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Symptoms and Signs – Differential Diagnosis of Splenomegaly
Splenomegaly, or an enlarged spleen, is not a diagnostic indicator in and of itself because it can occur in up to 5% of healthy persons and with a variety of illnesses. However, it typically indicates a hematologic, autoimmune, neoplastic, or hepatic disease, infection, or trauma. Since the spleen is the largest lymph node in the body, any process that causes lymphadenopathy can lead to splenomegaly. It could be a sign of extramedullary hemopoiesis, phagocytic cell proliferation, vascular congestion linked to portal hypertension, reactive hyperplasia (a reaction to infection or inflammation), or neoplastic cell proliferation or infiltration.
TIP FOR EXAMINATION
How to Check for Splenomegaly via Palpating Careful and delicate probing is necessary to detect splenomegaly without rupturing the enlarged spleen. Pay close attention to these steps: Position yourself at the patient's right side while she is in the supine position. To move the spleen forward, place your left hand beneath the left costovertebral angle and provide a slight push. Next, lightly place your right hand beneath the front costal edge on the left. Ask the patient to inhale deeply and then release it. Feel for the edge of the spleen with your right hand when she exhales by moving it along the tissue contours beneath the rib border. When you touch the enlarged spleen, it should feel like a solid lump. Don't forget to start your abdominal palpation low enough to reach the edge of a large spleen. The splenomegaly can be categorized as moderate (1½ to 3″ [4 to 8 cm] below the costal margin), considerable (more than or equal to 3″ [8 cm] below the costal margin), or minor (½ to 1½″ [1 to 4 cm] below the costal margin). To shift the spleen forward, place the patient back on her right side with her hips and knees slightly bent. The palpation process should then be repeated. Light palpation beneath the left costal border can reveal splenomegaly.
However, as this method isn't always recommended or successful, a computed tomography or radionuclide scan would be required to confirm splenomegaly.
Interventions for Emergencies
Avoid palpating the abdomen if the patient has a history of thoracic or abdominal injuries since this could worsen internal bleeding. Instead, look for symptoms of shock, like tachypnea and tachycardia, as well as pain in the left upper quadrant. You should consider splenic rupture if you notice these symptoms. For emergency blood and fluid replacement, establish an intravenous line and give oxygen. Additionally, start cardiac monitoring and catheterize the patient to assess urine output. Get the patient ready for any upcoming procedure. Physical examination and history Start by looking into related symptoms and indicators if splenomegaly is discovered during a standard physical examination. Inquire as to whether the patient has been abnormally exhausted recently. Does he have sore throats, colds, or other diseases often? Is he prone to bruises? Inquire about early satiety, stomach fullness, and pain in the left upper quadrant. Lastly, check for pallor and ecchymoses on the patient's skin and feel for lymphadenopathy in his neck, groin, and axillae.
Medical Reasons
Brucellosis
Splenomegaly is a significant symptom of severe cases of brucellosis, an uncommon infection. Fatigue, headache, backache, anorexia, arthralgia, fever, chills, sweating, and malaise are the typical sneaky symptoms of brucellosis. Hepatomegaly, lymphadenopathy, weight loss, and pressure-induced spinal or peripheral nerve discomfort are possible later symptoms.
Cirrhosis
Moderate to significant splenomegaly develops in about one-third of people with severe cirrhosis. Jaundice, hepatomegaly, leg edema, hematemesis, and ascites are among additional late symptoms. Hepatic encephalopathy symptoms include slurred speech, asterixis, fetor hepaticus, and a lowered state of consciousness that could lead to a coma. Serious pruritus, poor tissue turgor, spider angiomas, palmar erythema, pallor, and indications of bleeding tendencies are possible cutaneous side effects in addition to jaundice. Menstrual abnormalities or testicular atrophy, gynecomastia, and axillary and chest hair loss are examples of endocrine consequences. Additionally, the patient may experience fever and right upper abdomen pain that gets worse when they sit up or lean forward.
Feely's syndrome
Felty's syndrome, which is associated with persistent rheumatoid arthritis, is characterized by splenomegaly. Rheumatoid nodules, palmar erythema, lymphadenopathy, leg ulcers, joint discomfort and deformity, and sensory or motor loss are all associated findings.
Histoplasmosis
Both hepatomegaly and splenomegaly are frequently caused by acute disseminated histoplasmosis. Additionally, it may result in lymphadenopathy, jaundice, fever, anorexia, emaciation, and anemia symptoms like malaise, weakness, exhaustion, and pallor. Pain, hoarseness, and dysphagia can occasionally be caused by ulceration of the patient's tongue, palate, epiglottis, and larynx.
Leukemia
An early indicator of both acute and chronic leukemia is moderate to severe splenomegaly. Splenomegaly in patients with chronic granulocytic leukemia can occasionally be unpleasant. Hepatomegaly, lymphadenopathy, exhaustion, malaise, pallor, fever, gum edema, bleeding disorders, anorexia, weight loss, and discomfort in the bones, joints, and abdomen may accompany it. Acute leukemia can also occasionally result in palpitations, tachycardia, and dyspnea. Confusion, headache, vomiting, seizures, papilledema, and nuchal rigidity are all possible symptoms of severe disease.
infectious mononucleosis
Splenomegaly, a frequent symptom of mononucleosis, is most noticeable in the second and third weeks of the illness. A sore throat, cervical lymphadenopathy, and a fluctuating fever with an evening peak of 101°F to 102°F (38.3°C to 38.9°C) are the three main symptoms that are typically present. Hepatomegaly, jaundice, and a maculopapular rash can also occasionally happen. carcinoma of the pancreas. If the splenic vein is compressed by tumor growth, pancreatic cancer may result in moderate to severe splenomegaly. Back or abdominal discomfort, anorexia, nausea, vomiting, weight loss, gastrointestinal hemorrhage, jaundice, pruritus, skin lesions, emotional instability, weakness, and exhaustion are further distinctive symptoms. Hepatomegaly and a painful abdominal mass may be palpable; auscultation indicates a bruit in the left upper quadrant and periumbilical region.
Vera polycythemia
The spleen may grow significantly in the latter stages of polycythemia vera, causing pleuritic chest discomfort, stomach fullness, and easy satiety. Splenomegaly has several different and common signs and symptoms. The patient may have headache, vertigo, weakness, exhaustion, disorientation, and deep, purplish-red oral mucous membranes. In addition, he might experience tinnitus, hazy or double vision, scotoma, elevated blood pressure, intermittent claudication, finger and toe paresthesia, and impaired mentation. Pruritus, urticaria, reddish cyanosis, epigastric pain, weight loss, hepatomegaly, and bleeding tendencies are other symptoms.
Sarcoidosis
Sarcoidosis is a granulomatous disease that can cause hepatomegaly and splenomegaly, as well as possibly some nebulous stomach pain. A nonproductive cough, dyspnea, malaise, exhaustion, arthralgia, myalgia, weight loss, lymphadenopathy, skin lesions, an irregular pulse, blurred vision, dysphagia, and seizures are some of its further symptoms, which differ depending on the body system that is impacted. rupture of the spleen. Splenomegaly can be caused by a ruptured spleen and significant bleeding. Additionally, the patient may have Kehr's sign, abdominal rigidity, and pain in the left upper quadrant.
Purpura caused by thrombotic thrombocytopenia
Along with fever, pallor, jaundice, vaginal bleeding, hematuria, and splenomegaly and hepatomegaly, thrombotic thrombocytopenic purpura can also cause these symptoms. Additional side effects include arthralgia, headache, pallor, weakness, exhaustion, and abdominal pain. The patient eventually exhibits symptoms of renal failure and neurologic decline.
Get the patient ready for diagnostic procedures such a full blood count, blood cultures, and splenic computed tomography and radionuclide scans. Counseling for Patients Emphasize the value of adhering to medication therapy and teach the patient how to prevent infection.
In addition to the previously mentioned causes, children may develop splenomegaly as a result of sickle cell disease, Gaucher's disease, Niemann-Pick disease, congenital hemolytic anemia, hereditary spherocytosis, sickle cell disease, or beta-thalassemia (Cooley's anemia). The most frequent cause of splenomegaly in children with impaired immune systems is a splenic abscess.
Splenomegaly, or an enlarged spleen, is not a diagnostic indicator in and of itself because it can occur in up to 5% of healthy persons and with a variety of illnesses. However, it typically indicates a hematologic, autoimmune, neoplastic, or hepatic disease, infection, or trauma. Since the spleen is the largest lymph node in the body, any process that causes lymphadenopathy can lead to splenomegaly. It could be a sign of extramedullary hemopoiesis, phagocytic cell proliferation, vascular congestion linked to portal hypertension, reactive hyperplasia (a reaction to infection or inflammation), or neoplastic cell proliferation or infiltration.
TIP FOR EXAMINATION
How to Check for Splenomegaly via Palpating Careful and delicate probing is necessary to detect splenomegaly without rupturing the enlarged spleen. Pay close attention to these steps: Position yourself at the patient's right side while she is in the supine position. To move the spleen forward, place your left hand beneath the left costovertebral angle and provide a slight push. Next, lightly place your right hand beneath the front costal edge on the left. Ask the patient to inhale deeply and then release it. Feel for the edge of the spleen with your right hand when she exhales by moving it along the tissue contours beneath the rib border. When you touch the enlarged spleen, it should feel like a solid lump. Don't forget to start your abdominal palpation low enough to reach the edge of a large spleen. The splenomegaly can be categorized as moderate (1½ to 3″ [4 to 8 cm] below the costal margin), considerable (more than or equal to 3″ [8 cm] below the costal margin), or minor (½ to 1½″ [1 to 4 cm] below the costal margin). To shift the spleen forward, place the patient back on her right side with her hips and knees slightly bent. The palpation process should then be repeated. Light palpation beneath the left costal border can reveal splenomegaly.
However, as this method isn't always recommended or successful, a computed tomography or radionuclide scan would be required to confirm splenomegaly.
Interventions for Emergencies
Avoid palpating the abdomen if the patient has a history of thoracic or abdominal injuries since this could worsen internal bleeding. Instead, look for symptoms of shock, like tachypnea and tachycardia, as well as pain in the left upper quadrant. You should consider splenic rupture if you notice these symptoms. For emergency blood and fluid replacement, establish an intravenous line and give oxygen. Additionally, start cardiac monitoring and catheterize the patient to assess urine output. Get the patient ready for any upcoming procedure. Physical examination and history Start by looking into related symptoms and indicators if splenomegaly is discovered during a standard physical examination. Inquire as to whether the patient has been abnormally exhausted recently. Does he have sore throats, colds, or other diseases often? Is he prone to bruises? Inquire about early satiety, stomach fullness, and pain in the left upper quadrant. Lastly, check for pallor and ecchymoses on the patient's skin and feel for lymphadenopathy in his neck, groin, and axillae.
Medical Reasons
Brucellosis
Splenomegaly is a significant symptom of severe cases of brucellosis, an uncommon infection. Fatigue, headache, backache, anorexia, arthralgia, fever, chills, sweating, and malaise are the typical sneaky symptoms of brucellosis. Hepatomegaly, lymphadenopathy, weight loss, and pressure-induced spinal or peripheral nerve discomfort are possible later symptoms.
Cirrhosis
Moderate to significant splenomegaly develops in about one-third of people with severe cirrhosis. Jaundice, hepatomegaly, leg edema, hematemesis, and ascites are among additional late symptoms. Hepatic encephalopathy symptoms include slurred speech, asterixis, fetor hepaticus, and a lowered state of consciousness that could lead to a coma. Serious pruritus, poor tissue turgor, spider angiomas, palmar erythema, pallor, and indications of bleeding tendencies are possible cutaneous side effects in addition to jaundice. Menstrual abnormalities or testicular atrophy, gynecomastia, and axillary and chest hair loss are examples of endocrine consequences. Additionally, the patient may experience fever and right upper abdomen pain that gets worse when they sit up or lean forward.
Feely's syndrome
Felty's syndrome, which is associated with persistent rheumatoid arthritis, is characterized by splenomegaly. Rheumatoid nodules, palmar erythema, lymphadenopathy, leg ulcers, joint discomfort and deformity, and sensory or motor loss are all associated findings.
Histoplasmosis
Both hepatomegaly and splenomegaly are frequently caused by acute disseminated histoplasmosis. Additionally, it may result in lymphadenopathy, jaundice, fever, anorexia, emaciation, and anemia symptoms like malaise, weakness, exhaustion, and pallor. Pain, hoarseness, and dysphagia can occasionally be caused by ulceration of the patient's tongue, palate, epiglottis, and larynx.
Leukemia
An early indicator of both acute and chronic leukemia is moderate to severe splenomegaly. Splenomegaly in patients with chronic granulocytic leukemia can occasionally be unpleasant. Hepatomegaly, lymphadenopathy, exhaustion, malaise, pallor, fever, gum edema, bleeding disorders, anorexia, weight loss, and discomfort in the bones, joints, and abdomen may accompany it. Acute leukemia can also occasionally result in palpitations, tachycardia, and dyspnea. Confusion, headache, vomiting, seizures, papilledema, and nuchal rigidity are all possible symptoms of severe disease.
infectious mononucleosis
Splenomegaly, a frequent symptom of mononucleosis, is most noticeable in the second and third weeks of the illness. A sore throat, cervical lymphadenopathy, and a fluctuating fever with an evening peak of 101°F to 102°F (38.3°C to 38.9°C) are the three main symptoms that are typically present. Hepatomegaly, jaundice, and a maculopapular rash can also occasionally happen. carcinoma of the pancreas. If the splenic vein is compressed by tumor growth, pancreatic cancer may result in moderate to severe splenomegaly. Back or abdominal discomfort, anorexia, nausea, vomiting, weight loss, gastrointestinal hemorrhage, jaundice, pruritus, skin lesions, emotional instability, weakness, and exhaustion are further distinctive symptoms. Hepatomegaly and a painful abdominal mass may be palpable; auscultation indicates a bruit in the left upper quadrant and periumbilical region.
Vera polycythemia
The spleen may grow significantly in the latter stages of polycythemia vera, causing pleuritic chest discomfort, stomach fullness, and easy satiety. Splenomegaly has several different and common signs and symptoms. The patient may have headache, vertigo, weakness, exhaustion, disorientation, and deep, purplish-red oral mucous membranes. In addition, he might experience tinnitus, hazy or double vision, scotoma, elevated blood pressure, intermittent claudication, finger and toe paresthesia, and impaired mentation. Pruritus, urticaria, reddish cyanosis, epigastric pain, weight loss, hepatomegaly, and bleeding tendencies are other symptoms.
Sarcoidosis
Sarcoidosis is a granulomatous disease that can cause hepatomegaly and splenomegaly, as well as possibly some nebulous stomach pain. A nonproductive cough, dyspnea, malaise, exhaustion, arthralgia, myalgia, weight loss, lymphadenopathy, skin lesions, an irregular pulse, blurred vision, dysphagia, and seizures are some of its further symptoms, which differ depending on the body system that is impacted. rupture of the spleen. Splenomegaly can be caused by a ruptured spleen and significant bleeding. Additionally, the patient may have Kehr's sign, abdominal rigidity, and pain in the left upper quadrant.
Purpura caused by thrombotic thrombocytopenia
Along with fever, pallor, jaundice, vaginal bleeding, hematuria, and splenomegaly and hepatomegaly, thrombotic thrombocytopenic purpura can also cause these symptoms. Additional side effects include arthralgia, headache, pallor, weakness, exhaustion, and abdominal pain. The patient eventually exhibits symptoms of renal failure and neurologic decline.
Get the patient ready for diagnostic procedures such a full blood count, blood cultures, and splenic computed tomography and radionuclide scans. Counseling for Patients Emphasize the value of adhering to medication therapy and teach the patient how to prevent infection.
In addition to the previously mentioned causes, children may develop splenomegaly as a result of sickle cell disease, Gaucher's disease, Niemann-Pick disease, congenital hemolytic anemia, hereditary spherocytosis, sickle cell disease, or beta-thalassemia (Cooley's anemia). The most frequent cause of splenomegaly in children with impaired immune systems is a splenic abscess.
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