 36. SUMMARY  Splenomegaly – major physical finding  Step wise approach- history,physical exam  Look for associated features  Lab investigation & Imaging  Search for etiology & treat