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 Splenomegaly

 

Causes of splenomegaly

  • Portal hypertension (33%)
    • Chronic liver disease
    • Portal/splenic venous obstruction; Budd-Chiari; heart failure
  • Haematological (30%)
    • Lymphoproliferative (usually with nodes)
      • Leukaemias (AML, CML, ALL, CLL)
      • Lymphomas
    • Myeloproloferative (usually without nodes)
        • Myelofibrosis
        • Polycythaemia rubra vera (PRV)
        • Essential thrombocythaemia
    • Haemolytic anaemias
      • Hb disorders: Thalassaemia, sickle cell disease (eventually leads to splenic atrophy)
      • Red cell structure: Spherocytosis/elliptocytosis
      • Enzyme: G6PD deficiency, pyruvate kinase deficiency
  • Infection
    • Viral hepatitis
    • EBV, CMV, HIV
    • Bacterial
      • Infective endocarditis
    • Foreign/tropical
      • Malaria
      • Schistosomiasis
      • Visceral leishmaniasis (Kala-azar)
    • Tuberculosis, brucellosis
    • Hydatid cyst
    • Splenic abscesses
  • Infiltration
    • Amyloidosis
  • Connective tissue disorders
    • SLE
    • RA (Felty’s syndrome: triad of RA, neutropenia and splenomegaly)
  • Splenic metastases
  • Genetic
    • Gaucher’s disease, Niemann Pick, Histiocytosis X

 

Massive splenomegaly Moderate splenomegaly Mild splenomegaly
Myelofibrosis Lymphoproliferative PRV
CML Portal hypertension Haemolysis
Malaria Thalassaemia Infection
Visceral leishmaniasis Glycogen storage disorders Infiltration
Connective tissue disorders

 

 History in splenomegaly

  • Presenting complaint
    • Abdominal distension
    • Abdominal pain
    • Constitutional symptoms: nights sweats, fever, weight loss, malaise
    • Abnormal bruising/bleeding
  • Past medical history
    • Malignancy
    • Connective tissue disease
  • Family history
    • Malignancy
  • Social history
    • Alcohol consumption
    • Travel history
    • Risk factors for viral hepatitis (see pages on viral hepatitis)

 

 Examination of splenomegaly

  • Anaemia
  • Lymphadenopathy
  • Signs of chronic liver disease
  • Splenomegaly (differentiation from kidney)
    • Spleen has a medial notch, kidney doesn’t
    • You can’t get above the spleen (ribs overly it)
    • The spleen moves towards RIF with inspiration, the kidney moves posterior only (if at all)
    • The spleen is not ballotable like the kidney

 

 Initial investigation of splenomegaly

  • Blood tests:
    • Full blood count
    • Blood film
    • Liver function tests
    • Urea and electrolytes
    • Autoimmune screen
    • Inflammatory markers
    • LDH
  • Ultrasound of abdomen

 

Further investigation and management of splenomegaly depends on cause but can include

  • CT abdomen/pelvis
  • Bone marrow aspirate and trephine
  • Lymph node biopsy
  • Full liver screen

 

Click here for medical student OSCE and PACES questions about splenomegaly

Common splenomegaly exam questions for medical students, finals, OSCEs and MRCP PACES

 

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Perfect revision for medical students, finals, OSCEs and MRCP