Physical Exam - Splenomegaly

"Does this Patient Have Splenomegaly?"

What is splenomegaly? Normal spleen is 12x7x3. Radiographically splenomegaly can be defined as 13cm cephalocaudad on ultrasound

Inspection:

• Look for left upper quadrant masses (low sensitivity)

Percussion:

• Castell's Sign (in Traube's Space):
  The patient is supine. You percuss in the lowest intercostal space in the left-anterior axillary line in full expiration and inspiration. Splenomegaly is suggested when the percussion is dull or becomes dull on inspiration.
  SENSITIVITY 60-85% SPECIFICITY 72-82%
• Nixon's Method:
  Place the patient in the right lateral decubitus position. Initiate percussion half-way along the costal margin and percuss cephalad in a line perpendicular to the costal margin. Dullness of >8cm suggests splenomegaly.
  SENSITIVITY 60% SPECIFICITY 95%

Palpation:

• One-handed technique: Patient is supine, you palpate with the tips of your fingers starting in the right lower quadrant and moving towards the left upper quadrant in small (~2cm) incriments. The patient takes slow deep breaths at each point and you feel for a descending spleen
• "Middleton's Manouver"/Splenic Hook: The patient lies flat with their left hand under their left CVA. The examiner, standing on the left of the patient, curls the fingers of both hands under the left costal margin and the patient is asked to take a deep breath.
• To distinguish the spleen from other LUQ organs one can feel for the splenic notch. Also, one should not be able to palpate superiorly to the spleen. The spleen should also move with respiration while large kidneys will not.
  SENSITIVITY: 60-70% SPECIFICITY: >90%

Auscultation:

• Listen for splenic rub (suggests infarction), splenic artery bruit (suggests congestive splenomegaly). These signs were not evaluated in this article.
  

Who should I examine for splenomegaly in? In patients with a pre-test probablility of splenomegaly of less than 10%, the likelihood of the physicial exam being helpful to exclude or rule in splenomegaly is quite low. That is, a negative exam could be a false negative, a positive exam a false positive.

Consequently, the physical exam should be performed in those with a pre-test probability of >10%.

How do I interpret my exam? In patients with no dullness to percussion, you should move on to ultrasound if the clinical question remains significantly important. Palpation will not add useful information because of its poor sensitivity.

In patients with dullness but a non-palpable spleen ultrasound/imaging should be performed to definitively confirm/exclude.

In patients with dullness to percussion and a palpable spleen, the diagnosis is established.