Station 1.3: Splenomegaly

Question 1

Clinical signs

What are the general signs of Splenomegaly

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

Answer 1

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

Question 2

Clinical signs

What are the Abdominal signs of Splenomegaly

Splenomegaly

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

Answer 2

*  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 3

Clinical signs

What are the underlying causes?

Splenomegaly

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

Answer 3

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 4

Discussion

Elaborate on the causes?

Splenomegaly

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

Answer 4

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

Question 5

Discussion

What investigations?

Splenomegaly

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

Answer 5

•   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 6

Discussion

What Indications for splenectomy?

Splenomegaly

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

Answer 6

• Rupture (trauma)
• Haematological (ITP and hereditary spherocytosis)

Question 7

Discussion

What splenectomy work-up?

Splenomegaly

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

Answer 7

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