The spleen is subject to trauma, particularly from overlying fractured ribs. Splenomegaly is often accompanied by hepatomegaly, as in blood disorders (sickle cell, Mediterranean anemia, leukemia, Hodgkin’s and Non-Hodgkin’s lymphoma) and lipid storage diseases (Gaucher’s and Niemann-Pick’s). It is also enlarged with many liver infections, such as glandular fever, brucellosis, typhoid, relapsing fever, kala aza, malaria, toxoplasmosis, trypanosomiasis, schistosomiasis. The spleen becomes rather fragile in some of these conditions, particularly the malarial spleen, and can be ruptured independent of rib fractures. Table 9 considers causes of splenic enlargement.

Table 9 Splenomegaly

INFECTIONCONGESTIVECELLULAR INFILTRATION/ METABOLICCELLULAR PROLIFERATION/ BLOOD DYSPLASIASCOLLAGEN DISEASESPACE OCCUPYING LESIONSINFARCTION
Viral: Infectious mononucleosis Bacterial: Typhoid Typhus TB Syphilis Liptospirosis Septicemia/abscess Protozal: Malaria Schistosomiasis Trypanosomiasis Tropical splenomegaly Hydatid cyst Kala azaPortal hypertension Hepatic vein obstruction Right sided heart failureAmyloidosis Gaucher’s disease PorphyriaLeukemia Myelofibrosis Polycythemia rubra vera Pernicious anemia Hereditary spherocytosis Thalassemia Sickle Cell Disease Thrombocytopenic purpura IdiopathicFelty’s syndrome Still’s diseaseSolitary cyst Polycystic disease Angioma LymphomaEmbolic Splenic artery/vein thrombosis

The spleen enlarges from beneath the left costal margin, across the umbilicus, to the right iliac fossa. Like the liver, it descends with inspiration and the same hand movements are used to define and dip under the notched anterior margin.

Start palpation below and to the right of the umbilicus, pass upwards across the midline, and end subcostally in the midaxillary line (figure 37a–d).

Palpation is facilitated by bimanual palpation and turning the patient 45 degrees to the right side; the spleen is first ‘tipped’ in the midaxillary line (figure 38a,b). Normal splenic dullness should never extend beyond this point. Check the position again by percussion (figure 38c).