Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Splenomegaly

  • Author: Neetu Radhakrishnan, MD; Chief Editor: Emmanuel C Besa, MD  more...
 
Updated: Apr 29, 2016
 

Background

Splenomegaly is defined as enlargement of the spleen. 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 spleen is a functionally diverse organ with active roles in immunosurveillance and hematopoiesis. It lies within the left upper quadrant of the peritoneal cavity and abuts ribs 9-12, the stomach, the left kidney, the splenic flexure of the colon, and the tail of the pancreas. A normal spleen weighs 150 g and is approximately 11 cm in craniocaudal length.[1]

The normal spleen is usually not palpable, although it can sometimes be palpated in adolescents and individuals with a slender build. However, an enlarged or palpable spleen is not necessarily of clinical significance. For example, certain individuals with broadly splayed costal margins have readily palpable, but small, spleens. (See Presentation.)

A spleen weight of 400-500 g indicates splenomegaly, while a weight of more than 1000 g is labelled massive splenomegaly. Poulin et al defined splenomegaly as moderate if the largest dimension is 11-20 cm, and severe if the largest dimension is greater than 20 cm.[2]

In many instances, the spleen enlarges as it performs its normal functions. The four most important normal functions of the spleen are as follows:

  • Clearance of microorganisms and particulate antigens from the blood stream
  • Synthesis of immunoglobulin G (IgG), properdin (an essential component of the alternate pathway of complement activation), and tuftsin (an immunostimulatory tetrapeptide)
  • Removal of abnormal red blood cells (RBCs)
  • Extramedullary hematopoiesis in certain diseases

For discussion of splenomegaly in children, see Pediatric Splenomegaly. For discussion of hyperreactive malarial syndrome, see Tropical Splenomegaly Syndrome.

Next

Etiology

Many of the mechanisms leading to splenomegaly are exaggerated forms of normal splenic function. Although a wide variety of diseases are associated with enlargement of the spleen, the following six etiologies of splenomegaly are considered primary:

  • Immune response work hypertrophy - Such as in subacute bacterial endocarditis or infectious mononucleosis
  • RBC destruction work hypertrophy - Such as in hereditary spherocytosis or thalassemia major
  • Congestive - Such as in splenic vein thrombosis, portal hypertension, or Banti disease
  • Myeloproliferative - Such as in chronic myeloid metaplasia
  • Infiltrative - Such as in sarcoidosis and some neoplasms
  • Neoplastic - Such as in chronic lymphocytic leukemia and the lymphomas

Miscellaneous causes of splenomegaly include the following:

  • Trauma
  • Cysts
  • Hemangiomas
  • Metastasis
  • Giant abscess (see the images below)
  • Certain drugs (eg, Rho(D) immune globulin [RhoGAM])
    This patient has a splenic abscess due to pneumoco 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 Resected specimen from the patient in the previous image. Note the discrete abscesses adjacent to normal parenchyma.

Inflammatory splenomegaly

Acute enlargement of the spleen due to various infections or inflammatory processes results from an increase in the defense activities of the organ. The demand for increased antigen clearance from the blood may lead to increased numbers of reticuloendothelial cells in the spleen and stimulate accelerated antibody production, with resultant lymphoid hyperplasia. Examples include splenomegaly from lupus and Felty syndrome, and from viral infections such as Epstein-Barr virus–induced mononucleosis.

Hyperplastic splenomegaly

Removal of abnormal blood cells from the circulation (either cells with intrinsic defects or cells coated with antibody) is the usual source of hyperplastic splenomegaly. In some cases, extramedullary hematopoiesis (ie, myeloproliferative disease) results in hyperplasia.[3]

Congestive splenomegaly

Cirrhosis with portal hypertension, splenic vein occlusion (thrombosis), or congestive heart failure (CHF) with increased venous pressure causes congestive splenomegaly. In patients receiving oxaliplatin-based chemotherapy, splenomegaly may result from hepatic sinusoidal obstructive syndrome caused by the chemotherapy; use of bevacizumab may reduce the splenomegaly in these cases.[4]

Infiltrative splenomegaly

Infiltrative splenomegaly is the result of engorgement of macrophages with indigestible materials (eg, sarcoidosis, Gaucher disease, amyloidosis, metastatic malignancy).

Infectious splenomegaly

Splenic filtering of blood-borne pathogens, especially encapsulated organisms, may lead to abscess formation. Because many splenic abscesses may be indolent in presentation, splenic size may increase as the abscess enlarges. This is a relatively uncommon, but important, process to recognize and treat.

Splenic sequestration

Acute splenic sequestration crisis (ASSC) is a major cause of morbididty and mortality in children with sickle cell disease and other hereditary hemolytic anemias. ASSC is characterized by sudden enlargement of the spleen due to trapping of a significant proportion of the blood volume, rapid drop in the hematocrit with hypovolemia, and thrombocytopenia. ASSC is rare in adults with sickle–beta thalassemia despite the frequent presence of spleneomegaly in this population of patients. Infection and high-altitude exposure are known precipitating factors for ASSC.[5]

Previous
Next

Epidemiology

In the United States, one large series reported a palpable spleen in 2% of patients and another in 5.6% of patients.[6] Tropical splenomegaly syndrome occurs most often in persons indigenous to the malarial belt of tropical Africa and in visitors to that region.

Race-, Sex-, and Age-related demographics

No race predilection is recognized for splenomegaly. However, note that blacks may have hemoglobin SC disease, a disorder related to sickle cell disease. Unlike sickle cell disease, which results in a small, autoinfarcted spleen, patients with hemoglobin SC disease may have splenomegaly that accompanies their pigment gallstones.

Tropical splenomegaly syndrome (or hyperactive malarial syndrome) has a female-to-male incidence ratio of 2:1. Otherwise, no sex predilection is documented for splenomegaly.

The capsules of older spleens are much thinner than their younger counterparts. The combination of capsular thinning with increased spleen weight and size makes splenic injury more common in elderly persons. These factors account for the increased likelihood of splenectomy for trauma in this subgroup.

Previous
Next

Prognosis

The prognosis for patients with splenomegaly is usually excellent and not substantially different from age-matched controls, but it is impacted by the underlying disease state rather than the presence of splenomegaly or the postsplenectomy state.

Morbidity and mortality

Morbidity and mortality in cases of splenomegaly principally stem from associated disease states or surgical procedures, rather than from the splenomegaly itself. The rates for morbidity and mortality are highly variable and relate to the presence or absence of comorbidities, hemorrhage, and organ failure.

Patients with enlarged spleens are more likely to have splenic rupture from blunt abdominal or low thoracic trauma. These patients are unlikely to undergo nonoperative management of their splenic injury or splenic salvage maneuvers, because their spleen is abnormal with regard to architecture, capsule tensile strength, and, commonly, hemostatic function.

Previous
Next

Patient Education

Patients with splenomegaly need education with regard to decreasing their risk of splenic trauma and rupture. These patients must be cautioned about contact sports and other activities that may acutely increase intra-abdominal pressure or place excessive forces on the left upper quadrant, left flank, or lateral back. This decreases the likelihood of splenic rupture in a patient with an abnormal splenic mass and capsule. The routine use of seat belts is essential while driving or riding in a motor vehicle.

Additional education regarding the signs and symptoms of postsplenectomy sepsis cannot be overstressed. Prompt antibiotic therapy may be lifesaving.

Education represents a mandatory strategy in the prevention of overwhelming postsplenectomy infection (OPSI). Asplenic patients should be encouraged to wear a medical alert bracelet and carry a wallet card explaining their lack of a spleen. Patients should also be aware of the need to notify their physician in the event of an acute febrile illness, especially if it is associated with rigors or systemic symptoms.

For patient education information, see the Infections Center, as well as Mononucleosis (Mono).

Previous
 
 
Contributor Information and Disclosures
Author

Neetu Radhakrishnan, MD Associate Professor (Adjunct) of Medicine, Division of Hematology/Oncology, University of Cincinnati Medical Center; Hematology/Oncology Medical Director, West Chester Outpatient Clinics

Neetu Radhakrishnan, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Coauthor(s)

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

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

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: GSK Pharmaceuticals,Alexion,Johnson & Johnson Talecris,,Grifols<br/>Received honoraria from all the above companies for speaking and teaching.

Chief Editor

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, 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 Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

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.

Acknowledgements

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. 1979 Feb. 66(2):311-20. [Medline].

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

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

  4. Arakawa Y, Shimada M, Utsunomiya T, Imura S, Morine Y, Ikemoto T, et al. Bevacizumab improves splenomegaly and decreases production of hyaluronic acid after L-OHP based chemotherapy. Anticancer Res. 2014 Apr. 34(4):1953-8. [Medline].

  5. Koduri PR, Kovarik P. Acute splenic sequestration crisis in an adult with sickle beta-thalassemia. Ann Hematol. 2006 Sep. 85 (9):633-5. [Medline].

  6. O'Reilly RA. Splenomegaly in 2,505 patients at a large university medical center from 1913 to 1995. 1963 to 1995: 449 patients. West J Med. 1998 Aug. 169 (2):88-97. [Medline].

  7. 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). 2011 Dec. 13(12):839-45. [Medline]. [Full Text].

  8. 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. 2009 Jun. 19(3):258-62. [Medline].

  9. 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. 2009 Sep. 24(9):1554-8. [Medline].

  10. Motta I, Filocamo M, Poggiali E, Stroppiano M, Dragani A, et al. A multicentre observational study for early diagnosis of Gaucher disease in patients with Splenomegaly and/or Thrombocytopenia. Eur J Haematol. 2015 Jun 1. [Medline].

  11. Olson AP, Trappey B, Wagner M, Newman M, Nixon LJ, Schnobrich D. Point-of-care ultrasonography improves the diagnosis of splenomegaly in hospitalized patients. Crit Ultrasound J. 2015 Dec. 7 (1):13. [Medline].

  12. 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. 2005 May. 184(5):1510-3. [Medline]. [Full Text].

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

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

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

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

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

  18. 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). 2007 Jan 5. 120(1):41-5. [Medline]. [Full Text].

  19. 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].

  20. Owusu-Ofori S, Remmington T. Splenectomy versus conservative management for acute sequestration crises in people with sickle cell disease. Cochrane Database Syst Rev. 2015 Sep 7. 9:CD003425. [Medline].

  21. Lavrenkov K, Krepel-Volsky S, Levi I, Ariad S. Low dose palliative radiotherapy for splenomegaly in hematologic disorders. Leuk Lymphoma. 2012 Mar. 53(3):430-4. [Medline].

  22. Bruns F, Bremer M, Dettmer A, Janssen S. Low-dose splenic irradiation in symptomatic congestive splenomegaly: report of five cases with literature data. Radiat Oncol. 2014 Mar 27. 9:86. [Medline]. [Full Text].

  23. Mistry PK, Lukina E, Ben Turkia H, Amato D, Baris H, et al. Effect of oral eliglustat on splenomegaly in patients with Gaucher disease type 1: the ENGAGE randomized clinical trial. JAMA. 2015 Feb 17. 313 (7):695-706. [Medline].

  24. 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].

  25. 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). 2009 May 20. 122(10):1203-8. [Medline].

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

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.