Inpatient Workup for Splenomegaly
The inpatient workup for splenomegaly should include a complete blood count, liver function tests, abdominal imaging (preferably ultrasound), and targeted testing based on suspected etiology, with bone marrow examination reserved for cases with hematologic abnormalities or diagnostic uncertainty. 1, 2
Initial Assessment
Physical Examination
- Confirm splenomegaly through careful abdominal examination:
- Percussion and palpation of the entire liver and spleen with measurement of liver span at mid-clavicular line 3
- Grade splenomegaly: mild (<5 cm below left costal margin), moderate (5-10 cm below LCM), or massive (>10 cm below LCM) 1
- Note that physical examination alone has limited sensitivity (40%) but reasonable specificity (88%) 4
First-Line Laboratory Tests
- Complete blood count with differential and peripheral smear examination 3, 1
- Comprehensive liver function tests:
- Fibrosis indices calculation:
- AST-to-Platelet Ratio Index (APRI)
- Fibrosis-4 (FIB-4)
- GGT-to-Platelet Ratio (GPR) 3
Imaging Studies
- Abdominal ultrasound (first-line imaging):
- CT or MRI scan (if ultrasound is inconclusive or further characterization needed):
Second-Line Investigations Based on Suspected Etiology
Infectious Causes
- Blood cultures if fever present
- Viral studies:
- EBV, CMV, HIV serology
- Hepatitis panel (A, B, C)
- Malaria smears if travel to endemic areas
- Tuberculosis testing (interferon-gamma release assay or tuberculin skin test)
- Schistosomiasis serology if relevant travel history 2
Hematologic Causes
- Flow cytometry of peripheral blood
- Bone marrow aspiration and biopsy:
- Indicated for suspected hematologic malignancy
- Particularly important with abnormal blood counts or peripheral smear 3
- JAK2, CALR, MPL mutation testing for suspected myeloproliferative neoplasms 1, 5
Hepatic Causes
- Additional liver function tests
- Hepatitis serology
- Autoimmune markers (ANA, ASMA, AMA)
- Ceruloplasmin, alpha-1 antitrypsin, ferritin, iron studies 2
Autoimmune/Inflammatory Causes
- Rheumatologic panel:
- ANA, RF, anti-CCP
- Complement levels
- ESR, CRP
Special Considerations
Isolated Splenomegaly
When extensive workup fails to yield a diagnosis:
- Consider splenic biopsy in selected cases
- Diagnostic splenectomy is rarely needed but may be considered when:
- Massive splenomegaly causes mechanical symptoms
- Hypersplenism with severe cytopenias is present
- Splenic infarction or rupture has occurred 6
Risk Assessment
- Patients with splenomegaly should avoid contact sports to reduce rupture risk 2
- For patients requiring procedures, assess need for:
- Platelet transfusions if thrombocytopenic
- Antibiotic prophylaxis for respiratory tract procedures 1
Common Pitfalls to Avoid
- Relying solely on physical examination - Point-of-care ultrasound significantly improves diagnostic accuracy 4
- Premature invasive testing - Complete non-invasive workup before considering splenic biopsy or splenectomy 6
- Missing underlying liver disease - Always evaluate hepatic function and portal hypertension as common causes of splenomegaly 2
- Overlooking tropical diseases - In patients with travel history to endemic areas, consider malaria and schistosomiasis, which can affect up to 80% of people in some regions 2
- Neglecting medication review - Several medications can cause splenomegaly and should be considered in the differential diagnosis
By following this systematic approach, clinicians can efficiently diagnose the underlying cause of splenomegaly and develop an appropriate management plan focused on treating the primary condition.