Spleen Examination o563i

6/13/2008

Anatomy Does This Patient Have Splenomegaly?

Lung Diaphragm

Grover S.A. et al., JAMA 1993

Lung Diaphragm Ribs (10th rib)

Stomach Pancreas

Alison Kydd June 2008

Spleen „

Colon Kidney

Examination of the Spleen

Normal Spleen: { {

{

Autopsy: <250g Radioisotope Scintiscan: 12cm long x 7cm wide Ultrasound: <13cm cephalocaudad diameter

„

Inspection

„

Percussion {

„

„

~3% of healthy people have splenomegaly

Examination of the Spleen „

Percussion cont {

Castell’s Method „ „ „ „

„

Supine p Lowest intercostal space Left anterior axillary line Full inspiration and expiration Splenomegaly = dullness

Nixon’s Method Right Lateral Decubitus ≤8cm

Examination of the Spleen „

Percussion cont {

Traube’s Space „ „ „ „ „ „

Supine p 6th rib Costal margin Midaxillary line Normal breathing Splenomegaly = dullness

1

6/13/2008

Examination of the Spleen „

Spleen vs Kidney

Palpation

„

Right Lateral Decubitus

{

„

{

„ „ „ „

{

Two-Handed

{

Supine “Hooking Maneuver of Middleton”

{

Spleen

{ { A. Chandrasekhar, Loyola University

Supine Patient’s Fist under L CVA Stand on left facing patient’s feet Hook fingers over costal margin

{ {

Hackett’s Classification

No. of Patients 118

Criterion Standard Ultrasound

umbilicus 65

3 Not below the umbilicus 4 Below the umbilicus 5 >½ the way to the pubic symphysis

Accuracy of Palpation Criterion Standard

Maneuver

Kidney No notch Never crosses midline May get above Doesn’t move with respiration Ballotable No rub

{ { { {

{ {

Accuracy of Percussion

0 Not Palpable 1 Palpable on deep inspiration 2 Palpable but <½ the way to the

No. of Patients

„

Splenic notch Can cross midline Can’t get above Moves down on inspiration Not ballotable Splenic rub

Scintigraphy

Maneuver

Sensitivity %

Specificity %

Traube’s space p

62

72

Traube’s space (nonobese, fasting)

78

82

Nixon Method

59

94

Castell Method

82

83

Combining Tests

Sensitivity %

Specificity %

Routine Examination (Chart) 47

Autopsy

Physical Exam

20

100

217

Scintigraphy

Clinical Impression

28

98

Overall

27

98

Examination in a Study 99

Scintigraphy

Palpation

57

100

32

Operation

Palpability

59

100

100

Scintigraphy

56

69

65

Scintigraphy

71

90

118

Ultrasound

Supine 2-handed palpation Supine and right lateral decubitus palpation Supine palpation or Middleton’s maneuver

56

93

Overall

58

92

Palpation is a better discriminator among patients in whom percussion is positive „

Percussion dullness present

„

Percussion dullness absent

{

{

Palpation discriminated 87% of the time Palpation discriminated 55% of the time

2

6/13/2008

Approach to Splenomegaly „

Depends on Pretest Probability {

Normal, asymptomatic patients (<10%) „

„

Low specificity of tests Î not high enough to rule splenomegaly even if both positive Will require imaging

Approach to Splenomegaly „

Depends on Pretest Probability {

Clinical Suspicion of Splenomegaly (>10%) „ „

„

„

Percuss first and if positive palpate If percussion is negative and suspicious, order an ultrasound If percussion positive but palpation is negative, order an ultrasound Both percussion and palpation positive = SPLENOMEGALY

References „

„

J.C. Grover, A.N. Barkun and D.L. Sackett. Does This Patient have Splenomegaly. JAMA, 1993, Nov. Vol 270 (18) 2218-2221. J C. J. C Yang Yang, L L. S S. Rickman Rickman, and S S. K K. Bosser Bosser. The clinical diagnosis of splenomegaly. West J Med. 1991 July; 155(1): 47–52.

3