Splenomegaly and Hypersplenism

done by Anas M.kamel Hindawi5th 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 vesseleslymph 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

• 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

Spleen functions

90% of blood passing “300 ml/min “ thru the spleen moves in an open circulation :

from arteries to the cords to the sinusesthus 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

• Nixon’s method

• Castel's sign

• Traube’s sign

Nixon’s 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

Traube’s sign

• The borders of Traube’s 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• Can’t get above

• Moves with resp.• Splenic rub• No ballotable

• No notch• Can’t 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 (felty’s 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 of……ctd

• 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 felty’s 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

• Bailey and loves’s short practice of surgery

• Cecil Textbook of medicine• Harrison’s principal of inernal medecine

17th edition

• Goljan pathology 2nd edition

References

Thanks 4 u all my friendspeace