Is ultrasound (US) surveillance recommended for splenomegaly?

Ultrasound Surveillance for Splenomegaly

Ultrasound surveillance is recommended for patients with splenomegaly, with frequency determined by the underlying cause, but generally every 2 years for most conditions. 1

Diagnostic Confirmation and Initial Evaluation

• Abdominal ultrasound is the first-line imaging modality to confirm splenomegaly after physical examination suggests an enlarged spleen 1
• Initial evaluation should include:
  • Complete blood count with differential
  • Liver function tests
  • Peripheral blood smear examination 1

Surveillance Recommendations by Condition

Cystic Fibrosis-Related Hepatobiliary Involvement

• Abdominal ultrasound should be performed at least every 2 years to monitor for progression of disease 2
• For patients with cystic fibrosis and hepatobiliary involvement, US should be used to detect evolving heterogeneity of liver parenchyma, nodularity, hepatomegaly, splenomegaly, and portal venous flow changes 2

Portal Vein Thrombosis

• Screening for portal hypertension with ultrasound should begin as soon as an occlusive main portal vein thrombosis or portal cavernoma is identified, and then annually thereafter 2
• If physical examination and ultrasound screening do not suggest portal hypertension after 5 years, further surveillance may not be necessary 2

Myeloproliferative Neoplasms

• For patients with polycythemia vera (PV) or essential thrombocythemia (ET), assessment of splenomegaly can be carried out by palpation at each follow-up visit 2
• Initial ultrasound scan is recommended to exclude subclinical splanchnic vein thrombosis or splenic infarcts 2
• Subsequent imaging is not routinely indicated unless there is suspicion of disease progression 2

Surveillance Techniques

Standard Ultrasound

• Conventional ultrasound remains the method of choice for splenic imaging due to its high sensitivity (97.8%) compared to CT (79.6%) 3
• Doppler ultrasound should be included to evaluate:
  • Splenic vascularization
  • Portal venous flow direction
  • Signs of portal hypertension 2, 1

Advanced Ultrasound Techniques

• Contrast-enhanced ultrasound (CEUS) increases visualization of splenic abnormalities and characterization of focal lesions 2, 4
• Elastography (when available) can be used to assess splenic stiffness, which correlates with portal hypertension severity 4

Special Considerations

Splenic Trauma

• E-FAST (Extended Focused Assessment with Sonography for Trauma) is effective and rapid for detecting free fluid in trauma patients 2
• CT scan with intravenous contrast is the gold standard for detailed evaluation in hemodynamically stable trauma patients 2

Malignancy Surveillance

• For suspected lymphoma or other malignancies affecting the spleen, ultrasound may be supplemented with PET/CT imaging 1

Common Pitfalls to Avoid

• Focusing only on the liver when splenomegaly is present without investigating potential hematologic causes 1
• Failure to recognize that splenomegaly may be the first sign of a serious hematologic condition 1
• Delaying hematology consultation when cytopenias are present 1
• Inappropriate splenectomy without thorough evaluation 1

Ultrasound surveillance for splenomegaly provides valuable information about disease progression and complications while being non-invasive, readily available, and cost-effective compared to other imaging modalities.