Splenomegaly: Diagnosis and Management in Adults

 

Am Fam Physician. 2021 Sep ;104(2):271-276.

Author disclosure: No relevant financial affiliations.

Splenomegaly can be due to several mechanisms but is almost always a sign of a systemic condition. Patient habits, travel, and medical conditions can increase risk of splenomegaly and suggest etiology. Symptoms can suggest infectious, malignant, hepatic, or hematologic causes. Physical examination will typically reveal splenomegaly, but abdominal ultrasonography is recommended for confirmation. Physical examination should also assess for signs of systemic illness, liver disease, and anemia or other hematologic issues. The most common causes of splenomegaly in the United States are liver disease, malignancy, and infection. Except for apparent causes such as infectious mononucleosis, basic laboratory analysis and ultrasonography are the first-line steps in determining etiology. Malaria and schistosomiasis are common in tropical regions, where as many as 80% of people may have splenomegaly. Management of splenomegaly involves treating the underlying disease process. Splenectomies and spleen reduction therapies are sometimes performed. Any patient with limited splenic function requires increased vaccination and prophylactic antibiotics for procedures involving the respiratory tract. Acute infections, anemia, and splenic rupture are the most common complications of splenomegaly, and people with splenomegaly should refrain from participating in contact sports to decrease risk of rupture.

The spleen is part of the hepatoportal system and is the largest organ of the lymphatic system. Functions of the spleen include removing aging or abnormal blood cells, storing platelets and red blood cells, and producing and distributing immune cells and antibodies.1 The spleen is a major site of blood production outside of the bone marrow, especially during times of stress.13 Several general pathophysiologic mechanisms cause splenic enlargement. Hyperplasia and hypertrophy cause splenomegaly due to increased function of the spleen. Infiltrative processes can cause accumulation of abnormal cells in the spleen, which can be malignant, benign, or caused by glycogen storage disorders. Congestive processes result in blood pooling due to blockage of venous outflow.2,3 These mechanisms can lead to transient splenomegaly, such as with blood loss, infection, and during pregnancy, but in these cases the spleen returns to normal size after the condition resolves.2,4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

History of liver disease and alcohol use should be assessed in patients presenting with splenomegaly in the United States.13,5

C

Expert opinion based on cirrhosis being one of the most common causes of splenomegaly in the United States

Abdominal ultrasonography is the first-line imaging study suggested to confirm a suspected diagnosis of splenomegaly.3,5,6,8,14

C

Blinded clinical trial and expert opinion based on low sensitivity and specificity of the abdominal examination for splenomegaly and cost of other imaging modalities

Vaccinations against encapsulated organisms are indicated in functionally asplenic patients to prevent infection.24,25

C

Expert opinion based on clinical guidelines and a review article on management of functionally asplenic patients

Patients with infectious mononucleosis should restrict sports participation for at least 21 to 31 days after symptom onset.26,27

C

Sports medicine guidelines based on expert opinion and a retrospective analysis on splenic rupture in patients with infectious mononucleosis and when they are likely to have a rupture


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

History of liver disease and alcohol use should be assessed in patients presenting with splenomegaly in the United States.13,5

C

Expert opinion based on cirrhosis being one of the most common causes of splenomegaly in the United States

Abdominal ultrasonography is the first-line imaging study suggested to confirm a suspected diagnosis of splenomegaly.3,5,6,8,14

C

Blinded clinical trial and expert opinion based on low sensitivity and specificity of the abdominal examination for splenomegaly and cost of other imaging modalities

Vaccinations against encapsulated organisms are indicated in functionally asplenic patients to prevent infection.24,25

C

Expert opinion based on clinical guidelines and a review article on management of functionally asplenic patients

Patients with infectious mononucleosis should restrict sports participation for at least 21 to 31 days after symptom onset.26,27

C

Sports medicine guidelines based on expert opinion and a retrospective analysis on splenic

The Authors

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SOMMER ALDULAIMI, MD, is associate program director and co-director of the Global Health Track and an associate professor in the Department of Family and Community Medicine at the University of Arizona and Banner University Medical Center, Tucson....

ANA M. MENDEZ, MD, MPH, is the clinic medical student coordinator and attending faculty at Banner University Medical Center and an assistant professor in the Department of Family and Community Medicine at the University of Arizona.

Address correspondence to Sommer Aldulaimi, MD, Banner University Medical Center - South Campus, 2800 E Ajo Way, Tucson, AZ 85713 (email: sommer.aldulaimi@bannerhealth.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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