A 65-year-old African woman presents with two months of fevers and 25-pound weight loss along with a month of nausea and retching, accompanied by left-sided abdominal pain. The exam is significant for axillary lymphadenopathy, abdominal distension, splenomegaly, and palpable purpura on her arms, legs, and back. Labs are significant for leukocytosis, lymphopenia, microcytic anemia, increased ferritin, and positive hepatitis C virus PCR. Abdominal CT shows multiple enlarged nodes and an enlarged spleen (splenomegaly).
As I prepare to present my diagnosis of hepatitis C-associated lymphoma at the Clinical Pathology Conference, I focus on one of the key findings–splenomegaly–observed on exam and CT scan. I wonder if suspicion for splenomegaly played a role in the decision to examine the spleen and which technique was used. In other words, what is the recommendation for when and how we should examine for splenomegaly?
The role of the spleen
Hippocrates and Galen referred to the spleen as the repository of the most noxious bodily substance–“black bile”–an excess of which caused melancholia . Hence, it was thought that the spleen prevented depression by sequestering black bile from the rest of the body.
For many years, the spleen was regarded as a useless organ, similar to the appendix. It was not until the past 50 years that the spleen’s role in the immune response to infection and the potentially fatal consequences of its removal become increasingly recognized .
The normal spleen is about the size of a fist. Splenomegaly is most commonly caused by hepatic disease (cirrhosis), malignancy (leukemia and lymphoma), and infectious disease (HIV, mononucleosis, and malaria) . Physicians may need to examine the spleen in situations ranging from a patient with B symptoms and lymphadenopathy suspicious for malignancy to a patient with splenomegaly secondary to infectious mononucleosis eager to return to sports.
How to examine for splenomegaly
Splenomegaly can be examined by two primary techniques: palpation and percussion. There are three well-studied palpation maneuvers:
–Supine two-handed palpation
–Right lateral decubitus one-handed palpation
–The supine hooking maneuver of Middleton .
A normal-sized spleen almost always lies entirely within the rib cage and thus cannot be palpated, but with enlargement it displaces the stomach and descends below the rib cage . Thus, splenomegaly is suggested by palpation of the descending spleen on inspiration using any palpation maneuver, with a sensitivity of 18-78%, specificity of 89-99%, positive likelihood ratio (+LR) of 8.5, and negative likelihood ratio (-LR) of 0.5 . Palpation may yield false positives in the presence of left hepatic lobe enlargement and intra-abdominal tumors . In addition, false negatives are possible, given that the spleen generally needs to be increased in size by at least 40% before becoming palpable .
Three percussion maneuvers have been validated against imaging:
–Supine percussion of Traube’s space (defined by the sixth rib superiorly, the mid-axillary line laterally, and the left costal margin inferiorly)
–Castell’s method while supine (percussing in the lowest intercostal space on the left axillary line)
–Nixon’s method in the right lateral decubitus position (percussing from the midpoint of the costal margin perpendicularly to the left mid-axillary line) .
Splenomegaly is suggested by dullness to percussion of Traube’s space (sensitivity of 11-76%, specificity of 63-95%, +LR = 2.1, -LR = 0.8), Castell’s spot (sensitivity of 25-85%, specificity of 32-94%, +LR = 1.7, -LR = 0.7), and Nixon’s method if greater than 8 cm (sensitivity of 25-66%, specificity of 68-95%, +LR = 2.0, -LR = 0.7) . Percussion may yield both false positives and negatives. For instance, percussion of Traube’s space may be falsely positive in patients examined too soon after a meal  or with pleural effusions , and may be falsely negative in obese patients .
Positive percussion is less convincing than palpation (+LR = 1.7 to 2.1 for percussion vs. 8.5 for palpation) . More extensive evaluation has been devoted to Traube’s space percussion and supine one-handed palpation, so there is greater confidence in these maneuvers . Combining percussion and palpation of Traube’s space produces a sensitivity and specificity of 46% and 97%, respectively .
When to examine for splenomegaly
It is recommended that if suspicion for splenomegaly is sufficiently high (ie, the pretest probability is greater than 10%), examination should start with Traube’s space percussion . If percussion is not dull, there is no need to palpate, as the results will not effectively rule in or out splenomegaly . If the possibility of missing splenomegaly remains a concern after negative percussion, imaging is indicated . If percussion is dull, it should be followed by supine one-handed palpation . If only one technique is performed, palpation may be superior to percussion, particularly in lean patients . If both tests are performed and are positive, splenomegaly is diagnosed. If palpation following percussion is negative, imaging is required to confidently rule in or out splenomegaly. In contrast, if the initial suspicion for splenomegaly is low, routine examination cannot definitively rule in or out splenomegaly .
Summary of splenomegaly on exam
The examination of splenomegaly is more specific than sensitive and thus is best used when ruling in the diagnosis, provided the clinical suspicion of splenomegaly is sufficiently high. Positive palpation is more useful than percussion. The finding of a palpable spleen increases greatly the probability of splenomegaly , which is further increased by combining techniques . Splenomegaly detected on exam provides information that the spleen is congested and, whether full of black bile or lymphoma cells, it hints at a possible underlying disease, which helps in generating and narrowing down the differential diagnosis.
Jenna Tarasoff is a 3rd year medical student (3-year program) at NYU Langone Medical Center
Reviewed by Dr. Michael Tanner, Executive Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
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