Splenomegaly and

Hypersplenism

done by Anas M.kamel Hindawi

5th year beirut arab university
salamtak workshop
It lies in the left upper quadrant of the
abdomen
normal spleen 10 cm length ,150 gms
Lies beneath 9 th to the 12 th rib
lymphatic organ suspended within the
greater omentum
 connected to stomach by gastrosplenic
ligament ,and to the kidney by splenorenal
 Blood supply by splenic vesseles
lymph drainage follow its bld supply
paraortic and caeliac Ln.s
 Spleen has only efferent lymph
vessels

and caeliac symp. Supply along the

art.
 white pulp
• Composed of malphigian corpuscles wich are :

• Lymphoid follicles “B lymphocytes”

• Periarteriolar lymphoid sheath “T lymphocutes”
• macrophages

• Active immune response through humoral and

cell-mediated pathways.
 Red pulp

• Contains the cords of Billroth with fixed

macrophages and sinusoids

• Mechanical filtration of RBC.s

 Spleen functions
• Blood filtration; macrophages remove:
Hematopoietic elements
Intraerythrocytic parasites
Encapsulated bacteria

• Enhancement of Ag trapping and processing in

macrophages

• Reservoir for one third of the peripheral blood platelet pool

and 10 % of RBC.s

• Pitting :howel jolly and heinz bodies removal from RBC.s

• Site for extramedullary hematopoiesis

90% of blood passing “300 ml/min “ thru the spleen
moves in an open circulation :

from arteries to the cords to the sinuses

thus spleen pulp pressure reflects

pressure of the portal system

 Hypersplenism
• Clinical syndrome characterized by :

• Splenic enlargment “splenomegaly”

• Anaemia ,leukopenia and thrombocytopenia
• Compensatory bone marrow hyperplasia
• Improvement after splenectomy
 splenomegaly
• Mild splenomegaly : largest dimension bt
12 and 20 cm ,400-500 g

• Severe splenomegaly : largest dimension

more than 20 cm ,more than 1000 g

• If spleen below costal margin 750-1000 g

 Symptoms
• Pain

• Early satiety

• Heavy sensation in the left upper quadrant

signs
Inspection : fullness moved with resp. mov.
Auscultation : venous hum or friction rub
Bimanual examiaton (palpitation)
• Supine flexed knees

• Lt hand at the costovertebral angle

• Rt hand feels the tip or notch of the spleen

during resp.

• identify the lower edge of spleen by examining

from Lt lower quadrant and the right lower quad.
 Percussion

• Nixon’s method

• Castel's sign

• Traube’s sign
Nixon’s method
 Castell's sign
• Patient is placed in the supine position

• Percussion in the lowest intercostal space in the

anterior axillary line (eighth or ninth) produces a
resonant note if the spleen is normal in size during
either expiration or during full inspiration bcz of air in
the stomach and colon

• A dull percussion note on full inspiration suggests

splenomegaly

• Difficult in obese
 Traube’s sign
• The borders of Traube’s space are the sixth rib
superiorly, the left midaxillary line laterally, and the left
costal margin inferiorly

• Patient is supine with the left arm slightly abducted

• During normal breathing, this space is percussed from

medial to lateral margins, yielding a normal resonant
sound

• A dull percussion note suggests splenomegaly.

 How to differentiate in examination
the kidney from the spleen
• Splenic notch • No notch
• Can cross the midline • Can’t cross midline
• Can’t get above • May get above
• Moves with resp. • Not moves with resp.
• Splenic rub • No rub
• No ballotable • ballotable
 Causes of splenomegaly
• Increased function

• Abnormal bld flow

• Infiltration
 Increased demand for splenic
function
• Reticuloendothelial system hyperplasia (for
removal of defective erythrocytes) as in :

• spherocytosis
• thalassemia
• nutritional anaemia
• Early sickle cell anaemia
 Increased demand…..ctd
• Immune hyperplasia

• Either in response to infection whether

viral ,bacterial ,fungal or parazite

• Or disordered immunity as rehumatoid

arthritis (felty’s syndrome),SLE ,collagen
vascular ,drug reaction ,sarcoidosis
,thyrotoxicosis
 Increased demand…..ctd
• Extramedullary hematopoiesis as in
myelofibrosis ,marrow damage by toxins
or radiation ,marrow infiltration by tumour
or leukemia or gausher disease
 Abnormal splenic or portal blood
flow
• Cirrhosis
• Congestive Heart failure
• Hepativ vein obstruction either int. or ext.
• Portal vein obstruction
• Splenic vein ostruction
• Hepatic schiztosomiasis
• Portal hypertension
 Infiltration of the spleen
• Intacel. Or extrcel. Infiltration

• Amylodosis
• Gaicher disease
• Nimen pick disease
• hperlipidaemia
 Infiltration of……ctd
• Benign and malignant cellular infiltrations

• Leukemia (acute ,chronic ,lymphoid)

• Hodgkin and NHL
• Myeloproloferative
• Angiosarcoma
• Metastatic tumors
• Haemangioma ,fibroma ,lymphangioma
• Splenic cysts
Diseases associated with massive
splenomegaly
• Thalassemia
• visceral leishmaniasis (Kala Azar)
• schistosomiasis
• Chronic myelogenous leukemia
• Chronic lymphocytic leukemia
• lymphomas
• hairy cell leukemia
• myelofibrosis
• polycythemia vera
• Gauchers disease
• Niemann Pick disease
• sarcoidosis
• Autoimmune hemolytic anemia
• Malaria
 Diagnostic Approach
• History and physical examination

• Laboratory and imaging studies

• Bone marrow biopsy in advanced

•
• suspected cases

• splenectomy
 Laboratory Tests
• Erythrocyte count

• If inc. polycythemia vera

• If decr. Thalassemia major ,SLE ,cirrhosis
,portal HT
 Granulocyte counts may be

• Decrease as in felty’s syndrome

,congestive splenomegaly

• Increase in infections and inflam. Process

also in myelofibrosis
 Platelet count

• Decrease in cong.splenomeg.
,myeloproliferative dis ,LSD

• Increase in polycythemia vera

• SGPT ,SGOT

• PT ,pPT
 Imaging
• US

• CT

• MRI
 treatment
• Treat the underlying disorder.
• Splenectomy is indicated in certain clinical
situations.
• Symptom control in patients with massive
splenomegaly
• Disease control in patients with traumatic
splenic rupture
• Correction of cytopenias in patients with
hypersplenism or immune-mediated
Multiple cysts
Massive splenomegaly
Normal spleen dimensions
Spleen injury
 Pseudo cyst treated by
percutanous drainage if child
Splenomegaly compressing the
stomach
Spleen abcess
 References
• Bailey and loves’s short practice of
surgery
• Cecil Textbook of medicine
• Harrison’s principal of inernal medecine
17th edition
• Goljan pathology 2nd edition
Thanks 4 u all my friends
peace