Splenomegaly and Hypersplenism

done by Anas M.kamel Hindawi 5th year beirut arab university salamtak workshop

It lies in the left upper quadrant of the abdomen

normal spleen 10 cm length ,150 gms

Lies beneath 9 th to the 12 th rib

lymphatic organ suspended within the greater omentum

connected to stomach by gastrosplenic ligament ,and to the kidney by splenorenal

Blood supply by splenic vesseles lymph drainage follow its bld supply paraortic and caeliac Ln.s

Spleen has only efferent lymph vessels and caeliac symp. Supply along the art.

white pulp
Composed of malphigian corpuscles wich are :
Lymphoid follicles B lymphocytes Periarteriolar lymphoid sheath T lymphocutes macrophages

Active immune response through humoral and cell-mediated pathways.

Red pulp
Contains the cords of Billroth with fixed macrophages and sinusoids Mechanical filtration of RBC.s

Spleen functions
Blood filtration; macrophages remove: Hematopoietic elements Intraerythrocytic parasites Encapsulated bacteria Enhancement of Ag trapping and processing in macrophages Reservoir for one third of the peripheral blood platelet pool and 10 % of RBC.s Pitting :howel jolly and heinz bodies removal from RBC.s Site for extramedullary hematopoiesis

90% of blood passing 300 ml/min thru the spleen moves in an open circulation : from arteries to the cords to the sinuses thus spleen pulp pressure reflects

pressure of the portal system

Hypersplenism
Clinical syndrome characterized by :
Splenic enlargment splenomegaly Anaemia ,leukopenia and thrombocytopenia Compensatory bone marrow hyperplasia Improvement after splenectomy

splenomegaly
Mild splenomegaly : largest dimension bt 12 and 20 cm ,400-500 g Severe splenomegaly : largest dimension more than 20 cm ,more than 1000 g If spleen below costal margin 750-1000 g

Symptoms
Pain Early satiety Heavy sensation in the left upper quadrant

signs

Inspection : fullness moved with resp. mov.

Auscultation : venous hum or friction rub

Bimanual examiaton (palpitation)

 Supine flexed knees

Lt hand at the costovertebral angle Rt hand feels the tip or notch of the spleen during resp.

identify the lower edge of spleen by examining from Lt lower quadrant and the right lower quad.

Percussion
Nixons method Castel's sign Traubes sign

Nixons method

Castell's sign
Patient is placed in the supine position Percussion in the lowest intercostal space in the anterior axillary line (eighth or ninth) produces a resonant note if the spleen is normal in size during either expiration or during full inspiration bcz of air in the stomach and colon A dull percussion note on full inspiration suggests splenomegaly Difficult in obese

Traubes sign
The borders of Traubes space are the sixth rib superiorly, the left midaxillary line laterally, and the left costal margin inferiorly Patient is supine with the left arm slightly abducted During normal breathing, this space is percussed from medial to lateral margins, yielding a normal resonant sound A dull percussion note suggests splenomegaly.

How to differentiate in examination the kidney from the spleen

Splenic notch Can cross the midline Cant get above Moves with resp. Splenic rub No ballotable No notch Cant cross midline May get above Not moves with resp. No rub ballotable

Causes of splenomegaly
Increased function Abnormal bld flow Infiltration

Increased demand for splenic function

Reticuloendothelial system hyperplasia (for removal of defective erythrocytes) as in : spherocytosis thalassemia nutritional anaemia Early sickle cell anaemia

Increased demand..ctd
Immune hyperplasia Either in response to infection whether viral ,bacterial ,fungal or parazite Or disordered immunity as rehumatoid arthritis (feltys syndrome),SLE ,collagen vascular ,drug reaction ,sarcoidosis ,thyrotoxicosis

Increased demand..ctd
Extramedullary hematopoiesis as in myelofibrosis ,marrow damage by toxins or radiation ,marrow infiltration by tumour or leukemia or gausher disease

Abnormal splenic or portal blood flow

Cirrhosis Congestive Heart failure Hepativ vein obstruction either int. or ext. Portal vein obstruction Splenic vein ostruction Hepatic schiztosomiasis Portal hypertension

Infiltration of the spleen

Intacel. Or extrcel. Infiltration Amylodosis Gaicher disease Nimen pick disease hperlipidaemia

Infiltration ofctd
Benign and malignant cellular infiltrations Leukemia (acute ,chronic ,lymphoid) Hodgkin and NHL Myeloproloferative Angiosarcoma Metastatic tumors Haemangioma ,fibroma ,lymphangioma Splenic cysts

Diseases associated with massive splenomegaly

Thalassemia visceral leishmaniasis (Kala Azar) schistosomiasis Chronic myelogenous leukemia Chronic lymphocytic leukemia lymphomas hairy cell leukemia myelofibrosis polycythemia vera Gauchers disease Niemann Pick disease sarcoidosis Autoimmune hemolytic anemia Malaria

Diagnostic Approach
History and physical examination Laboratory and imaging studies Bone marrow biopsy in advanced suspected cases splenectomy

Laboratory Tests
Erythrocyte count If inc. polycythemia vera If decr. Thalassemia major ,SLE ,cirrhosis ,portal HT

Granulocyte counts may be

Decrease as in feltys syndrome ,congestive splenomegaly Increase in infections and inflam. Process also in myelofibrosis

Platelet count
Decrease in cong.splenomeg. ,myeloproliferative dis ,LSD Increase in polycythemia vera

 SGPT ,SGOT

PT ,pPT

Imaging
US CT MRI

treatment
Treat the underlying disorder. Splenectomy is indicated in certain clinical situations. Symptom control in patients with massive splenomegaly Disease control in patients with traumatic splenic rupture Correction of cytopenias in patients with hypersplenism or immune-mediated

Multiple cysts

Massive splenomegaly

Normal spleen dimensions

Spleen injury

Pseudo cyst treated by percutanous drainage if child

Splenomegaly compressing the stomach

Spleen abcess

References
Bailey and lovess short practice of surgery Cecil Textbook of medicine Harrisons principal of inernal medecine 17th edition Goljan pathology 2nd edition

Thanks 4 u all my friends peace