Day #287 - Massive Splenomegaly

Today we heard about a patient with massive splenomegaly who presented with symptoms anorexia and weight loss.

We discussed the physical diagnosis of splenomegaly. We also talked about differentiating the spleen from an enlarged kidney or stomach based.

Spleen

• Has notch
• Cannot palpate above
• Descends with inspiration
• Cannot ballot
• Splenic rub

Kidney

• No notch
• Can ballot
• May be able to palpate above
• No change with inspiration

Stomach

• No notch
• Cannot ballot
• Can not palpate above
  
• Succession splash
  

We then discussed the differential diagnosis for massive splenomegaly (8cm below costal margin or greater than 1kg) which includes:

• CML, CLL, Hairy Cell Leukemia, and other lymphomas
• Myelofibrosis (less commonly PRV)
• Gaucher's disease (or rarely sarcoidosis)
• Autoimmune Haemolytic Anemia
• Kala-Azar

Remember, the spleen can be enlarged by three mechanisms:

1. Hypertrophy or hyperplasia related to increased splenic function (i.e. thalasemia, infection, autoimmune disease)
2. Congestion due to portal hypertension
3. Infiltration (i.e. lymphomas, leukemias, extramedulary haematopoesis, amyloid)

We finally ended up talking about making the diagnosis in this case, which is likely lymphoma.