Splenomegaly Clinical Presentation

  • Author: Gina M Matacia-Murphy, MD; Chief Editor: Emmanuel C Besa, MD   more...
 
Updated: Apr 20, 2012
 

History

The most common history in patients with splenomegaly is mild, but vague, abdominal pain. Pain may be referred to the left shoulder. Increased abdominal girth is less common. Early satiety from gastric displacement occurs with massive splenomegaly. Associated symptoms or signs are typically related to the underlying disorder and may include the following:

  • 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)[3]
  • Alcoholism, hepatitis (cirrhosis)[4, 5]
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Physical Examination

Splenic size is not a reliable guide to splenic function, and palpable spleens are not always abnormal. Patients with chronic obstructive pulmonary disease (COPD) and low diaphragms commonly have palpable spleens. In one study, 3% of college freshmen had palpable spleens; an additional study showed that 5% of hospitalized patients with normal spleens based on scan results were thought to have palpable spleens by their physicians.

The physical examination should include palpation with the patient in the supine and right lateral decubitus position, with knees up and hips flexed. Apply light fingertip pressure as the patient slowly inspires. The use of the reverse Trendelenburg position may aid in bringing the spleen into contact with the examiner's fingers. This is especially helpful in patients with morbid obesity. The spleen moves with respiratory patterns and may be palpable only at the end of inspiration.

In extreme splenomegaly, shown in the image below, the lower splenic pole may extend into the pelvis or cross the abdominal midline. In these circumstances, palpation at the pelvic brim or the right upper quadrant may be necessary to delineate splenic size and location.

The margins of this massive spleen were palpated eThe margins of this massive spleen were palpated easily preoperatively. Medially, the 3.18 kg (7 lb) spleen crosses the midline. Inferiorly, it extends into the pelvis.

Percussion of the abdomen may disclose caudal displacement of the gastric bubble in massive splenomegaly. Additional signs that identify possible etiologies of splenomegaly include the following:

  • Signs of cirrhosis - Eg, asterixis, jaundice, telangiectasias, gynecomastia, caput medusa, and ascites
  • Heart murmur - Endocarditis or congestive failure
  • Jaundice
  • Scleral icterus - Spherocytosis or cirrhosis
  • Petechiae - Any other bleeding manifestation secondary to thrombocytopenia
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Contributor Information and Disclosures
Author

Gina M Matacia-Murphy, MD  Fellow in Hematology/Oncology, University of Cincinnati College of Medicine

Gina M Matacia-Murphy, MD is a member of the following medical societies: American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Ronald A Sacher, MB, BCh, MD, FRCPC  Professor, Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center

Ronald A Sacher, MB, BCh, MD, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, and Royal College of Physicians and Surgeons of Canada

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Talecris Honoraria Board membership

Chief Editor

Emmanuel C Besa, MD  Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Clinical Oncology, American Society of Hematology, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Wadie F Bahou, MD Chief, Division of Hematology, Hematology/Oncology Fellowship Director, Professor, Department of Internal Medicine, State University of New York at Stony Brook

Wadie F Bahou, MD is a member of the following medical societies: American Society of Hematology

Disclosure: Nothing to disclose.

David Coffman, MD Fellow, Department of Surgery, Division of Trauma and Critical Care, Yale University School of Medicine

Disclosure: Nothing to disclose.

Marcel E Conrad, MD Distinguished Professor of Medicine (Retired), University of South Alabama College of Medicine

Marcel E Conrad, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Blood Banks, American Chemical Society, American College of Physicians, American Physiological Society, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Association of Military Surgeons of the US, International Society of Hematology, Society for Experimental Biology and Medicine, and Southwest Oncology Group

Disclosure: No financial interests None None

Emmanuel N Dessypris, MD Professor of Medicine, Medical College of Virginia; Chief, Medical Service, Hunter Holmes McGuire Department of Veterans Affairs Medical Center

Emmanuel N Dessypris, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society of Hematology, New York Academy of Sciences, Society for Experimental Biology and Medicine, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

David J Draper, MD Fellow, Department of Hematology/Oncology, The University Hospital, University of Cincinnati College of Medicine

Disclosure: Nothing to disclose.

Lewis J Kaplan, MD, FACS, FCCM, FCCP Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine

Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

  1. Eichner ER. Splenic function: normal, too much and too little. Am J Med. Feb 1979;66(2):311-20. [Medline].

  2. Ginzel AW, Kransdorf MJ, Peterson JJ, Garner HW, Murphey MD. Mass-like extramedullary hematopoiesis: imaging features. Skeletal Radiol. Nov 20 2011;[Medline].

  3. Butler JR, Eckert GJ, Zyromski NJ, Leonardi MJ, Lillemoe KD, Howard TJ. Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding. HPB (Oxford). Dec 2011;13(12):839-45. [Medline]. [Full Text].

  4. Zhu JH, Wang YD, Ye ZY, Zhao T, Zhu YW, Xie ZJ, et al. Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis. Surg Laparosc Endosc Percutan Tech. Jun 2009;19(3):258-62. [Medline].

  5. Anegawa G, Kawanaka H, Uehara H, Akahoshi T, Konishi K, Yoshida D, et al. Effect of laparoscopic splenectomy on portal hypertensive gastropathy in cirrhotic patients with portal hypertension. J Gastroenterol Hepatol. Sep 2009;24(9):1554-8. [Medline].

  6. Bezerra AS, D'Ippolito G, Faintuch S, Szejnfeld J, Ahmed M. Determination of splenomegaly by CT: is there a place for a single measurement?. AJR Am J Roentgenol. May 2005;184(5):1510-3. [Medline]. [Full Text].

  7. Goldstone J. Splenectomy for massive splenomegaly. Am J Surg. Mar 1978;135(3):385-8. [Medline].

  8. Laws HL, Burlingame MW, Carpenter JT, Prchal JT, Conrad ME. Splenectomy for hematologic disease. Surg Gynecol Obstet. Oct 1979;149(4):509-12. [Medline].

  9. Musser G, Lazar G, Hocking W, Busuttil RW. Splenectomy for hematologic disease. The UCLA experience with 306 patients. Ann Surg. Jul 1984;200(1):40-5. [Medline]. [Full Text].

  10. Wilhelm MC, Jones RE, McGehee R, et al. Splenectomy in hematologic disorders. The ever-changing indications. Ann Surg. May 1988;207(5):581-9. [Medline]. [Full Text].

  11. Flowers JL, Lefor AT, Steers J, et al. Laparoscopic splenectomy in patients with hematologic diseases. Ann Surg. Jul 1996;224(1):19-28. [Medline]. [Full Text].

  12. Wang KX, Hu SY, Zhang GY, Chen B, Zhang HF. Hand-assisted laparoscopic splenectomy for splenomegaly: a comparative study with conventional laparoscopic splenectomy. Chin Med J (Engl). Jan 5 2007;120(1):41-5. [Medline]. [Full Text].

  13. Subhasis RC, Rajiv C, Kumar SA, Kumar AV, Kumar PA. Surgical treatment of massive splenomegaly and severe hypersplenism secondary to extrahepatic portal venous obstruction in children. Surg Today. 2007;37(1):19-23. [Medline].

  14. Poulin EC, Mamazza J, Schlachta CM. Splenic artery embolization before laparoscopic splenectomy. An update. Surg Endosc. Jun 1998;12(6):870-5. [Medline].

  15. Kawanaka H, Akahoshi T, Kinjo N, et al. Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism. J Hepatobiliary Pancreat Surg. 2009;16(6):749-57. [Medline].

  16. Xu WL, Li SL, Wang Y, Shi BJ, Li M, Li YC, et al. Laparoscopic splenectomy: color Doppler flow imaging for preoperative evaluation. Chin Med J (Engl). May 20 2009;122(10):1203-8. [Medline].

  17. Shaw JH, Print CG. Postsplenectomy sepsis. Br J Surg. Oct 1989;76(10):1074-81. [Medline].

 
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This patient has a splenic abscess due to pneumococcal bacteremia. Note that the massively enlarged spleen is readily visible, with minimal retraction in the left upper quadrant.
Resected specimen from the patient in the previous image. Note the discrete abscesses adjacent to normal parenchyma.
The margins of this massive spleen were palpated easily preoperatively. Medially, the 3.18 kg (7 lb) spleen crosses the midline. Inferiorly, it extends into the pelvis.
Massive splenomegaly does not preclude splenectomy through a minimally invasive approach. This photograph depicts a fragmented 3.2 kg (7.05 lb) spleen after removal via a hand-assisted laparoscopic technique.
A portion of a massive spleen is extracted via hand-assisted laparoscopy.
Intraoperative photograph of a laparoscopic splenectomy being taken down using the hanging-pedicle technique. The tip of the spleen is visualized in the background, whereas the stapler is detailed in the foreground across a segment of the pedicle.
A massive spleen that was removed from an elderly woman with lymphoma.
 
 
 
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