Does This Patient Have Splenomegaly?

Grover, Steven A, et al. Does This Patient Have Splenomegaly? JAMA Novermber 10, 1993,
Volum 270, No. 18 (2218-221)

Bottom Line
Percussion followed by palpation is deemed to be the most useful in detecting splenomegaly
Consistently, palpation and percussion of the spleen had lower sensitivity than specificity. The
best representations of sensitivity for percussion or palpation ranged from 50-60%. Specificity of
palpation or percussion was consistently higher and ranged from 80-100%.
Kappa values for detecting splenomegaly ranged from poor to moderate in agreement, and
confirmatory methods as noted below must be used to properly detect splenomegaly.
The average weight of the spleen is variable (90 g-170 g); this range of sizes has led to a rule of
thumb that is the following: any spleen under 250 grams is normal.
Confirmatory diagnostic testing is likely to be necessary, especially if finding splenomegaly is
crucial to clinical diagnosis.

SORT Grade of Recommendation: C, the recommendation to clinically detect splenomegaly is not

based on patient-oriented evidence.

Updated Search Findingsmost articles are consistent with this article as far as sensitivity and
specificity of detecting splenomegaly.

Comments/Hints/Suggestions

There are three ways to assess splenomegaly that can be categorized as the following
a. Inspection: not typically used because a bulging mass would not be noticed in the left
upper quadrant unless the spleen was grossly enlarged and also, an enlargement of the left
upper quadrant could also be a sign of some other type of tumor
b. Percussion: 1. Nixons Method, 2. Castells Method, 3. Percussion of Traube's Space
c. Palpation: 1. Two handed palpation, with patient in right lateral decubitus (or can be
supine) 2. one handed palpation with patient supine 3. hooking maneuver of Middleton,
with patient supine

Prevalence
About 3% of otherwise healthy students entering a US college had unexplanable splenomegaly.
Also, 12% of otherwise normal postpartum women in a Canadian hospital had palpable spleen.
Accuracy of Exam

Method Sensitivit Specificity

y
Percussion
Traube's space
percussion
-All patients 62 72
-Nonobese pts who
have not eaten
recently 78 82
Nixon Method 59 94
Castell Method 82 83
Palpation
Supine two-handed 56 69
palpation
Supine and right 71 90
lateral decubitus
palpation
Supine palpation or 56 93
Middleton's manuever

Description of how symptoms elicited or defined

Generally, splenomegaly is defined by pathologists as any spleen that is greater than 250 grams.
On clinical examination, the normal spleen lies entirely within the rib cage and cannot be
palpated; however, as it enlarges, it displaces the stomach and its anterior pole continues to follow
the projection of the bony portion of the left 10th rib and then it moves below the rib cage across
the abdomen towards the right iliac fossa.
On inspection a bulging mass may be seen under the left costal margin and descending on
inspiration yet is of low sensitivity because only massive spleen can cause such changes in the
abdominal wall. Also other masses could present in the same way as splenomegaly
With percussion, a loss of tympany is noticed as the enlarging spleen impinges on the adjacent
air-filled lung, stomach and colon.
With palpation, the descending spleen should be able to be felt with the different techniques and
because of its position in the ribcage, the upper border of the spleen (according to texts) cannot be
felt so it is the lower part of the rib that is felt upon its descent.

Description of how exams were done

Inspection:
-a possible bulging mass may be seen under the left costal margin and descending upon
inspiration.
Percussion:
1. Nixons Method (as modified by Sullivan and Williams)
-patient is placed in the right lateral decubitus position and percussion is initiated midway
along the left costal margin and continued upward along a line perpendicular to the costal
margin. Normal exam=dullness extends no further than 8 cm above the costal margin.
Splenomegaly=upper limit of dullness extends more than 8 cm above the costal margin
2. Castells Method
 -patient placed in supine position and percusion is carried out in the lowest intercostal space
in the left anterior axillary line in both expiration and full inspiration. Normal
exam=percussion remains resonant throughout the maneuver. Splenomegaly=percussion is
dull or becomes dull on full inspiration
3. Percussion at Traubes Space
-patient is supine with the left arm slightly abducted for access to the entire Traubes space
(six rib superiorly, the midaxillary line laterally and the left costal margin inferiorly) and with
the patient breathing normally, the triangle is percussed across one or more levels from its
medial to lateral margins. Normal exam=resonant or tympanitic note.
Splenomegaly=percussion note is dull.
Palpation:
1. Two-Handed Palpation, with Patient in Right Lateral Decubitus
-patient in the right lateral decubitus position and the examiners left hand is slipped front to
back around the left lower thorax, gently lifting the left lowermost rib cage anteriorly and
medially. Examiners right fingertips are pressed gently just beneath the left costal margin
and the patient is asked to take a long breath as the palpation of a descending spleen is sought
and if none is felt the procedure is repeated lowering the right hand 2 cm toward the
umbilicus each cycle until the examiner is confident that a massive spleen is not missed.
2. One-Handed Palpation, with patient supine
-identical to the above technique except there is no counter pressure applied by the left hand
to the rib cage. With the patient supine, the tips of the fingers of the examiners right hand
are pressed gently just beneath the left costal margin, and the patient is asked to take a long,
deep breath as the palpation of a descending spleen is sought and if none is felt, the procedure
is repeated, lowering the right hand 2 cm toward the umbilicus each cycle until the examiner
is sure that a massive spleen is not felt.
3. Hooking Maneuver of Middleton, with patient supine
-patient is asked to lie flat with his or her left fist under the left costovertebral angle and the
examiner is positioned to the patients left, facing the patients feet. The fingers of both the
examiners hands are curled under the left costal margin and the patient is asked to take a
long, deep breath as the palpation of a descending spleen is sought.

Precision
Kappa values as follows:
Percussion at Traube's spaces by 3 internists: range, 0.19-0.41 (of note: recent food intake
reduced the accuracy of Traube's space in this study and probably decreased the test precision
when different physicians examined the same patient at varying times after meals)
Interexaminer agreement studying palpation (same study as above): range 0.56-0.70

Updated Search Date: 02/18/2010

Article: Splenic Palpation for the Evaluation of Morbidity due to Schistosomiasis
Mansoni. Memrias do Instituto Oswald Cruz. Rio de Janeiro, Vol. 93, Supplement 1:
245-248, 1998
Description: study that tried to determine the accuracy of splenic palpation for the
diagnosis of splenomegaly and if the frequency of people with a palpable spleen could be
a standard of morbidity of schistosomiasis. Authors examined a rural population that was
highly endemic for Schistosomiasis mansoni and used a control population that did not
have any transmission of the parasite and measured for splenomegaly clinically and with
imaging.
 Findings: Authors standards of splenomegaly are as follows-splenomegaly=palpable
spleen below costal margin (criterion A) or distance between splenic border and costal
margin > 4 cm (criterion B). Criterion A yielded a sensitivity of 72% and specificity of
91% whereas criterion B yielded a sensitivity of 28% and specificity of 98% in the
endemic area.
Critique: this paper did not examine percussion. Furthermore, this paper used different
palpation standards to assess splenomegaly in comparison to the original article, and
possibly used a type of palpation different than the common types of palpation noted
above.
Level of Evidence : unknown
Fit: although this paper only analyzes palpation in individuals that live in an endemic
area for a particular parasite and also tried to examine another medical outcome, this
paper seems to be consistent with the original journal article that palpation has a lower
sensitivity for ruling in splenomegaly whereas it has a high specificity for ruling out
splenomegaly. Furthermore, this article uses another standard (imaging) to properly
confirm splenomegaly.

Article: Accuracy of palpation and percussion manoeuvers in the diagnosis of

splenomegaly. Indian Journal of Medical Sciences. 1997, Volume 51, Issue 11, 409-416.
Description: study done 3-4 years prior to publication in which patients were admitted
to a medicine ward due to hepatic, renal, cardiac and infectious problems and were
randomly chosen for the study. Investigator blinded to any details about patients.
Findings : in this study, sensitivity for palpation ranged from 78.6%-85.7%. The
specificity of the supine maneuver was 92.1%. It was difficult to tell if the Traubes
space percussion sensitivity and specificity were increased for this paper or the
referenced paper. However, Nixon percussion had a sensitivity of 66.7 and specificity of
81.6%. Castell percussion had a sensitivity of 85.7 and specificity 31.7% (this maneuver
led to more false positives, lowering the specificity).
Critique: there was no standard of combining palpation with percussion as in the
original paper. Also, I could not access any type of tables and found it difficult to exactly
elicit specificities and sensitivities from the different methods because this was a full text
article and I did not have access to the pdf. Furthermore, there were only 2 types of
palpation done (supine palpation and Middletons maneuver). Furthermore, confusion
with use of Traubes space percussion information makes me feel as though this data is
incomplete. Furthermore, the study sample in this paper was only 80 versus the study
sample in my original paper. Just from the above chart, there were 183 patients used for
percussion, and for palpation, the number of patients was 283.
Level of Evidence : unknown
Fit: the benefit to this paper is that the patients were randomly chosen patients.
Furthermore, this paper excluded confounders (such as obesity) from the very beginning
in order to obtain more accurate information. Unfortunately, the authors of this paper
think that palpation versus percussion is a better way to discern splenomegaly in non-
obese patients because the sensitivity range starts lower with percussion and the supine
palpation specificity is highest at 92% versus with any type of percussion.
Article: Percussion of Traubes Spacea useful index of splenic enlargement. The
Journal of the Association of Physicians of India 2000; March 48 (3): 326-8
Description: this is a study that examined 100 random patients in a medical ward by
palpation and percussion of Traubes space.
Findings: Traubes space percussion had a sensitivity of 67% and specificity of 75%;
however, increased BMI led to an increase in false negatives. Sensitivity with palpation
was 44.44% and specificity was 96.87%.
Critique : Could only access an abstract. Furthermore, they only did one form of
unknown palpation and only Traubes space percussion according to the abstract.
Level of Evidence : unknown
Fit: from what was able to be ascertained, this study confirmed much of the information
that was shown in the other studies. Again, using more than one form of palpation and
percussion might have been more informative to continue to prove that sensitivity is low
in comparison to sensitivity. Furthermore, this abstract confirmed that palpation plus
percussion needs to be done in order to determine splenomegaly.

Article: Examiner Dependence on Physical Diagnostic Tests for the Detection of

Splenomegaly: A Prospective Study with Multiple Observers. Journal of General
Internal Medicine, 1993; 8:69-75.
Description: A prospective double blind study that is trying to determine the reliability
and validity of 3 methods of palpation and three methods of percussion in comparison to
splenomegaly found by ultrasound.
Findings Palpation among 8 different examiners revealed the following range of
sensitivities: 0-58.3% and specificities: 63.6-100% (bimanual technique); sensitivities:
0-58.3% and specificities: 50-100% (ballottment technique) and sensitivities: 0-64.3%
and specificities: 50-100% (palpation from above). Percussion among the same 8
different examiners revealed the follow range of sensitivities: 23.1-66.7% and
specificities: 70-100% (Nixon method); sensitivities: 23.1-54.6% and specificities: 60-
100% (Castell method); sensitivities: 7.7-54.6% and specificities: 80-100% (Barkun, et
al method=Traubes space).
Critique : Methods of palpation are slightly altered from original patient and
ballottement is a totally different technique. The population was all HIV positive which
could alter the amount of splenomegaly detected as HIV positive patients could have
more enlarged spleens than the general population. Also, this paper did not consider time
of eating meals in examining patients. Because of the absence of obesity, the results
might not be generalizable to the general public although obesity tends to be a
confounder when trying to detect splenomegaly. There was no particular order of doing
palpation and percussion and there was no combination of the best way of combining the
techniques to try and determine splenomegaly clinically. Also, the number of subjects
was small (only 59)
Level of Evidence : unknown
Fit: the major downfall to this paper is that the subjects were HIV positive. This might
not correlate to the general population. Although the subjects were small and the
patients were HIV positive, again, it supported my original paper in that palpation and
percussion of the spleen seems to have generally lower sensitivity and higher specificity
in trying to discern splenomegaly.

Reviewed by: Verietta Sarone Williams MD; Lee Chambliss MD MSPH Date: 02/28/11