Splenomegaly Treatment & Management

Successful medical treatment of the primary disorder in cases of splenomegaly can lead to regression of the hypersplenism without the need for surgery.

Splenectomy is indicated to help control or stage the basic disease in cases of splenomegaly. These diseases can include hereditary spherocytosis, autoimmune thrombocytopenia or hemolysis, or Hodgkin disease (as part of a staging celiotomy).

Splenectomy is also indicated for the treatment of chronic, severe hypersplenism.^[13] This can occur in conditions such as the following:

• Hairy cell leukemia
• Felty syndrome
• Agnogenic myeloid metaplasia
• Thalassemia major
• Gaucher disease
• Hemodialysis splenomegaly
• Splenic vein thrombosis^[3]

In rare cases, splenectomy may be used to treat thrombotic thrombocytopenic purpura (TTP); however, therapeutic plasma exchange transfusion (plasmapheresis) has largely supplanted the need for splenectomy.

Inpatient care

Inpatient care for patients with splenomegaly depends on the modality used to treat the underlying cause of the condition and on the complications of that care. These therapies are not unique to splenomegaly treatment and, therefore, are not discussed here.

Outpatient care

Outpatient care of patients with splenomegaly consists of 2 main focus areas: (1) monitoring for thrombocytosis and (2) monitoring for overwhelming postsplenectomy infection (OPSI).

Thrombocytosis may require treatment when the platelet count exceeds 1 million/μL. Multiple modalities have been used, including hydroxyurea and aspirin. No randomized, placebo-controlled studies have demonstrated a better survival benefit with one therapy over the other. Whether any discrete benefit is gained by also controlling the platelet count remains unclear.

Transfer

Transfer of patients with splenomegaly is not generally required except for complications of surgery or OPSI. Patients undergoing elective splenectomy for splenomegaly may develop significant hemorrhaging during their operation if difficulty occurs controlling the splenic hilum. Such patients may require abdominal packing and transfer to a tertiary center with personnel who have expertise in angioembolization and splenic resection for splenomegaly.^[14]

Such centers usually have the additional resources (eg, a well-stocked blood bank, a tertiary level intensive care unit) to support the organ systems in these patients. Multisystem organ failure is not uncommon following severe hemorrhage, and these patients are no exception.

Consultations

Consultation with a hematologist is ideal before surgery for enlarged spleens in order to secure necessary blood products. Postoperative management does not usually require intervention from a hematologist.

Chemotherapy is used for hematologic malignancies. Antibiotics are used for infection, with the exception of infection associated with a splenic abscess; this requires surgical intervention.

Immunosuppression is used for autoimmune or inflammatory disorders, treatment of cirrhosis, and CHF. All patients scheduled for elective splenectomy (either diagnostic or therapeutic) should receive a pneumococcal vaccine. Also consider administering prophylaxis against Haemophilus influenzae and Neisseria meningitidis.

The vast majority of splenectomies are performed using laparoscopic techniques. Laparoscopic splenectomy is safe and is associated with reduced hospital stays. Furthermore, this procedure has a postoperative survival advantage when compared with open procedures. Laparoscopic surgery can be performed even on individuals with massive splenomegaly. (See the images below.)^{[15, 16]}

Occasionally, a reactive thrombocytosis occurs following splenectomy. Thrombocytosis in the face of splenectomy rarely requires treatment. It is most common in patients with massive splenomegaly from myeloproliferative disorders.

An onset of fever several days following splenectomy can be due to a recrudescence of malaria. This should be considered as a cause of fever in patients who have lived in areas commonly associated with malaria and in persons who abuse intravenous (IV) drugs who share needles.

With Plasmodium malariae infection, this may occur decades after the initial infection. Malaria from P vivax (3-7 y) and P falciparum (about 1 y) remain active for shorter intervals after the initial infection.

Fulminant, life-threatening infection represents a major long-term sequela after splenectomy in patients with splenomegaly. Splenic macrophages play a major role in filtering and phagocytizing bacteria and parasitized blood cells from the circulation. In addition, the spleen is a significant source of antibody production.

Overwhelming postsplenectomy infection (OPSI), also known as postsplenectomy sepsis syndrome, begins as a nonspecific, flulike prodrome that is followed by a rapid evolution to full-blown bacteremic septic shock—accompanied by hypotension, anuria, and clinical evidence of disseminated intravascular coagulation—thus making this syndrome a true medical emergency. The subsequent clinical course often mirrors that of the Waterhouse-Friderichsen syndrome, with bilateral adrenal hemorrhages noted at autopsy.

Despite appropriate antibiotics and intensive therapeutic intervention, the overall mortality rate in older published studies of established cases of OPSI varied from 50-70%. Information now suggests, however, that if patients seek medical attention promptly, the mortality rate may be reduced to approximately 10%. Of those patients who die, more than 50% do so within the first 48 hours of hospital admission.

Most instances of serious infection are due to encapsulated bacteria, such as pneumococci (eg, Streptococcus pneumoniae). Because these organisms are encapsulated and the spleen is integral in the removal of opsonized bacteria, affected patients are at increased risk for unimpeded sepsis. Pneumococcal infections account for 50-90% of cases reported in the literature and may be associated with a mortality rate of up to 60%. H influenza type B, meningococci, and group A streptococci account for an additional 25% of infections.

Possible OPSI involving an asplenic individual constitutes a medical emergency. The critical point in management remains early recognition of the patient at risk, followed by subsequent aggressive intervention. The diagnostic workup should never delay the use of empiric therapy. Possible choices of empiric antimicrobial agents include cefotaxime (adult dose of 2 g IV q8h; pediatric dose of 25-50 mg/kg IV q6h) or ceftriaxone (adult dose of 2 g q12-24h; pediatric dose of 50 mg/kg IV q12h). Unfortunately, some penicillin-resistant pneumococcal isolates are also resistant to cephalosporins. If such resistance is suggested, consider using vancomycin.

The precise incidence of OPSI remains controversial. Overall, the most reliable data related to incidence estimate approximately 1 case occurring per 500 person-years of observation. Asplenic children younger than 5 years, especially infants splenectomized for trauma, may have an infection rate of greater than 10%.

Splenectomy performed for a hematologic disorder, such as thalassemia, hereditary spherocytosis, or lymphoma, appears to carry a higher risk than splenectomy performed as a result of trauma. A major contributing factor is the frequent existence of splenic implants or accessory spleens in traumatized patients.

Prevention

Preventative strategies for OPSI fall into 3 major categories: education, immunoprophylaxis, and chemoprophylaxis.

As previously mentioned, education represents a mandatory strategy in the prevention of OPSI. Asplenic patients should be encouraged to wear a Medi-Alert (Pinellas Park, Fla/Henderson, Nev) 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.

Vaccination is also appropriate in the prevention of OPSI. This has best been defined for S pneumoniae. Unfortunately, the most virulent pneumococcal serotypes tend to be the least immunogenic, and evidence indicates that the efficacy of the vaccine is poorest in younger patients, who would be at higher risk. However, under ideal conditions in a healthy, immunocompetent host, the vaccine offers a 70% protection rate.

The pneumococcal vaccine should be administered at least 2 weeks before an elective splenectomy. If the time frame is not practical, the patient should be immunized as soon as possible after recovery and before discharge from the hospital.

Most authorities recommend antibiotic prophylaxis for asplenic children, especially for the first 2 years after splenectomy. Some investigators advocate continuing chemoprophylaxis in children for at least 5 years or until age 21 years. However, the value of this approach in older children or adults has never been adequately evaluated in a clinical trial.

Preprocedure prophylaxis

A major concern is antibiotic use in splenectomized patients. Those who have undergone splenectomy should receive antibiotic prophylaxis prior to undergoing procedures associated with a risk of transient or sustained bacteremia. Antibiotics should cover encapsulated organisms and organisms likely to be found at the operative site.

The usual postoperative activity restrictions imposed on a patient who has undergone a laparotomy or laparoscopy also apply to patients after a laparoscopic splenectomy.

Patients with uncorrected splenomegaly should be counseled to refrain from contact sports or activities that would predispose them to blunt abdominal trauma. Examples include skydiving, horseback riding, soccer, football, and ice hockey. These restrictions reduce the likelihood that blunt injury will lead to splenic rupture and uncontrolled hemorrhage.