Splenomegaly

Question 1

Splenomegaly

Answer 1

This man presents with tiredness and lethargy. Please examine his abdominal system and discuss your diagnosis.

Question 2

Clinical signs

General

Answer 2

• Anaemia
• Lymphadenopathy (axillae, cervical and inguinal areas)
• Purpura

Question 3

Clinical signs

Abdominal

Answer 3

• Left upper quadrant mass that moves inferomedially with respiration, has a notch, is dull to percussion and you cannot get above nor ballot
• Estimate size
• Check for hepatomegaly

Question 4

Clinical signs

Underlying cause

Answer 4

• Lymphadenopathy –> Haematological and infective
• Stigmata of chronic liver disease –> Cirrhosis with portal hypertension
• Splinter haemorrhages, murmur, etc. –> Bacterial endocarditis
• Rheumatoid hands –> Felty’s syndrome

Question 5

Causes

Answer 5

• Massive splenomegaly (>8 cm):
⚬⚬ Myeloproliferative disorders (CML and myelofibrosis)
⚬⚬ Tropical infections (malaria, visceral leishmaniasis: kala azar)
• Moderate (4–8 cm):
⚬⚬ Myelo/lymphoproliferative disorders
⚬⚬ Infiltration (Gaucher’s and amyloidosis)
• Tip (<4 cm):
⚬⚬ Myelo/lymphoproliferative disorders
⚬⚬ Portal hypertension
⚬⚬ Infections (EBV, infective endocarditis and infective hepatitis)
⚬⚬ Haemolytic anaemia

Question 6

Investigations

Answer 6

• Ultrasound abdomen
Then if:
• Haematological:
⚬⚬ FBC and film
⚬⚬ CT chest and abdomen
⚬⚬ Bone marrow aspirate and trephine
⚬⚬ Lymph node biopsy
• Infectious:
⚬⚬ Thick and thin films (malaria)
⚬⚬ Viral serology

Question 7

Indications for splenectomy

Answer 7

• Rupture (trauma)
• Haematological (Immune Thrombocytopenic Purpura [ITP] and hereditary spherocytosis)

Question 8

Splenectomy work‐up

Answer 8

• Vaccination (ideally 2/52 prior to protect against encapsulated bacteria):
⚬⚬ Pneumococcus.
⚬⚬ Meningococcus.
⚬⚬ Haemophilus influenzae (Hib).
• Prophylactic penicillin: (lifelong).
• Medic alert bracelet.