Splenomegaly

Question 1

How do you determine that a LUQ mass is splenomegaly

Answer 1

Splenomegaly extends from the left costal margin towards the umbilicus
Dull to percussion
It descends on respiration
Unable to get above it
Unable to ballot it
A notch may be palpable on the superomedial surface

Question 2

What ribs does the spleen underlie

Answer 2

Ribs 9-11

Question 3

How large is the spleen

Answer 3

1 x 3 x 5 inches

Question 4

How much does the spleen weigh

Answer 4

7 oz

Question 5

What are some causes of splenomegaly

Answer 5

Infective:-
Acute - EBV, CMV, HIV, infective endocarditis
Chronic - Malaria, toxoplasmosis, leishmaniasis

Haematological:-
Haemolytic anaemia
Myeloproliferative disorders (esp. myelofibrosis)
Sickle cell disease/thalassaemia
Leukaemia (esp. CML)
Lymphoma

Portal hypertension:-
Cirrhosis
Hepatic, portal or splenic vein thrombosis

Systemic diseases:-
Amyloidosis
Sarcoidosis
RA (Felty’s syndrome)

Question 6

What is Felty’s syndrome

Answer 6

Combination of:-
RA
Splenomegaly
Neutropaenia

Question 7

What are the causes of massive splenomegaly

Answer 7

Haem: Myelofibrosis, chronic myeloid leukaemia

Infectious: Malaria, tropical splenomegaly, Kala-azar (visceral leishmaniasis)

Question 8

What are the indications for splenectomy

Answer 8

Trauma

Hypersplenism

Question 9

What is hypersplenism

Answer 9

Pancytopaenia occurring in patients with enlarged spleens

Due to large numbers of cells being pooled and destroyed in the spleen’s reticulo-endothelial system

Question 10

What are some causes of hypersplenism

Answer 10

Autoimmune thrombocytopaenia/haemolytic anaemia
Hereditary spherocytosis
Thrombotic thrombocytopaenia
Sickle cell/thalassaemia
Myelofibrosis

Question 11

What are the functions of the spleen

Answer 11

Produces IgM - to capture and process foreign antigen
Filters - esp. capsulated microorganisms (eg. pneumococcus)
Sequesters and removes old red blood cells and platelets
Recycles iron
Pools platelets - 30% of total platelets within spleen

Question 12

What immunizations would a patient require if they’ve had a splenectomy

Answer 12

Pneumococcal
Haemophils influenzae type B
Meningococcal
Annual flu vaccine

*Consider lifelong penicillin/penicillin as required during infection

Question 13

Why does a patient with a splenectomy need to warned about their risk of malaria

Answer 13

As circulating malarial infected cells are destroyed in the spleen

Question 14

What are the appearances on a blood film after a splenectomy

Answer 14

Increased platelet count
Large platelets
Increased neutrophils
Nucleated red cells with Howell-Jolly bodies and target cells
Tend to mount more of a leukocytosis in response to infection

Question 15

How would you confirm splenomegaly

Answer 15

LUQ ultrasound

CT

Question 16

How might a patient with splenomegaly present

Answer 16

LUQ mass/discomfort
Early satiety from compressed stomach
Pancytopaenia (due to hypersplenism)

Question 17

How can pancytopaenia present

Answer 17

Anaemia
Infection
Bleeding

Question 18

How do you define massive splenomegaly

Answer 18

Whether or not it crosses the midline

Question 19

What are the significant negatives in splenomegaly?

Answer 19

Hepatomegaly
Haem signs- pallor, bruising, LNs
CLD
IE: splinters, clubbing
RA hands: Felty's syndrome

Question 20

What are the symptoms of hypersplenism?

Answer 20

Anaemia, bruising, infections

SCD: Hypovolaemic shock due to sequestration crisis

Question 21

What are the causes of hyposplenism?

Answer 21

Splenectomy
Coeliac disease
IBD
SCD

Question 22

What would you expect to see on blood film in hyposplenism?

Answer 22

Howell-Jolly bodies

Target cells

Question 23

How would you manage hyposplenism?

Answer 23

Conservative:
Immunisations: Pneumovax, HiB, Men C, flu (i.e. encapsulated organisms)
Alert card ± bracelet

Medical: Prophylactic daily abx e.g. Pen V, erythromycin

Question 24

What are the indications for splenectomy?

Answer 24

Trauma
Rupture e.g. secondary to EBV
AIHA
ITP
Hypersplenism

Question 25

What are complications of splenectomy?

Answer 25

Early:
Early VTE (due to redistributive thrombocytosis)
–> give temporary post-op aspirin prophylaxis

Transient ileus: Due to gastric dilatation
–> Prophylactic NGT post op

Pancreatitis: Tail and spleen share blood supply

LLL atelectasis

Late:
Increased susceptibility to infection