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Make the Diagnosis: Splenomegaly

During the general physical examination, patients should not be evaluated for splenomegaly.

Prior Probability

The prevalence of palpable splenomegaly in an otherwise healthy student population is low, approximating 3%8; 12% of normal postpartum women had palpable spleens.9 The prevalence of splenomegaly increases significantly among other selected populations, such as HIV patients (up to 66%10), or in areas in which schistosomiasis is prevalent.11

Population for Whom the Physical Examination of Splenomegaly Should Be Sought

  • Suspected or proven viral illness, lymphoproliferative disorder, or malignancy

  • Cirrhosis

  • Suspected portal hypertension

  • Suspected or proven malaria

  • Connective tissue disorders associated with splenomegaly

Detecting Splenomegaly

In cases in which splenomegaly is questioned, the clinical examination is more specific than sensitive and is best used when ruling in the diagnosis among patients for whom the suspicion is at least 10%. Moreover, the examination should start with Traube space percussion, followed, if dull, by supine 1-handed palpation (Table 46-5). These maneuvers have received more extensive evaluation than other maneuvers, allowing us greater confidence in the findings. Middleton maneuver, in which the physician stands to the left of the patient and hooks the examining hand under the ribs, may work as well.

Table 46-5Summary Likelihood Ratios for Palpation to Detect Splenomegaly and Percussion of Traube Space

Palpation may be superior to percussion, especially in lean patients. When it remains important not to miss splenomegaly, imaging will be necessary because the clinical examination does not provide sufficient clinical certainty.

Reference Standard Tests

Ultrasonography, CT, nuclear liver-spleen imaging.

Original Article: Does This Patient Have Splenomegaly?

Clinical Scenario

Among the patients you are seeing today are the following 3:

The first is an elderly woman who complains of easy fatigability, and her conjunctivae and nail beds are pale. You suspect that she is anemic because of gastrointestinal blood loss, but among your differential diagnoses you consider a lymphoproliferative disorder and decide to examine her for splenomegaly.

The second is a college student with failing appetite, ability to concentrate, energy, and grades. You think that he is depressed but want to rule out infectious mononucleosis and decide to examine him for splenomegaly.


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