Splenomegaly

Today at physical exam rounds we discussed splenomegaly.

Some important points:

3 Percussion methods (Castell's is easiest and best):
1. Castell's: Pt supine, percuss lowest ICS L ant axillary line and full insp and exp. +ve is any dullness.
2. Traube's: Pt supine, L arm out of the way. Space is bordered by 6th rib superiorly, midax line laterally, L costal margin inferiorly. Pt breathes normally, and space is percussed. +ve is any dullness
3. Nixon's: Pt in RLD position. Percuss in midpoint of L costal margin (nipple line), and move perpendicular to margin. +ve is dullness over 8cm above costal margin.


3 Palpation methods:
1) Patient supine: Start in RLQ and move up to LUQ; Pt inspires, and feel for spleen tip meeting examiner's stationary hand. If not felt, move 2cm towards LUQ on expiration.
2) Patient in R decubitus: Examiner's L hand is across patient's thorax, lifting the L ribcage anteriorly and medially. R hand is just below costal margin. Pt takes deep breath, and feel for spleen tip. If not felt, move 2cm towards umbilicus to ensure massive spleen not missed.
3) Hooking: Pt lies flat with fist under CVA on L. Examiner is on pt's L side, facing pt's feet, with fingers of both hands under costal margin. Pt takes deep breath, and feel for tip.


Evidence:
In general, percussion is sensitive, and palpation is specific.
When the pre-test probability is low, physical exam cannot reliably rule out or rule in splenomegaly.
Examination is most useful in ruling in splenomegaly when the pre-test probability is high (i.e. if percussion and palpation are both positive, the diagnosis is established).
In high pre-test probability, no method is sensitive enough to exclude; need imaging.

Most sensitive signs (i.e. make it unlikely if not present):
1) Castell's sign (~80% range)
2) Traube's space palpation (~60%)
3) Nixon's method (~60%)
All palpation methods are insensitive (~50-60%)

Most specific signs (i.e. make it likely if present)
Any of the above palpation methods; (~90% specific)

Spleen vs. kidney:
1) upper pole never palpable in spleen
2) respiratory movement with spleen, not kidney
3) notch
4) kidney may be balotable
5) spleen expands towards RLQ; kidney expands vertically

Bonus:
Bruit: heard in splenic hemangioma
Rub: heard in splenic infarct

Link:
Click here for JAMA Rational Clinical Exam on splenomegaly (need log-in; ask me how to obtain)