Splenomegaly
Because it occurs with various disorders and in up to 5% of normal adults, splenomegaly — an enlarged spleen — isn’t a diagnostic sign by itself. Usually, however, it points to infection, trauma, or a hepatic, autoimmune, neoplastic, or hematologic disorder.
Because the spleen functions as the body’s largest lymph node, splenomegaly can result from any process that triggers lymphadenopathy. For example, it may reflect reactive hyperplasia (a response to infection or inflammation), proliferation or infiltration of neoplastic cells, extramedullary hemopoiesis, phagocytic cell proliferation, increased blood cell destruction, or vascular congestion associated with portal hypertension.
Splenomegaly may be detected by light palpation under the left costal margin. (See How to palpate for splenomegaly, page 572.) However, because this technique isn’t always advisable or effective, splenomegaly may need to be confirmed by a computed tomography or radionuclide scan.
Emergency interventions
If the patient has a history of abdominal or thoracic trauma, don’t palpate the abdomen because this may aggravate internal bleeding. Instead, examine him for left upper quadrant pain and signs of shock, such as tachycardia and tachypnea. If you detect these signs, suspect splenic rupture. Insert an I.V. line for emergency fluid and blood replacement, and administer oxygen. Also, catheterize the patient to evaluate urine output, and begin cardiac monitoring. Prepare the patient for possible surgery.
History and physical examination
If you detect splenomegaly during a routine physical examination, begin by exploring associated signs and symptoms. Ask the patient if he has been unusually tired lately. Does he frequently have colds, sore throats, or other infections? Does he bruise easily? Ask about left upper quadrant pain, abdominal fullness, and early satiety. Finally, examine the patient’s skin for pallor and ecchymoses, and palpate his axillae, groin, and neck for lymphadenopathy.
Medical causes
Brucellosis
With severe cases of brucellosis, a rare infection, splenomegaly is a major sign. Typically, brucellosis begins insidiously with fatigue, a headache, a backache, anorexia, arthralgia, a fever, chills, sweating, and malaise. Later, it may cause hepatomegaly, lymphadenopathy, weight loss, and vertebral or peripheral nerve pain on pressure.
Cirrhosis
About one-third of patients with advanced cirrhosis develop moderate to marked splenomegaly. Among other late findings are jaundice, hepatomegaly, leg edema, hematemesis, and ascites. Signs of hepatic encephalopathy — such as asterixis, fetor hepaticus, slurred speech, and a decreased level of consciousness that may progress to coma — are also common. Besides jaundice, skin effects may include severe pruritus, poor tissue turgor, spider angiomas, palmar erythema, pallor, and signs of bleeding tendencies. Endocrine effects may include menstrual irregularities or testicular atrophy, gynecomastia, and a loss of chest and axillary hair. The patient may also develop a fever and right upper abdominal pain that’s aggravated by sitting up or leaning forward.
Felty’s syndrome
Splenomegaly is characteristic in Felty’s syndrome, which occurs with chronic rheumatoid arthritis. Associated findings are joint pain and deformity, sensory or motor loss, rheumatoid nodules, palmar erythema, lymphadenopathy, and leg ulcers.
Histoplasmosis
Acute disseminated histoplasmosis commonly produces splenomegaly and hepatomegaly. It may also cause lymphadenopathy, jaundice, a fever, anorexia, emaciation, and signs and symptoms of anemia, such as weakness, fatigue, pallor, and malaise. Occasionally, the patient’s tongue, palate, epiglottis, and larynx become ulcerated, resulting in pain, hoarseness, and dysphagia.
Leukemia
Moderate to severe splenomegaly is an early sign of acute and chronic leukemia. With chronic granulocytic leukemia, splenomegaly is sometimes painful. Accompanying it may be hepatomegaly, lymphadenopathy, fatigue, malaise, pallor, a fever, gum swelling, bleeding tendencies, weight loss, anorexia, and abdominal, bone, and joint pain. At times, acute leukemia also causes dyspnea, tachycardia, and palpitations. With advanced disease, the patient may display confusion, a headache, vomiting, seizures, papilledema, and nuchal rigidity.
Mononucleosis (infectious)
A common sign of mononucleosis, splenomegaly is most pronounced during the second and third weeks of illness. Typically, it’s accompanied by a triad of signs and symptoms: a sore throat, cervical lymphadenopathy, and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Occasionally, hepatomegaly, jaundice, and a maculopapular rash may also occur.
Pancreatic cancer
Pancreatic cancer may cause moderate to severe splenomegaly if tumor growth compresses the splenic vein. Other characteristic findings include abdominal or back pain, anorexia, nausea and vomiting, weight loss, GI bleeding, jaundice, pruritus, skin lesions, emotional lability, weakness, and fatigue. Palpation may reveal a tender abdominal mass and hepatomegaly; auscultation reveals a bruit in the periumbilical area and left upper quadrant.
Polycythemia vera
Late in polycythemia vera, the spleen may become markedly enlarged, resulting in easy satiety, abdominal fullness, and left upper quadrant or pleuritic chest pain. Signs and symptoms accompanying splenomegaly are widespread and numerous. The patient may exhibit deep, purplish red oral mucous membranes, a headache, dyspnea, dizziness, vertigo, weakness, and fatigue. He may also develop finger and toe paresthesia, impaired mentation, tinnitus, blurred or double vision, scotoma, increased blood pressure, and intermittent claudication. Other signs and symptoms include pruritus, urticaria, ruddy cyanosis, epigastric distress, weight loss, hepatomegaly, and bleeding tendencies.
Sarcoidosis
Sarcoidosis is a granulomatous disorder that may produce splenomegaly and hepatomegaly, possibly accompanied by vague abdominal discomfort. Its other signs and symptoms vary with the affected body system, but may include a nonproductive cough, dyspnea, malaise, fatigue, arthralgia, myalgia, weight loss, lymphadenopathy, skin lesions, an irregular pulse, impaired vision, dysphagia, and seizures.
Splenic rupture
Splenomegaly may result from massive hemorrhage with splenic rupture. The patient may also experience left upper quadrant pain, abdominal rigidity, and Kehr’s sign.
Thrombotic thrombocytopenic purpura
Thrombotic thrombocytopenic purpura may produce splenomegaly and hepatomegaly accompanied by fever, generalized purpura, jaundice, pallor, vaginal bleeding, and hematuria. Other effects include fatigue, weakness, a headache, pallor, abdominal pain, and arthralgia. Eventually, the patient develops signs of neurologic deterioration and renal failure.
Special considerations
Prepare the patient for diagnostic studies, such as a complete blood count, blood cultures, and radionuclide and computed tomography scans of the spleen.
Pediatric pointers
Besides the causes of splenomegaly described above, children may develop splenomegaly in histiocytic disorders, congenital hemolytic anemia, Gaucher’s disease, Niemann-Pick disease, hereditary spherocytosis, sickle cell disease, or beta-thalassemia (Cooley’s anemia). Splenic abscess is the most common cause of splenomegaly in immunocompromised children.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Swollen spleen
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Swollen spleen
» Next page: Hepatomegaly (A Pocket Manual of Differential Diagnosis)
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