Spleen palpable: Spleen – Clinical Methods – NCBI Bookshelf
Spleen – Clinical Methods – NCBI Bookshelf
Definition
The normal adult spleen lies immediately under the diaphragm in the left upper quadrant of the abdomen. It ranges in length from 6 to 13 cm and in weight from 75 to 120 g. The spleen is not normally palpable except in slender young adults. When the spleen can be felt below the left costal margin, at rest or on inspiration, splenic enlargement should be assumed and the explanation sought. Although the normal-size, or even the abnormally small, spleen can be involved in pathologic processes, with the exception of rubs associated with splenic infarcts, physical examination is generally not helpful in identifying the problem. Nevertheless, the enlarged and palpable spleen is an important clue to the presence of a variety of illnesses.
Technique
When examining the left upper quadrant of the abdomen, foremost in the examiner’s mind should be the question of whether or not the spleen is enlarged. The examiner should intend to feel the spleen.
A perfunctory examination while assuming the spleen is not going to be palpable is the best way to miss an enlarged spleen. The approach to this part of the physical examination should be to operate on the hypothesis that the spleen is enlarged and only be convinced that this is incorrect if your best attempts to confirm the hypothesis fail.
Each of the four physical examining techniques—inspection, auscultation, palpation, and percussion—is important in examining for splenic enlargement. The examiner should begin with observing the patient’s abdomen on inspiration. In the extremely enlarged spleen, this can lead to observation of the splenic edge descending in the left upper or lower abdomen or, in the extreme case, in the right abdomen. If the spleen cannot be seen, the left upper quadrant should be auscultated during inspiration. Both the maneuvers of inspection and auscultation are most efficiently incorporated into the initial part of the entire abdominal examination. The left upper quadrant and left lower ribs anteriorly and laterally should be auscultated for evidence of a splenic rub (i.
e., a coarse, scratching sound coincident with inspiration). A splenic rub should be especially sought in patients complaining of left upper quadrant pain or pain on top of the left shoulder that is associated with inspiration, and in patients with recent trauma to the left upper quadrant.
Palpation of the left upper quadrant for splenic enlargement can be performed in a variety of ways. Each examiner should use techniques with which he or she is comfortable and always perform them in exactly the same manner and order. A standard approach is the key to avoiding mistakes. Palpation for splenic enlargement should begin with the patient supine and with knees flexed. Using the right hand, the examiner should begin well below the left costal margin and feel gently but firmly for the splenic edge by pushing down, then cephalad, then releasing (). This maneuver should be repeated, working toward the left costal margin. If the spleen cannot be felt below the left costal margin with the patient breathing quietly, the left hand should be placed behind the left lateral ribs and the right just below the left costal margin ().
The patient, on instruction from the examiner, should inspire deeply. The examiner’s right hand should then repeat the maneuver of pressing down, cephalad, and releasing. This should be performed with the right hand at the mid-left costal margin and more laterally until the examiner finds the spleen or is convinced that he or she cannot feel the splenic edge. The splenic edge is frequently “sharp,” but can feel “rounded.” If the spleen still has not been felt, the patient should be placed in the right lateral position and approached in one of two ways (see and ), depending on which is preferred by the examiner. In either case, once the examiner is in position, the same hand movements should be repeated while the patient inspires deeply. It should be noted that when this maneuver is performed with the examiner standing behind the patient, the fingers are “hooked” over the costal margin.
Figure 150.1
By palpating only the splenic edge at the right costal margin, it is possible to miss an extremely enlarged spleen by never feeling low enough to feel the edge.
Palpation of the spleen should begin well below the left costal margin using the hand movements (more…)
Figure 150.2
This is the classic position for splenic palpation. As the patient inspires, the edge of an enlarged spleen descends to the examiner’s fingertips.
Figure 150.3
With the patient in the right lateral position, minimal splenic enlargement can be detected by examining either from in front or in back of the patient. In the position illustrated here, the examination is performed much as in Figure 150.2.
Figure 150.4
Some examiners feel more comfortable examining for the spleen from behind the patient, in the right lateral position. In this case, the fingers are “hooked” over the costal margin.
All these maneuvers can be done in a few minutes when the examiner is confident in his or her technique. When a left upper quadrant mass is found, it is important to consider that it might not be the spleen. The most frequent organ to be confused with an enlarged spleen is an enlarged left kidney.
The position in the abdomen, characteristics of the palpated “edge,” and movement on inspiration are usually sufficient to identify with confidence an enlarged spleen. If any question exists, however, it can be resolved by an abdominal ultrasound examination.
If all these maneuvers fail to demonstrate splenic enlargement, it is appropriate to use percussion as a final step. In both the supine and right lateral positions, the left upper quadrant immediately below the costal margin and the left lower rib margin should be percussed on inspiration and expiration. Dullness that is not present during expiration but is present during inspiration should suggest the presence of an enlarged spleen that has descended with inspiration. In this case, palpation should be repeated to try to confirm this impression.
Basic Science
The normal adult spleen contributes to the homeostasis of the body by removing from the blood useless or potentially injurious materials (e.g., abnormal or “wornout” red blood cells and microorganisms) and by synthesizing immunoglobulins and properdin.
Splenic enlargement can be associated with decreased or increased function, depending on the cause of the enlarged spleen. The causes of splenic enlargement include vascular congestion (e.g., portal hypertension secondary to cirrhosis or splenic vein thrombosis), reticuloendothelial hyperplasia (e.g., systemic infections such as typhoid fever and endocarditis), “work hypertrophy” (e.g., certain hemolytic anemias), and infiltrative processes (e.g., tumor, extramedullary hematopoiesis, amyloidosis). When splenic enlargement is associated with a change in splenic function, it is most frequently associated with splenic hyperfunction. This is reflected in the peripheral blood by thrombocytopenia, leukopenia, rapid red blood cell destruction, or a combination of these findings. This clinical syndrome of an enlarged spleen and peripheral cytopenias is often referred to as hypersplenism. When splenic enlargement is secondary to an infiltrative process (i.e., tumors or amyloidosis), splenic hypofunction can result.
This is reflected in the peripheral blood by Howell–Jolly bodies and abnormal red blood cell forms. The presence of an enlarged spleen should lead to examination of the peripheral blood by the physician.
Clinical Significance
The presence of an enlarged spleen can frequently be the clue that puts the other physical findings in perspective and leads to the correct diagnosis. Splenic enlargement is a finding that should never be ignored. The differential diagnosis is extensive. gives one approach to categorizing the causes of splenic enlargement. It is extremely important to correlate the presence of an enlarged spleen with the historical findings, other physical findings, laboratory results, and x-ray findings to identify the cause of splenic enlargement in a particular patient. For example, vascular spiders, red palms, and small testes in a patient with splenic enlargement would strongly suggest liver disease as the etiology. Roth spots and a new heart murmur would suggest endocarditis.
Extensive lymphadenopathy, weight loss, night sweats, and an enlarged spleen would suggest a malignant lymphoproliferative disease. By making these correlations, it is possible to utilize the presence of an enlarged spleen to plan a patient’s subsequent evaluation and quickly and efficiently reach the correct diagnosis.
Table 150.1
Causes of Splenomegaly.
References
Eichner ER. Splenic function: normal, too much and too little. Am J Med. 1979;66:311–20. [PubMed: 371397]
Eichner ER, Whitfield CL. Splenomegaly: an algorithmic approach to diagnosis. JAMA. 1981;246:2858–61. [PubMed: 7310979]
McIntyre OR, Ebaugh FG. Palpable spleens in college freshmen. Ann Intern Med. 1967;66:301–6. [PubMed: 6016543]
Splenomegaly – PACES
Definition:
The abnormal enlargement of the spleen (subdivided into mild, moderate and massive splenomegaly)
Mild: just palpable (1-3cm below the costal margin)
Moderate: between the costal margin and umbilicus (4-8cm below the costal margin)
Massive: crosses umbilicus and midline (>8cm)
Signs:
A spleen should be palpable as a mass originating in the LUQ, with palpable splenic notch, moves inferomedially with inspiration, is not ballotable and which you are unable to get above
Other signs may be present depending on the underlying condition causing splenomegaly, for example:
Myeloproliferative causes such as chronic myeloid leukaemia and myelofibrosis may be associated with massive splenomegaly.
Patient may appear anaemic
Lymphadenopathy may be present due to an underlying lymphoproliferative process or associated infection
Purpura
Chronic liver disease signs may be present as portal hypertension is a common cause of splenomegaly
Look for stigmata of infective endocarditis such as Oslers nodes, janeway lesions, finger clubbing and splinter haemorrhages
Look for features of rheumatoid arthritis suggesting Felty’s syndrome
Jaundice may be present – this could imply haemolytic anaemia
Symptoms:
Very varied and depend on underling cause:
Splenomegaly can be an incidental finding or present with:
Weight loss
Pallor
Noticeable lymphadenopathy
Fatigue
Night sweats – from haematological malignancy or infection
Fever
Abdominal pain – particularly if massive
Causes: It is often helpful to break causes of splenomegaly down into those which cause massive, moderate or mild splenomegaly.
Causes of Massive splenomegaly include: myeloproliferative disorders such as chronic myeloid leukaemia, acute myeloid leukaemia and myelofibrosis
Tropical infections such as malaria and visceral leishmaniasis
HIV
Causes of Moderate splenomegaly include: myeloproliferative disorders,
lymphoproliferative disorders such as chronic lymphocytic leukaemia and lymphoma, infiltrative conditions such as Gauchers disease and amyloidosis
Causes of Mild splenomegaly include: myelo and lymphoproliferative disorders, portal hypertension, infections such as infective endocarditis, Epstein Barr virus infection and viral hepatitis, haemolytic anaemia and autoimmune causes e.g. SLE.
Investigations:
Investigations for splenomegaly should be targeted to the most likely underlying cause and include:
Blood tests: FBC/blood film/U+E/LFTs/LDH/autoimmune screen/blood cultures
HIV test
Viral serology
CXR – looking for bihilar lymphadenopathy which may suggest an underlying lymphoproliferative process or infection
Malaria film if recent foreign travel to a malaria endemic area
Echo if infective endocarditis is suspected
CT thorax/abdo/pelvis if underlying malignancy suspected
Bone marrow aspirate and trephine if an underlying haematological process is likely
Lymph node biopsy
Management:
Depends on the underlying condition:
Myelo/lymphoproliferative conditions require referral to haematology for consideration of chemotherapy
Infective endocarditis suspected: TTE (transthoracic) +/- TOE (transoesophageal) for vegetations, at least 3 different sets of blood cultures from different sites at different time should be sent and discuss with cardiology and microbiology for appropriate treatment
If there is associated hypersplenism then patient may sometimes require splenectomy if treatment of underlying condition fails
Top tip: Splenomegaly patients appear in the exam frequently and the enlarged spleen may be the only sign to elicit.
It is worth spending time practising spleen palpation technique as it is fairly obvious when candidates are not confident in this. However if you have been unable to pick up any signs including a spleen DONT MAKE IT UP as it is not uncommon for the examiners to use a normal abdomen in this station to throw candidates.
Written by Jo Corrado
Resources used to write this document are listed in the references section of this webpage
Palpation of the spleen
Palpation
the spleen is carried out in the position of the patient
lying on your back or on your right side. In the first
case, the patient lies on a bed with a low
headboard, his arms outstretched along
torso, legs are also extended. In the second
the patient is placed on the right
side, his head is slightly tilted
forward to chest, left hand,
bent at the elbow joint, freely
lies on the anterior surface of the chest
cells, right leg extended, left
bent at the knee and hip
joints. In this position, one achieves
maximum relaxation of the abdominal
the press and spleen move closer
anteriorly.
All this makes it easier to determine
palpation even with slight
increase. The doctor sits to the right of the patient
facing him. The doctor places the left hand
on the left side of the patient’s chest
between the 7th and 10th ribs along the axillary
lines and squeezes it a little,
restricting her breathing.
Right hand with slightly bent fingers
the doctor places on the anterolateral
surface of the patient’s abdominal wall
edges of the costal arch, at the junction
with it the end of the X edge, or if the data
examination and preliminary percussion
suggest an increase
spleen, at the intended location
its anteroinferior edge. Then on the exhale
patient with the right hand doctor slightly
compresses the abdominal wall, forming
pocket; then the doctor offers the patient
take a deep breath. At the moment of inhalation
if the spleen is palpable and
it is carried out correctly, the spleen,
shifted down by a descending diaphragm,
with its anteroinferior edge approaches
to the fingers of the doctor’s right hand, rests
in them and during its further movement
slips under them.
This technique
repeat several times trying
explore all available palpation
edge of the spleen. At the same time, they turn
attention to size, pain,
density (consistency), shape,
mobility of the spleen
the presence of notches on the front edge.
Characteristic of the spleen, one or
several notches on the front edge
determined at high magnification.
They allow the spleen to be distinguished from
other enlarged abdominal organs
cavity, such as the left kidney. At
significant enlargement of the spleen
it is also possible to explore its front
surface coming out from under the edge
costal arch.
IN
Normally, the spleen is not palpable. She
becomes accessible to palpation only
with significant omission (rarely with
extreme degree of enteroptosis), most often
when enlarged. Enlargement of the spleen
observed in some acute and
chronic infectious diseases
(typhoid and relapsing fever, disease
Botkin, sepsis, malaria, etc.), cirrhosis
liver, thrombosis or compression
splenic vein, as well as in many
diseases of the hematopoietic system
(hemolytic anemia, thrombocytopenic
purpura, acute and chronic leukemias).
Significant enlargement of the spleen
is called splenomegaly (from the Greek.
Splen – spleen, megas – large). Greatest
enlargement of the spleen is seen in
end-stage chronic myelogenous leukemia,
in which it often occupies the entire
the left half of the abdomen, and with their lower
pole goes into the small pelvis.
At
acute infectious diseases
the density of the spleen is low; especially
soft, doughy consistency spleen
with sepsis. For chronic infectious
diseases, liver cirrhosis and leukemia
the spleen becomes dense; Very
it is dense with amyloidosis.
At
most diseases palpation
spleen is painless. She becomes
painful with spleen infarction,
perisplash, as well as in the case of a quick
enlargement due to stretching of the capsule,
for example, with stagnation of venous blood in it
with thrombosis of the splenic vein.
The surface of the spleen is usually smooth,
unevenness of its edge and surface
determined during perisplenitis and old
heart attacks (there are retractions), tuberosity
its surface is observed at
syphilitic gummah, echinococcal
and other cysts and extremely rare
tumors of the spleen.
Mobility
the spleen is usually quite sizable;
it is limited to the perispleen.
Sharply enlarged spleen during breathing
remains immobile, but it usually
still manage to shift by hand during
palpation. Often with leukemia
not only the spleen is enlarged, but
and the liver (due to metaplasia), which
also examined by palpation.
8. Rules for palpation of the spleen, reasons for its enlargement.
The normal spleen
not palpable because it is
deep in the left hypochondrium, not reaching
to the edge of the costal arch by 3-4 cm. Therefore
successful palpation of the spleen
indicates either an increase
or omission. Palpation should be
carry out in two positions of the patient
– on the back and on the right side. Principle
palpation is the same as that of the liver.
First moment –
hand setting. The left hand is laid flat
on the lower part of the left side of the chest
cages to delimit her movements
outward during inhalation and increase displacement
down the diaphragm, and with it the spleen.
Right hand with slightly bent fingers
placed on the anterior abdominal
wall parallel to the costal margin,
opposite X
ribs.
Second and third
moment – the formation of artificial
pocket according to V.P. Obraztsov. For this on
exhalation is necessary superficial
pull the skin down
towards the navel and immerse the tips
fingers of the right hand into the depth of the abdominal
cavities with their simultaneous movement
towards the left hypochondrium.
Fourth moment
– palpation of the spleen. researched
are asked to inhale slowly and deeply.
The edge of the spleen, descending under
diaphragm pressure, reaches the tips
fingers, creating a moment of tactile
Feel. If you feel the spleen
succeed, fingers move in the direction
to the edge of the costal arch by 1-2 cm. Research
carried out until the finger
phalanges of the right hand will not feel the spleen
or the edge of the costal arch.
characteristic
The spleen is characterized by the presence
on its front edge from 1 to 3 notches, which
makes it possible to distinguish an enlarged spleen
from other entities.
Enlargement of the spleen
often seen in infections
diseases (typhoid, typhus,
malaria, sepsis, brucellosis, infectious
mononucleosis), in diseases of the hematopoietic
systems (leukemia, anemia, lymphogranulomatosis
etc.), liver diseases (hepatitis, cirrhosis),
metabolic disorders (amyloidosis),
circulatory disorders (thrombosis
splenic and portal veins)
inflammation or traumatic injury
spleen, tumors.
For acute
infectious diseases of the spleen
has a fairly soft texture.
For chronic infections, diseases
blood, normal hypertension syndrome
the spleen becomes denser.
It reaches its highest density
in amyloidosis and cancer. With echinococcosis,
syphilitic gummah, heart attacks
spleen its surface becomes
uneven.
Soreness
palpation of the spleen is noted with
her heart attacks and perisplenitis. In the last
case, friction noise is also detected
sheets of peritoneum over the spleen.
1. Symptom
Ortner-Grekov is:
pain with deep
palpation at the “vesical” point;pain with deep
palpation at the “bubbly” point,
occurring during inhalation;pain on tapping
the edge of the palm along the right costal arch;pain on tapping
fingertips in the right hypochondrium;pressure pain
between the legs of the sternocleidomastoid muscle on the right.
2. Ker’s symptom –
is:
pain with deep
palpation at the “vesical” point;pain with deep
palpation at the “bubbly” point,
arising at the height of inspiration;pain on tapping
the edge of the palm along the right costal arch;pressure pain
between the legs of the right sternocleidomastoid muscle.
3. Symptom Murphy –
is:
pain with deep
palpation at the “vesical” point;pain with deep
palpation at the “bubbly” point,
arising at the height of inspiration;pain on tapping
the edge of the palm along the right costal arch;pain on tapping
fingertips in the right hypochondrium.
4. Symptom
Lepene-Vasilenko is:
pain with deep
palpation at the “vesical” point;pain with deep
palpation at the “bubbly” point,
occurring during inhalation;pain on tapping
the edge of the palm along the right costal arch;pain on tapping
fingertips in the right hypochondrium.
