History
The most common complaint in patients with splenomegaly is mild, vague, abdominal discomfort. Patients may also experience pain,which 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:
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Febrile illness (infectious)
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Pallor, dyspnea, bruising, and/or petechiae (hemolytic process)
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History of liver disease (congestive)
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Weight loss, constitutional symptoms (neoplastic)
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Pancreatitis (splenic vein thrombosis) [8]
Family history should be reviewed to disclose relevant hereditary diseases, such as hemolytic anemias.
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 healthy 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. [7]
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 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:
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Signs of cirrhosis - Eg, asterixis, jaundice, telangiectasias, gynecomastia, caput medusa, and ascites
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Heart murmur - Endocarditis or congestive failure
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Jaundice
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Scleral icterus - Spherocytosis or cirrhosis
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Petechiae - Any other bleeding manifestation secondary to thrombocytopenia
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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.
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Resected specimen from the patient in the previous image. Note the discrete abscesses adjacent to normal parenchyma.
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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.
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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.
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A portion of a massive spleen is extracted via hand-assisted laparoscopy.
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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.
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A massive spleen that was removed from an elderly woman with lymphoma.
