Evaluation of splenomegaly

Splenomegaly generally denotes a palpably enlarged spleen. However, it may also refer to an enlarged spleen detected by an imaging test. It is not uncommon for a radiologist interpreting a chest x-ray to comment that the spleen seems enlarged (usually considered an incidental finding). Splenomegaly can be found in 2.0% to 5.6% of unselected medical outpatients.[1]Pozo AL, Godfrey EM, Bowles KM. Splenomegaly: investigation, diagnosis and management. Blood Rev. 2009 May;23(3):105-11. http://www.ncbi.nlm.nih.gov/pubmed/19062140?tool=bestpractice.com [2]Schloesser LL. The diagnostic significance of splenomegaly. Am J Med Sci. 1963 Jan;245:84-90.​​

An average human spleen is 10 cm long and weighs 150 grams.[3]McKenzie CV, Colonne CK, Yeo JH, et al. Splenomegaly: pathophysiological bases and therapeutic options. Int J Biochem Cell Biol. 2017 Dec 2;94:40-3. http://www.ncbi.nlm.nih.gov/pubmed/29191734?tool=bestpractice.com It may be difficult to palpate an enlarged spleen in the settings of obesity, a muscular abdominal wall, or the inability to sufficiently relax the abdominal musculature. In these cases, spleen size may need to be determined by imaging.

Approach to splenomegaly

It is difficult to create a stepwise algorithmic approach to the patient with splenomegaly.[4]Lichtin AE, Cook JR. Diseases of the spleen. In: Young NS, Gerson SL, High KA, eds. Clinical hematology. 1st ed. Philadelphia, PA: Elsevier; 2006:697-705.[5]Sjoberg BP, Menias CO, Lubner MG, et al. Splenomegaly: a combined clinical and radiologic approach to the differential diagnosis. Gastroenterol Clin North Am. 2018 Sep;47(3):643-66. http://www.ncbi.nlm.nih.gov/pubmed/30115442?tool=bestpractice.com Urgent presentations include sudden pain associated with splenomegaly, splenic sequestration crisis of sickle cell anemia, and splenic vein or portal vein thrombosis. Otherwise, presentation is often incidental on physical exam or imaging. Categorization by presentations such as massive splenomegaly, isolated splenomegaly, or accompanying symptoms could be considered. However, these categories encompass diverse diagnoses. For example, thalassemia, chronic myeloid leukemia, Gaucher disease, hairy cell leukemia, myelofibrosis, and malaria may all present with a markedly enlarged spleen. Isolated splenomegaly is a feature of diagnoses such as splenic marginal lymphoma or benign splenic neoplasms. Accompanying symptoms are nonspecific; for example, fever may occur with lymphomas, malaria, endocarditis, or infectious mononucleosis.