MODULE I

ABDOMEN II
 THE SPLEEN
Splenomegaly
Borderline measurements
Length - <12 cm
Breadth – 7 cm
Thickness – 5 cm
Differential diagnosis for splenomegaly is extensive
– includes :
Infection
Neoplasia
Trauma
Blood dyscrasias – leukemia, hemophilia
Storage disorders
Portal hypertension
Sonography not helpful in specific diagnosis of splenomegaly
 THE SPLEEN
Splenomegaly
On u/s, the degree of splenomegaly helps narrow down
the differential diagnosis
Mild to moderate splenomegaly
Infection
Portal hypertension
AIDs
Marked/moderate splenomegaly
Leukaemia
Lymphoma
Massive/severe splenomegaly
Myelofibrosis
Focal lesions within the spleen may suggest
lymphomatous involvement, metastatic disease,
haematoma and cysts
 THE SPLEEN
Splenomegaly
Portal hypertension
The cause of splenomegaly in association with
Portosystemic venous collaterals
Splenic vein varices
Ascites
Splenomegaly may however, be the sole finding
SPLENIC VARICES
NORMAL VASCULATURE
 THE SPLEEN

Focal abnormalities
Cysts
Solid masses
 THE SPLEEN
Cysts
Display normal sonographic appearance
Small cysts located within the parenchyma
Larger ones become exophytic
Spleen is least common site for hydatid cysts
Post-traumatic cysts – pseudocysts
Do not have epithelial lining
Primary congenital cysts – epidermoid cysts
Pancreatic pseudocysts can extend into spleen
Diagnosed in association with pancreatitis
EPIDERMOID CYST

Rumack et al
 THE SPLEEN
Splenic abscess
May appear similar to simple cysts
Diagnosis can be made in conjunction with clinical
findings
 THE SPLEEN
Splenic abscess – Causes
infection: anaerobes are thought to be most common
infective agent
metastatic infection
blood bacterial dissemination, such as sepsis
infective endocarditis
continuous infection, such as perinephric abscess or
infected pancreatitis
splenic infarction and superimposed infection
trauma
immunodeficiency conditions (e.g. chemotherapy /
transplant recipients, leukaemia and AIDS): especially
for those with multiple splenic abscesses
 THE SPLEEN
Splenic abscess
Clinical manifestations
Nonspecific signs
Pyrexia
Left upper quadrant tenderness
Rigors and chills
Leukocytosis
Vomiting
SPLENIC ABSCESS
 THE SPLEEN
Splenic abscess sonographic appearance

Poorly demarcated with a variable appearance

Hypoechoic with some internal echoes to
hyperechoic.
May contain septae of varying thicknesses
Presence of gas bubbles may also be seen
SPLENIC ABSCESS
 THE SPLEEN
Solid masses
Uncommon
Causes
Previous granulomatous infections
Histoplasmosis - fungus found in the droppings of birds and
bats in humid areas.
Tuberculosis
Calcification of artery is common – not to be confused
with calcified lesion
Primary malignancy is very rare
Primary lymphoma
Angiosarcoma
Metastatic splenic disease
Late occurring feature
Malignant melanoma
Lymphoma
Leukaemia
Can also occur in Ca of breast, ovary, lung and stomach
PRIMARY MALIGNANCY

Rumack et al
SPLENIC METASTASIS

Rumack et al
 THE SPLEEN
Solid masses
Haemangioma
Not as common found in the liver
Reported in up to 14% cases
Usually isolated
Similar sonographic appearance as the liver
Other masses
Splenic infarction
Candidiasis
Miliary tuberculosis
SPLENIC HAEMANGIOMA

Rumack et al
SPLENIC INFARCT

Rumack et al
 THE SPLEEN
Splenic trauma
U/S very useful and highly accurate at detecting
haematomas
intraparenchymal
Subcapsular
Pericapsular
CT scanning still has the advantage here however
u/s still useful
Fast
Portable
Easily integrated into the resuscitation of a patient
Good for patients in distress
 THE SPLEEN
Splenic trauma
If capsule remains intact, haematoma may be
Intraparenchymal
Subcapsular
If capsule ruptures
Pericapsular fluid – left upper quadrant
Peritoneal cavity – Morison’s pouch

Subcapsular haematomas are crescentric and conform to the

contour of the spleen
Intraparenchymal or subcapsular haematomas appear
inhomogenous in the normal uniform splenic parenchyma
Perisplenic collections are more irregular shaped
Perisplenic fluids can persist for weeks and even months
Perisplenic haematoma can have the same appearances as a
perisplenic abscess – distinction made clinically or by FNA
 THE SPLEEN
SPLENIC INFARCTION
A result of ischaemia to the spleen
Many cases requires no treatment.
Identification of the cause of infarction is essential.
 THE SPLEEN
SPLENIC INFARCTION
Clinical manifestations
Left upper quadrant pain, diffuse abdominal pain
Some may have constitutional symptoms such as
fevers and chills
Referred pain to the left shoulder is also a feature
 THE SPLEEN
Splenic infarction- aetiology
haematologic disorders
more common in younger patients
e.g. sickle cell disease
embolic events
more common in older patients
e.g. infective endocarditis
 THE SPLEEN
Other Aetiology
splenic vascular disease
splenic arterial aneurysms
variant anatomy, e.g. wandering spleen, which may
undergo splenic torsion
collagen vascular disease
pancreatic disease: pancreatitis
non-haematologic malignancies
blunt trauma: a segmental splenic infarct can occur
as a rare complication
splenic artery compression, e.g. by pancreatic tumour
 THE SPLEEN
Splenic infarction sonographic appearance:
wedge-shaped (classic)
round
irregularly
smooth (uncommon)
During contrast enhanced ultrasound, the infarcted
area remains hypo-intense throughout all phases of
the study
SPLENIC INFARCTION
 THE SPLEEN
Congenital anomalies
Accessory spleens (Splenunculi)
common
Up to 30%
Can be misdiagnosed as lymph nodes or abnormal
masses
Acute abdominal pain due to torsion
Easy to recognise on u/s
Rounded mass < 5mm diameter
Located near splenic hilum
Isoechoic to spleen
SPLENUNCULI ( Accessory
spleen)
 THE SPLEEN
Congenital anomalies - Heterotaxy syndrome or situs
ambiguus
It occurs from an early embryological developmental
disturbance
Polysplenia(left isomerism) – multiple spleens
Asplenia ( right isomerism) - absence of spleen
Can be total (congenital asplenia) or partial (hypoplastic)
 THE SPLEEN
Heterotaxy syndrome or situs ambiguus
Right isomerism
presented with Cyanotic congenital heart disease
during early childhood
Left isomerism
present later in chilhood or even in adulthood
less associated with complex congenital heart
disease.
Intestinal malrotation with midgut volvulus may be
also be a presenting feature.
Heterotaxy spectrum
Polysplenia
Polysplenia