Splenomegaly and Hypersplenism done by Anas M.kamel Hindawi 5 th year beirut arab university salamtak workshop
Oct 24, 2014
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