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Toronto Notes 2019 Approach to Splenomegaly Approach to Splenomegaly
Hematology H13
Causes of Splenomegaly
CHINA
Cirrhosis/Congestion (portal HTN) Hematological
Infectious
Neoplasm (malignant, non-malignant) Autoimmunue
Table 9. Differential Diagnosis of Splenomegaly
Increased Demand for Splenic Function
Congestive
Cirrhosis
Portal HTN
Portal vein obstruction (including right heart failure) Splenic vein thrombosis
Infiltrative
Non-Malignant
Benign metaplasia
Cysts
Amyloidosis, Sarcoidosis Hamartomas
Vascular abnormalities Lysosomal storage diseases (Gaucher’s, Niemann-Pick) Glycogen storage diseases Malignant
Leukemia (CML, CLL) Lymphoproliferative disease Hodgkin lymphoma Myeloproliferative disorders Metastatic tumour
Hematological
Nutritional anemias Hemoglobinopathies Hemolysis Spherocytosis Sequestration crisis Elliptocytosis
Infectious
Viral e.g. EBV, HIV/ AIDS, CMV Bacterial
e.g. Bacterial endocarditis, TB Parasitic
e.g. Malaria, Histoplasmosis, Leishmaniasis Fungal
Inflammatory
SLE Sarcoidosis Felty syndrome Still’s disease
The underlined conditions cause massive splenomegaly (spleen crosses midline or reaches pelvis)
History
• constitutionalsymptoms,feelingoffullnessinLUQ,andearlysatiety • signsorsymptomsofinfection(e.g.mononucleosis)ormalignancy • historyofliverdisease,hemolyticanemia,orhigh-riskexposures
Clinical Features
• jaundice, petechiae
• signsofchronicliverdisease
• percussion(Castell’ssign,Traube’sspace,andNixon’smethod)andpalpation • associatedlymphadenopathyorhepatomegaly
• signsofCHF
Investigations
• CBCanddifferential,bloodfilm
• asindicated:liverenzymes(AST,ALT,ALP,andGGT)and/orLFTs(platelet,INR,albumin,and
bilirubin), reticulocyte count, Monospot®/EBV, haptoglobin, LDH, infectious, and autoimmune workup
• imaging
■ ultrasound of abdomen/liver to assess for cirrhosis and portal vein thrombosis (if positive, refer to hepatology for evaluation)
■ echo for cardiac function
■ CT to rule out lymphoma and assess splenic lesions
Microcytic Anemia
• MCV<80fL
• seeFigure2,ApproachtoAnemia,H6
Table 10. Iron Indices and Blood Film in Microcytic Anemia
Ferritin
Iron Deficiency Anemia ii Anemia of Chronic Disease N/h Sideroblastic Anemia N/h
Thalassemia N/h
Serum Iron
i i h
N/h
Lab Tests
TIBC
h i N
N
% saturation RDW
i h(>15)
N N N/h h
N/h N/h
Blood Film
Hypochromic, microcytic Normocytic/microcytic
Dual population Basophilic stippling
Hypochromic, microcytic Basophilic stippling Poikilocytosis
Causes of Microcytic Anemia
TAILS
Thalassemia
Anemia of chronic disease Iron deficiency
Lead poisoning Sideroblastic anemia
Iron Metabolism
Iron Intake (Dietary)
• averageNorthAmericanadultdiet=10-20mgiron(Fe)daily
• steadystateabsorptionis5-10%(0.5-2mg/d);enhancedbycitricacid,ascorbicacid(vitaminC)and
reduced by polyphenols (e.g. in tea), phytate (e.g. in bran), dietary calcium, and soy protein
• maleshavepositiveFebalance;upto20%ofmenstruatingfemaleshavenegativeFebalance