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 possible but less common. Early satiety from gastric displacement occurs with massive splenomegaly. Patients may complain of discomfort when lying supine or on their right side. 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) [10]
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. [9]
The physical examination includes both percussion and palpation techniques. Percussion is performed with the patient in the supine position. If the spleen is not enlarged, tympany to percussion will be present in the area known as Traube's space (defined by the left sternal border, the costal margin, and the lower border of the 9th ribs), due to the normal presence of the air-filled gastrum. Dullness to percussion in that area indicates displacement with non-hollow viscus, typically the spleen.
For palpation, the examiner applies light pressure with the fingertips in the space below the costal margin, with the patient first in the supine position and then in the right lateral decubitus position with the hips flexed. Gentle pressure to the right posterior rib cage can also help bring the spleen into contact with the examiner's fingers, as can the use of the reverse Trendelenburg position; the latter is especially helpful in patients with morbid obesity. Perform palpation during both inspiration and expiration. 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, left lower quadrant, or 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.
Additional physical exam findings to note include:
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Signs of cirrhosis - Eg, asterixis, jaundice, telangiectasias, gynecomastia, caput medusa, ascites
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Heart murmur - Endocarditis or congestive failure
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Jaundice
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Lymphadenopathy
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Scleral icterus - Spherocytosis or cirrhosis
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Evidence of skeletal hypertrophy
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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.
