Splenomegaly physical diagnosis pdf

Portal hypertension is an important cause of splenomegaly in most tropical countries. Other causes of splenomegaly include infections, liver disease and some cancers. Describe how the physical examination affects the physicianpatient. Splenomegaly is most often discovered under physical examination. Hypersplenism is a syndrome characterized by splenomegaly and any or all of the following cytopenias. However, in some people especially those who are slender a healthy, normalsized spleen can sometimes be felt during an exam. If your institution subscribes to this resource, and you dont have a myaccess profile, please contact your librarys reference desk for information on how to.

Your spleen is a fistsized organ located behind your stomach and just under your left rib cage. The classic causes of massive tropical splenomegaly are hyperreactive malarial splenomegaly formerly tropical splenomegaly syndrome1, schistosomiasis, visceral leishmaniasis, thalassaemia major, chronic myeloid leukaemia, myelofibrosis, and miscellaneous disorders such as splenic cysts, tumours, and lipid storage diseases. It has been found in up to 70% in a postmortem study. In the past, splenomegaly was a clinical finding, but in recent years, imaging studies have also helped to assess for or confirm mild splenomegaly. The differential diagnosis for splenomegaly is broad but can be grouped into. Pdf hypersplenism is a condition in which the spleen becomes increasingly active and then rapidly removes the blood cells. Assessment of splenomegaly differential diagnosis of. Splenomegaly can be found in 3% of the normal population. Congestion cirrhosis, hepatic fibrosis, portal vein thrombosis, splenic vein thrombosis, longstanding congestive heart failure.

Causes of massive splenomegaly beyond umbilicus in very large spleen lower splenic pole may extend into pelvis and cross abdominal midline. The spleen is enlarged in a number of important clinical diagnoses. Enlarged spleen splenomegaly diagnosis and treatment. It is important to understand that this condition can lead to a serious or lifethreatening symptoms, if proper medical treatment. It enlarges towards the right iliac fossa rif always start palpation in the rif and move across towards the right upper quadrant or a massive splenomegaly may be missed. The purpose of both palpation and percussion of the spleen is to look for splenic enlargement. A 48 yearold woman with abdominal cramping, vomiting, and no bowel movement for 2 days. Get a printable copy pdf file of the complete article 1. In normal individuals or in patients with mild splenomegaly, the spleen generally retains its usual tetrahedral shape and there appears to be a good cor relation between measurements whether by mr, ct or ultrasound 1. Palpation and percussion of the spleen are important techniques for identifying an enlarged. Brucellosis schistosomiasis stool ova and parasite s.

Pdf pointofcare ultrasonography improves the diagnosis of. However, a variety of disorders can cause the spleen to enlarge, sometimes to 2kg or more. Anatomy develops from condensations of mesoderm in the dorsal mesogastrium. The spleen is a fistsized organ in the upper left side of your abdomen, next to your stomach and behind your left ribs. It may also be felt in 1% of normal older children and adolescents. Imaging also delineates the architecture of the enlarged spleen, and distin.

Splenomegaly increases the spleens mechanical filtering and destruction of red blood cells rbcs and often of white blood cells wbcs and platelets. Patients and methods we identified 129 patients through the dnrp, that had been given the icd10 splenomegaly diagnosis code in 199420 at odense university hospital, denmark, excluding. The most common complaint in patients with splenomegaly is mild, vague, abdominal discomfort. Prevalence and clinical significance of splenomegaly in. Examiner dependence on physical diagnostic tests for the. In patients where the likelihood of splenomegaly is high, the physical exam is not sufficiently sensitive to detect it. The sensitivity for detection of ultrasounddocumented splenic enlargement is 60 to 70% for palpation and 60 to 80% for percussion.

A normalsized spleen cannot be palpated felt during the physical examination of the abdomen, except in slender people. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. It can be detected on physical examination by using castells sign, traubes space percussion or nixons sign, but an ultrasound can be used to confirm diagnosis. What is splenomegalycausessymptomstreatmentdiagnosis. When considering whether an luq mass is an enlarged spleen, features of an enlarged spleen include that. During two evaluations of refugee populations in western uganda in march and july 2015, refugees with splenomegaly on physical examination were offered additional assessment and treatment, including abdominal ultrasonography and laboratory testing. Diagnosis is made using criteria developed by the polycythemia vera study group. The differential diagnosis of splenomegaly includes.

It is a reservoir for platelets and a site for the proliferation of blymphocytes. Population for whom the physical examination of splenomegaly should be sought. Even in palpable splenomegaly, radiological assessment is usually necessary to quantitate the abnormality, as discussed above. Tuberculous splenomegaly with the hypersplenism syndrome. Splenomegaly increases the spleen s mechanical filtering and destruction of red blood cells rbcs and often of white blood cells wbcs and platelets. Splenomegaly is an enlargement of the spleen resulting from abnormalities of its lymphoid, reticuloendothelial, or vascular components. An enlarged spleen is usually detected during a physical exam. The differential diagnosis of splenomegaly is extensive table 1.

Splenomegaly pediatrics clerkship the university of. The main modalities used are ultrasound and ct fig. One third of neonates and one tenth of children may have a normal, palpable spleen. Reasons for feeling a normal spleen include an unusual position and being pushed down by hyperexpanded lungs. Clinical approach to isolated splenomegaly association physicians. Diagnosis of splenomegaly diagnosing splenomegaly involves a number of tests, including. Evaluation of splenomegaly approach bmj best practice. Splenomegaly may be a presenting or dominant feature of certain diseases.

Primary tuberculosis of the spleen coined by coley in 1846 1 refers to an enlarged spleen from tuberculosis no or little involvement of other organs 1938englebrethholm changed it to. The spleen is felt in 30% of normal newborns and up to 10% of one year olds. Myeloproliferative disorder proliferation of stem cells chronic myeloid leukemia polycythemia thrombocytosis 2. The term splenomegaly generally denotes a palpably enlarged spleen. Splenomegaly is an exception rather than the rule, and the hematologic profile is that of selective absence or reduction in the number of neutrophils, while monocytes, eosinophils, and basophils are either normal or increased. These maneuvers have received more extensive evaluation than other maneuvers.

Implicit in the definition is that the cytopenias will correct after splenectomy. All clinical records including laboratory result and medical imaging. Most often, the etiology is evident in light of historical and genealogical information and the concurrent presence of familiar, often pathognomonic, physical or laboratory findings e. In this study there was high interobserver variability, which did not appear to be associated to the level of experience. However, when the tip of the spleen is felt beyond 2 cm below the left costal margin, it is considered abnormal. Comparing physical examination with sonographic versions of the. Diagnosis is based on either the presence of 5 out of 8 criteria fever, splenomegaly, bicytopenia, hypertriglyceridemia andor hypofibrinogenemia, hemophagocytosis, low or absent nkcell activity, hyperferritinemia, and high levels of soluble interleukin2 receptor, or a molecular diagnosis.

The physical examination for splenomegaly had a sensitivity of 40 % 95 % ci 1277 % and specificity of 88 % 95 % ci 7495 % while physical examination plus pocus had a sensitivity of 100 % 95 % ci 57100 % and specificity of 74 % 95 % ci 5785 %. Evidencebased physical diagnosis essential here dermatologic diagnosis cellulitis zoster psoriasis neurologic diagnosis parkinsons disease bells palsy amyotrophic lateral sclerosis musculoskeletal diagnosis cardiologic diagnosis pericarditis mitral valve prolapse ophthalmologic diagnosis diabetic retinopathy psychiatric diagnosis. Enlarged spleen splenomegaly may be easier to palpate during careful abdominal examination. Splenomegaly is defined as enlargement of the spleen, measured by size or weight. Evaluation of splenomegaly is notoriously difficult and embarrassingly easy to miss when present. The spleen is a functionally diverse organ with active roles in immunosurveillance and hematopoiesis. Hepatosplenomegaly refers to an enlargement of the liver and spleen. Splenomegaly is a frequent finding among hivinfected adults 1, 2. Jan 22, 2019 splenomegaly is a pathological condition in which spleen of an individual gets enlarged. Splenomegaly and hypersplenism information page patient. Although several methods of palpation and percussion of the spleen have been described, until recently they have not been validated by noninvasive imaging techniques such as ultrasonography, radionuclide scanning, and computed tomography that offer objective means to assess splenomegaly. Increased workload of the spleen can be caused by immunologic stress infection, inflammation, or an autoimmune disorder or by increased rbc removal rbc membrane disorders, hemoglobinopathies. Physical and sonographic examinations for splenomegaly were performed by students, residents and attending physicians enrolled in an ultrasound training course. These maneuvers have received more extensive evaluation than other maneuvers, allowing us greater confidence in the findings.

Spleen should be twice the normal size to become palpable. Hepatosplenomegaly is a medical condition in which both the liver and the spleen become enlarged. Splenomegaly hematology and oncology merck manuals. Jan 09, 2018 a multicentre observational study for early diagnosis of gaucher disease in patients with splenomegaly andor thrombocytopenia. Ct and mri may provide more detail of the organs consistency. Pointofcare ultrasonography improves the diagnosis of. Mri is especially useful in detecting portal or splenic vein thromboses.

Pdf splenomegaly diagnostic validity, workup, and underlying. Early satiety from gastric displacement occurs with massive splenomegaly. The use of manual therapy or therapeutic touch has generated extensive literature. Generally it is less than 1 cm below the left costal margin. One third of newborns and 10% of children may normally have a palpable spleen. If your institution subscribes to this resource, and you dont have a myaccess profile, please contact your librarys reference desk for information on how to gain access to this resource from offcampus. If confirmation of splenomegaly is necessary because the examination is equivocal, ultrasonography is the test of choice because of its accuracy and low cost. Moreover, the examination should start with traube space percussion, followed, if dull, by supine 1handed palpation. Physical examination inspection, palpation, percussion, auscultation, vital signs, weight, height 3. Splenomegaly american academy of pediatrics textbook of. Tuberculous splenomegaly 1 thought that the term primary tb of the spleen is misleading considered that tuberculosis of the spleen must always be secondary.

The spleen can be enlarged in up to 30% of newborns and 10% of children. An increase in the size of the spleen can be caused by several mechanisms. Does this patient have intestinal obstruction blockage of intestine. Pdf purpose our aim was to assess the validity of the icd10 code for. Patients may also experience pain,which may be referred to the left shoulder. Treatment for splenomegaly treatment for splenomegaly depends on the underlying condition. Hypersplenism is a secondary process that can arise from splenomegaly of almost any cause see table common causes of splenomegaly. To determine whether sonographic versions of physical examination techniques can accurately identify splenomegaly, castells method ann intern med 1967. In case if an enlarged spleen or splenomegaly is suspected imaging studies and blood tests will be done to. If you understand the normal and abnormal characteristics of each organ system, you will recognize the pattern of the syndrome and reach the correct diagnosis. Although splenomegaly is often considered to be an ominous clinical finding, certain normal variants have been found.

Spleen problems and spleen removal some people are born without a spleen or need to have it removed because of illness or injury. Cause of splenomegaly is obscurelymphocytic infiltration of splenic liver sinosoids present. Pdf the detection of an enlarged spleen is important in clinical diagnosis but seems to be subject to considerable inaccuracies. Recent trauma in area of spleen associated symptoms asymptomatic causes of initially asymptomatic splenomegaly may include early myelproliferaitve disorders, splenic cyst, mild hereditary spherocytosis and even.

In cases in which splenomegaly is questioned, the clinical examination is more specific than sensitive and is best used when ruling in the diagnosis among patients for whom the suspicion is at least 10%. However, little is known about the prevalence and clinical significance of this finding in asymptomatic patients. The diagnosis of the cause requires a complete history and thorough physical examination with the following points of importance. Since the spleen enlarges in many conditions, a systematic approach may facilitate timely and costeffective diagnosis of the cause of splenomegaly. Splenomegaly causes of splenomegaly portal hypertension 33% chronic liver disease portalsplenic venous obstruction. A detailed history taking, appropriate clinical examination and relevant. An enlarged spleen may not be palpable until it is 23 times its normal size. Although splenomegaly is almost always present in hypersplenism, many patients with splenomegaly do not have hypersplenism. In an age when ever more refined laboratory tests are the keynote, it may seem anachronistic to describe again a simple method in bedside diagnosis. Pointofcare ultrasonography improves the diagnosis of splenomegaly in hospitalized patients. To determine whether sonographic versions of physical examination.

Also, a palpable left upper quadrant mass may indicate a problem other than an enlarged spleen. Signs of splenomegaly may include a palpable left upper quadrant abdominal mass or splenic rub. Comparing physical examination with sonographic versions of. Participants received less than 1 h training for ultrasound diagnosis of splenomegaly. The evaluation of splenomegaly in children and considerations related to elective or traumatic splenectomy are discussed separately. Its causes include a variety of conditions that affect these two organs, including liver disease, hiv, anemia, infections, and. Jul 08, 2019 splenomegaly in childhood is generally first suspected upon physical examination. However, it may also refer to an enlarged spleen detected by an imaging test. Splenomegaly general presentation the spleen is a hematopoietic organ supporting the megakaryotic, lymphoid, erythroid, myeloid, and reticuloendothelial systems. Physical diagnostic techniques for the detection of splenomegaly are relatively insensitive but specific. Clinical examination for splenomegaly is of questionable value even in the hands of experienced providers. Diagnosis is based on either the presence of 5 out of 8 criteria fever, splenomegaly, bicytopenia, hypertriglyceridemia andor hypofibrinogenemia, hemophagocytosis, low or absent nkcell activity, hyperferritinemia, and high levels of soluble interleukin2 receptor, or a molecular diagnosis consistent with hlh. Hepatosplenomegaly hpm is a disorder where both the liver and spleen swell beyond their normal size, due to one of a number of causes. For the clinical diagnosis of splenomegaly, two criteria have been tested.

Olson ap, trappey b, wagner m, newman m, nixon lj, schnobrich d. Sep 17, 2015 this was a prospective trial of diagnostic accuracy. On the other hand, as the spleen progressively and. Splenomegaly can be caused due to various medical conditions like some sort of an infection or problems with the liver. Splenomegaly, hypersplenism, and hereditary disorders with. A small percentage of the normal american population may have a palpable or enlarged spleen. There are different medical conditions that can lead to the simultaneous appearance of hepatomegaly and splenomegaly, as you will have the opportunity to discover below. Know the causes, symptoms, and treatment of splenomegaly. Physical diagnosis of the abdomen university of virginia. Spleen exam stanford medicine 25 stanford medicine. Because the physical examination is quite insensitive for detecting splenomegaly between 27 and 58 percent, depending on the examiners index of suspicion, the absence of splenomegaly should not be used as evidence against the diagnosis of infectious mononucleosis. Tropical splenomegaly massive splenomegaly occurring in people of endemic area for malariakalaazar but no parasite is demonstrable in blood.

Assessing for the presence of splenomegaly is an important component of the physical examination. All reported studies discuss splenomegaly arising from im and the assumption is made that detection of enlargement from other etiologies would not differ on physical examination. In children, as a result of the thinness of the abdominal musculature, a palpable spleen is commonly encountered. Conclusion our findings show that the splenomegaly diagnosis in the dnrp is. A combination of tests either palpation or percussion increased the diagnostic accuracy. Splenic palpation for the evaluation of morbidity due to. The algorithms herein attempt to present a rational, stepbystep diagnostic. Although studies on hypersplenism are few, two studies have shown that schistosomal portal hypertension is the commonest cause of hypersplenism, other common causes include hematological disorders, and visceral lesihmaniasis. The content on the uptodate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. This topic provides an overview of normal splenic size and function and an approach to evaluating splenic abnormalities in adults. It may be difficult to palpate an enlarged spleen in the settings of obesity, a muscular abdominal wall, or the inability to sufficiently relax the abdominal musculature. Up to 3% of normal, thin, people have a palpable spleen. Pdf reliability of clinical techniques for detecting splenic.

Your doctor can often feel it by gently examining your left upper abdomen. In part this is because the spleen enlarges in the inferior anteromedial direction, sometimes as far as the rlq. Any conditions that cause a rapid breakdown of blood cells, such as any of the haemolytic anaemias, can place great strain on the spleen and make it enlarge. Each patient was examined for splenomegaly using conventional. Articles causes of massive tropical splenomegaly in ghana. A list of disorders producing splenomegaly and hypersplenism is presented in table 2.