What are the next steps in managing an adult patient with borderline splenomegaly (enlarged spleen) found on a computed tomography (CT) scan?

Management of Borderline Splenomegaly on CT

For an incidentally discovered borderline splenomegaly on CT in a hemodynamically stable adult without trauma, initiate a systematic workup focusing on the three most common causes in the United States: liver disease, malignancy, and infection, while confirming the finding with abdominal ultrasonography. 1

Initial Diagnostic Approach

Confirm the Finding

• Obtain abdominal ultrasonography to confirm splenomegaly, as physical examination alone detects splenomegaly in only 30% of cases and is unreliable 2, 1
• Normal spleen dimensions are typically less than 13 cm in length; borderline findings warrant confirmation before extensive workup 1

Essential Clinical Assessment

• Obtain detailed history focusing on:

  • Recent or chronic infections (infectious mononucleosis, malaria, schistosomiasis if travel to endemic areas) 1
  • Symptoms of liver disease (jaundice, ascites, variceal bleeding) 1
  • Constitutional symptoms (fever, night sweats, weight loss) suggesting malignancy 1, 3
  • Hematologic symptoms (easy bruising, bleeding, fatigue) 1
  • Alcohol use and risk factors for viral hepatitis 1

• Physical examination should assess for:

  • Signs of chronic liver disease (spider angiomas, palmar erythema, ascites) 1
  • Lymphadenopathy suggesting lymphoproliferative disorders 1, 3
  • Signs of anemia or other hematologic abnormalities 1

First-Line Laboratory Workup

Order basic laboratory analysis including: 1

• Complete blood count with differential (to detect cytopenias, leukocytosis, or abnormal cells)
• Comprehensive metabolic panel (liver function tests to assess for hepatic causes)
• Peripheral blood smear (to identify hematologic malignancies or hemolytic processes)
• Viral hepatitis serologies if liver disease suspected
• Monospot or EBV titers if infectious mononucleosis suspected

Risk Stratification and Referral

Immediate Surgical Referral Required

Refer urgently to general surgery or surgical oncology if: 4

• Signs of splenic abscess (persistent fever with contrast-enhancing cystic lesions on CT) 4
• Evidence of splenic infarction with complications (rupture or hemorrhage) 2, 4
• Any hemodynamic instability or signs of active bleeding 4
• Peritonitis or acute abdominal findings 4

Trauma-Related Findings

• Refer immediately to trauma surgery or acute care surgery if the finding is trauma-related, even if hemodynamically stable 4
• Do not rely solely on CT injury grade to predict outcomes, as grade and contrast blush do not reliably predict need for intervention 4

Management Based on Etiology

When Initial Workup is Revealing

• Treat the underlying disease process as the primary management strategy for splenomegaly 1
• Liver disease: Address cirrhosis, portal hypertension with hepatology consultation 1
• Infection: Treat with appropriate antimicrobials 1
• Hematologic malignancy: Refer to hematology-oncology for definitive management 1, 3

Isolated Splenomegaly (No Clear Cause)

When extensive radiological and laboratory investigations fail to yield a diagnosis: 5

• Balance the risks of serious underlying disease against risks of invasive investigations (splenic biopsy, diagnostic splenectomy) 5
• Consider serial imaging and clinical monitoring rather than immediate invasive procedures in stable patients 5
• Reassess at regular intervals with repeat imaging and laboratory studies 5

Important Precautions and Activity Restrictions

Patient Counseling

• Advise patients to refrain from contact sports to decrease risk of splenic rupture, as this is one of the most common complications of splenomegaly 1
• Counsel on signs of acute complications: severe left upper quadrant pain, lightheadedness, or syncope requiring immediate evaluation 1

Monitoring for Complications

• Watch for acute infections, anemia, and splenic rupture as the most common complications 1
• Serial clinical examination with immediate access to surgery if complications develop 6

Common Pitfalls to Avoid

• Do not order obsolete nuclear medicine scans (99mTc liver-spleen scans, labeled white blood cell scans, gallium scans), as they provide no diagnostic value 6, 4
• Do not rely on clinical splenomegaly as a reliable indicator of severity or need for intervention 6
• Do not assume borderline findings are benign—some findings and clinical conditions warrant closer attention, particularly when accompanied by constitutional symptoms or cytopenias 7
• Do not skip ultrasonographic confirmation before initiating extensive workup, as CT measurements can be misleading 1

Special Imaging Considerations

Characterizing Hypodense Splenic Lesions on CT

If hypodense lesions are present: 7

• Most hypodense splenic lesions represent benign findings (hemangiomas are most common) 7
• Evaluate lesion borders, attenuation, calcifications, and solid components 7
• Lymphoma represents the most common malignant tumor of the spleen, usually secondary involvement 7
• Interpret findings in clinical context—isolated hypodense lesions in asymptomatic patients often require no further workup 7