Incidence: common in young adult. Male > Female. Common in lower Egypt.
Pathology:
(I) Pathogenesis: The splenic enlargement may be due to:
1- Hyperplasia of the reticulo-endothelial element in response to Bilharzial toxins. "Bilharzial ova rarely found in spleen".
2- Congestion due to portal hypertension.
3- Thickened capsule and trabeculae may play a role.
(II) Gross Picture:
Spleen; Marked enlargement may reach > 4kgm. Firm in consistency sharp border with prominent notch. Whitish area on the surface due to old infarction.
Blood vessels; especially the veins are dilated & tortuous with big anastomotic channels with diaphragm.
(III) Cut section:
Early: Congestion with prominent lymphoid follicles.
Late: Atrophy and fibrosis of the follicles.
(IV) Associated lesions:
Bilharzial periportal fibrosis of the liver & chronic Bilharzial colitis.
Clinical Picture:
Stage (I): Hepatomegaly. " Usually passed unoticed".
Stage (II): Hepatosplenomegaly " Moderate enlargement of both".
Stage (III): Splenamegaly (Marked) with shrunken liver.
Stage (IV): Ascitis + huge spleen + shrunken liver.
Stage (V): Liver cell failure " Cholaemia".
Simply, we can put the patient in one of two groups:
1- Compensated splenomegaly (Stages I, II, III).
2- Decompensated splenomegaly (Stages IV, V).
1) COMPENSATED SPLENOMEGALY:
Symptoms:
General weakness and easy fatiguability.
Heaviness in left hypochondrium
Stetching or stabbing pain indicate splenic infarction or perisplenitis.
Dyspepsia due to cogestion of the stomach and viscera.
Signs: Abdominal examination may reveal:
1- Enlarged tender liver. 2- Enlarged spleen.
3- Dilated veins over the abdomen (caput Medusa around umbilicus).
The Character of Splenic Mass:
1- Originated in the Lt. hypochondrium and directed downward and medially may reach Rt. iliac fossa.
2- It moves up and down with respiration.
3- You cann't insinuate your fingers between the costal margin and the mass to feel its upper border.
4- It has sharp border with noch. The noch may be closed due to fibrosis or malignancy.
5- Its dullness is contineous with the normal splenic dullness.
6- No band of resonance infront of the mass.
7- It gives no posterior pallotment.
Treatment of Compensated Splenomegaly:
Medical support of the liver and correction of anemia and follow up:
Splenectomy is indicated in:
1- To abolish hypersplenism which improve anaemia & leucopenia.
2- It was thought that its removal decrease the portal hypertension but now many surgeon denay this role as the patient may pass to uncompensated stage due to progress in liver pathology.
2- DECOMPENSATED SPLENOMEGALY:
With the result of progress in the periportal fibrosis of the liver. The liver function gradually impaired. The portal pressure will increase.
Which will leads to:
* Ascitis. * Bleeding varices. * Liver failure
SOURCE: DR. AYMAN SALEM'S BOOK
Copyright: Vascular Society of Egypt (www.vsegypt.org) &Medical Educational web (www.meduweb.com)
Not to be reproduced without permission of Vascular Society of Egypt