Splenomegaly : causes , clinical approach and examination
-
Upload
vasif-mayan -
Category
Health & Medicine
-
view
186 -
download
2
Transcript of Splenomegaly : causes , clinical approach and examination
![Page 1: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/1.jpg)
SPLENOMEGALY : APPROACH
DR VASIF MAYANGMKMCH
![Page 2: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/2.jpg)
INTRODUCTION Anatomy & Physiology
Classification
Etiology
Step-wise approach
Associated features
Investigations
![Page 3: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/3.jpg)
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.
![Page 4: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/4.jpg)
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.
![Page 5: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/5.jpg)
Normal spleenNormal size
12 cm length , 7 cm width13cm craniocaudal diameter
Weight < 250gmLocated along- 9th, 10th,11th ribs mid-axillarySpleen should be twice the size to be PALPABLEPalpable spleens are not always ABNORMAL3% normal population has palpable spleen
![Page 6: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/6.jpg)
Splenomegaly : Spleen weight of 400-500gm 750 – 1000gm : prominent below costal margin >1000gm : massive splenomegaly
![Page 7: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/7.jpg)
![Page 8: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/8.jpg)
FUNCTIONSImmune function: The spleen processes foreign antigens major site of specific immunoglobulin M (IgM) production. The non-specific opsonins, properdin are synthesized. These antibodies are of B- and T-cell origin and bind to the
specific receptors on the surface of macrophages and leukocytes, stimulating their phagocytic, bactericidal and tumoricidal activity.
![Page 9: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/9.jpg)
Filter function: Macrophages capture cellular and non-cellular material from
the blood and plasma. Remove old platelets and red blood cells. Iron is removed from the degraded hemoglobin during red
cell breakdown and is returned to the plasma. Removed non-cellular materials include bacteria particularly
capsulated organisms
![Page 10: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/10.jpg)
Pitting: Particulate inclusions from red cells are removed and
repaired red cells are returned to the circulation. These include Howell–Jolly - nuclear remnants Heinz bodies - precipitated hemoglobin or globin subunits
![Page 11: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/11.jpg)
EXAMINATION OF SPLEEN INSPECTION : Fullness in LUQ that descends on inspiration
Situated behind 9th, 10th and 11th ribs Long axis along line of 10th rib Anteriorly extends upto mid axillary line Posteriorly, the superior angle is 4cm lateral to D10 spine
![Page 12: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/12.jpg)
PALPATION BIMANUAL PALPATION
BALLOTMENT
PALPATION FROM ABOVE - MIDDLETON MANOUVRE
![Page 13: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/13.jpg)
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
![Page 14: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/14.jpg)
BIMANUAL PALPATION 2. Turn patient to right lateral position Palpate with right hand
![Page 15: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/15.jpg)
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
![Page 16: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/16.jpg)
differences Sharp edge Notch –medial border Cross midline Moves with respiration Cannot get above it Neither Finger insinuation not possible Band of colonic resonance absent
Round edge No notch Not cross midline Donot moves with resp. Can get above it Bimanually palpable and ballotable Fingers can be insinuated Band of colonic resonance present
spleen kidney
![Page 17: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/17.jpg)
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
![Page 18: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/18.jpg)
PERCUSSION CASTELLS METHOD Supine position Dull note over lowest ICS in Anterior axillary line on full
inspiration indicate splenomegaly
![Page 19: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/19.jpg)
PERCUSSION TRAUBE’S SEMILUNAR SPACE left sixth rib superiorly left anterior axillary line
laterally left costal margin inferiorly
Dull note : splenomegaly
![Page 20: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/20.jpg)
Differential diagnosis Enlarged left kidney Enlarged left lobe liver Carcinoma stomach Carcinoma splenic flexure colon Omental mass Malignancy tail of pancreas
![Page 21: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/21.jpg)
splenomegaly
Massive beyond umblicus, crosses mid line >8cm below left costal margin and or >1000gm weight
Moderate b/w costal margin & umblicus (4-8cm)
Mild just palpable (1-3cm)
![Page 22: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/22.jpg)
MECHANISM of SPLENOMEGALY 1. Hyperplasia or hypertrophy
Reticuloendothelial hyperplasia Immune hyperplasia in response to
A. systemic infectionB. immunological diseases
2. Passive congestion due to decreased blood flow
3. Infiltrative diseases
![Page 23: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/23.jpg)
CAUSES OF SPLENOMEGALY Inflammatory splenomegaly Hyperplastic splenomegaly Infectious splenomegaly
Congestive splenomegaly Infiltrative splenomegaly
INCREASED DEMAND FORSPLENIC FUNCTION
![Page 24: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/24.jpg)
1. INCREASED DEMAND A. RETICULOENDOTHELIAL SYSTEM HYPERPLASIA
SpherocytosisEarly sickle cell anemiaOvalocytosisThalassemia majorHemoglobinopathiesPNHPernicious anemia
![Page 25: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/25.jpg)
INCREASED DEMAND B. IMMUNE HYPERPLASIA
(i) Response to infection IMN, viral hepatitis,AIDS,CMV,IE,TB, Histoplasmosis, 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.
![Page 26: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/26.jpg)
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
![Page 27: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/27.jpg)
3. Infiltration of Spleen Intracellular or
extracellular depositsAmyloidosisGaucher diseaseNiemann PickTangier diseaseHurlers syndrome, Other
MPSHyperlipidemias
Benign and Malignant InfiltrationsLeukemiasLymphomasHodgkins diseaseMyeloproliferative syndromesAngiosarcomasMetastasis ( MC= Melanoma)Eosinophilic GranulomaHistiocytosis XHamartomasHemangiomaSplenic cysts
![Page 28: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/28.jpg)
4. Unknown Etiology Idiopathic splenomegaly Berylliosis Iron deficiency anemia
![Page 29: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/29.jpg)
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
![Page 30: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/30.jpg)
Moderate splenomegaly(4-8cm) Viral hepatitis Cirrhosis Lymphomas Amyloidosis Splenic abscess,infarct Hemolytic anemias IMN Hemochromatosis Polycythemias
![Page 31: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/31.jpg)
Mild splenomegaly (1-3cm) Acute malaria Typhoid kala-azar Septicemias SLE Infective endocarditis RA Thalassemia Minor Miliary TB Leptospirosis HIV CCF
![Page 32: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/32.jpg)
Step-wise approach to splenomegaly
HistoryPhysical examinationLaboratory testsImagingSpecialised tests
![Page 33: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/33.jpg)
history 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)
![Page 34: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/34.jpg)
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
![Page 35: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/35.jpg)
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
![Page 36: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/36.jpg)
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
![Page 37: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/37.jpg)
Imaging USG sensitive & specific non-invasive
CT scan - 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
![Page 38: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/38.jpg)
imaging MRI scan liver hemangiomas hemochromatosis erlenmeyer flask sign (Gaucher)
PET scan Dx & staging of lymphomas determine metabolic cells in spleen
![Page 39: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/39.jpg)
Specialised testing Abdominal fat pad aspiration JAK-2 mutation Gene testing ( bcr-abl , C282Y) Enzyme testing Lymph node biopsy FNAC spleen Splenectomy Liver biopsy
![Page 40: Splenomegaly : causes , clinical approach and examination](https://reader038.fdocuments.net/reader038/viewer/2022102522/58f27a5a1a28ab34538b4589/html5/thumbnails/40.jpg)