How to examine the spleen on physical examination (PE)?

How to Examine the Spleen on Physical Examination

The most effective approach to examining the spleen combines palpation techniques with percussion methods, with Middleton's maneuver and supine palpation offering the highest diagnostic accuracy for detecting splenomegaly.1

Positioning the Patient

• Position the patient supine or in right lateral decubitus position to optimize access to the left upper quadrant 2
• Ask the patient to take a deep breath to bring the spleen inferiorly during examination 3

Palpation Techniques

Supine Palpation

• Place the patient in supine position with knees slightly flexed to relax abdominal muscles 1
• Stand on the patient's right side 1
• Place your left hand behind the patient's left lower ribs for support 1
• Use your right hand to palpate from the right lower quadrant toward the left costal margin 1
• Ask the patient to take a deep breath while you palpate deeply under the left costal margin 3
• A palpable spleen edge confirms splenomegaly (highest specificity at 92.1%) 1

Middleton's Maneuver

• Position the patient in right lateral decubitus position with left arm extended above the head 1
• Stand behind the patient 1
• Place your hands over the left lower chest and upper abdomen 1
• Palpate deeply during inspiration to feel for the splenic edge 1
• This technique has high sensitivity (85.7%) and is recommended for routine use 1

Percussion Methods

Castell's Maneuver

• Have the patient take a deep breath and hold it 1
• Percuss in the lowest intercostal space in the left anterior axillary line 1
• A dull percussion note indicates splenomegaly 1
• This technique has high sensitivity (85.7%) but lower specificity (31.6%) 1

Traube's Space Percussion

• Percuss the Traube's space (area bounded by the 6th rib superiorly, left mid-axillary line laterally, and left costal margin inferiorly) 1
• Normally resonant, dullness suggests splenomegaly 1
• Moderate sensitivity (74%) 1

Nixon's Maneuver

• Percuss the lowest interspace in the left anterior axillary line with the patient supine 1
• Then repeat with the patient in right lateral decubitus position 1
• A change from resonant to dull suggests splenomegaly 1
• Has the lowest sensitivity (66.7%) among percussion methods 1

Grading Splenomegaly

• Normal spleen is typically 10-12 cm long and 3-5 cm thick 3
• Grading system based on palpable distance below left costal margin (LCM): 2
  • Score 0.5: Normal spleen (not palpable) 2
  • Score 1: Spleen extends halfway between left rib cage and first quadrant line 2
  • Score 2: Spleen extends to the median line 2
  • Score 3: Spleen extends halfway between median line and right rib cage 2
  • Score 4: Spleen extends to the right rib cage 2

Ultrasound-Enhanced Examination

• Consider point-of-care ultrasound to improve diagnostic accuracy 4
• Sonographic versions of traditional physical examination techniques have greater diagnostic accuracy 5
• The sonographic Castell's method has higher sensitivity (91.7%) than traditional Castell's method (83.3%) 5
• The sonographic spleen tip method is more sensitive than palpation alone (58.3% vs 33.3%) 5
• Use a 3.5 to 5 MHz transducer with an intercostal approach 3

Common Pitfalls and Limitations

• Physical examination techniques alone have limited sensitivity, especially with mild splenomegaly 6
• Obesity can significantly reduce the accuracy of all physical examination techniques 1
• Left pleural effusion or left lower lobe pneumonia can cause dullness that mimics splenomegaly 6
• A distended stomach or enlarged left kidney may be mistaken for splenomegaly 6
• Palpation may miss deep-seated splenomegaly or detect a mass that is not the spleen 6

When to Consider Additional Imaging

• When physical examination is equivocal 4
• In obese patients where palpation and percussion are less reliable 1
• When accurate measurement of spleen size is needed for monitoring disease progression 2
• To confirm suspected splenomegaly before invasive procedures 4