Palpation of the spleen: algorithm and technique

The spleen is an unpaired organ that is located in the left part of the abdominal cavity. The front part of the organ is attached to the stomach, and the posterior part to the kidney, adrenal and intestines.

Structure of the spleen

The composition of the spleen determines the serosa and its own capsule, the latter is formed by a combination of connective tissue, muscle and elastic fibers.

The capsule passes into the core of the organ, dividing the pulp (parenchyma) into separate "islets" with the help of trabeculae. In the pulp (on the walls of arterioles) there are round or oval nodules of lymphoid tissue (lymphoid follicles). At the heart of the pulp lies the reticular tissue, which is filled with various cells: erythrocytes (mostly decaying), leukocytes and lymphocytes.

Functions of the body

• The spleen is involved in lymphopoiesis (that is, it is the source of lymphocytes).
• Participates in the hematopoietic and immune functions of the body.
• Destruction of the spent platelets and erythrocytes.
• Deposition of blood.
• In the early stages of embryogenesis it works as an organ of hematopoiesis.

That is, the body performs many important functions, and therefore for the definition of pathologies at the initial stages of the examination, it is first of all necessary to perform palpation and percussion of the spleen.

Priority of palpation of internal organs

After collecting complaints, anamnesis and general examination, the doctor, as a rule, proceeds to physical methods of research, which include palpation and percussion.

Distinguish:

• Surface palpation, which reveals the soreness of a particular area, the tension of the muscles of the abdomen, puffiness, various seals and formations (hernias, tumors, nodes). It is carried out by light pressure with a half-bent fingers, starting from the left ileal region counter-clockwise.
• Deep palpation, carried out in the following sequence: the cecum, the ileum (its terminal part), the colon (ascending and descending sections), the transverse-colon intestine, stomach, liver, pancreas, spleen, kidneys, are carried out using deep penetration of the fingers Doctor in the abdominal cavity.

In case of suspicion of the presence of spleen diseases (or its increase due to liver diseases) it is necessary to perform percussion, palpation of the liver and spleen.

General rules of palpation

Palpation of the spleen is one of the most informative physical research techniques conducted by a doctor. In case of a slight increase in the organ, when the spleen is not easy to probe, the doctor necessarily recommends the passage of ultrasound to confirm / disprove the alleged pathology in the child or adult.

Position of the patient:

• Lying on the back (in this position, palpation of the liver and spleen is performed).
• Lying on his right side. The right hand is located under the head, and the left hand should be bent at the elbow and laid on the chest (this technique is called palpation of the spleen according to Sali). And the head of the patient should be slightly inclined to the chest, the right leg is straight, and the left leg should be bent in the hip and knee joints.

Palpation of the spleen: algorithm

1. The doctor should position his left hand so that it is on the left side of the subject's chest, in the interval between the 7th and 10th ribs in accordance with the axillary lines, and exert a slight pressure. In this case, the fingers of the right hand should be half-bent and located on the left costal arch in such a way that the middle finger adheres to the 10th rib.
2. When the patient inhales, the skin is shifted downward to form a fold of the skin.
3. After exhalation, the doctor's hand penetrates deep into the abdomen (abdominal cavity).
4. The patient at the request of the doctor takes a deep breath, while under the influence of the diaphragm the spleen moves downward. If it increases, the doctor's fingers will come across her lower pole. This action must be repeated several times.

Interpretation of results

Under normal conditions (in healthy people), the spleen is not palpable. Exceptions are asthenics (more often women). To feel the spleen in other cases is possible with the descent of the diaphragm (pneumothorax, pleurisy) and splenomegaly, that is, an increase in the size of the organ. Such a state is more often observed under the following conditions:

• Blood diseases.
• Chronic liver pathologies (here splenomegaly is a sign of portal hypertension or hepatolenal syndrome).
• Chronic and acute infectious processes (endocarditis infectious, malaria, typhus, sepsis).
• Diseases of connective tissue.
• Infarcts or abscesses of the spleen.

Most often, the palpation of an enlarged spleen is painless. Exceptions are organ infarcts, rapid capsule stretching, perispenitis. In these cases, the spleen becomes extremely sensitive (that is, painful on palpation).

With cirrhosis of the liver and other chronic pathologies, the edge of the spleen is dense, while in acute processes it is mild.

Consistency is usually mild in acute infections, with chronic infections and cirrhosis becomes dense.

According to the degree of organ enlargement, the palpable part may be smaller or larger, and the extent to which the spleen has emerged from under the ribs may indicate a true degree of organ enlargement. Thus, a relatively small increase indicates the outlet of the edge of the organ from beneath the costal arch to 2-7 centimeters, which is observed in acute infections (typhoid, meningitis, sepsis, croupous pneumonia and so on) or chronic pathologies (heart disease, cirrhosis, erythremia, Leukemia, anemia) and unexplained etiology, which often occurs in young people (possibly with hereditary syphilis, rickets)

Accordingly, the density of the palpable edge of the spleen (with its increase) it is possible to draw conclusions about the prescription of the process. That is, the longer the inflammation in the organ is, the denser and harder its parenchyma, from which it follows that in acute processes the edge of the spleen is more soft and elastic than in chronic ones.

If the size of the organ is too large, when the lower edge is defined in the pelvic cavity, it is very easy to perform palpation of the spleen, and no special skills are required.

In the case of splenomegaly as a result of neoplasm, palpation of the spleen (more precisely, its margo crenatus) determines notches (from 1 to 4). Such a diagnostic sign indicates the presence of amyloidosis, leukemia (myelogenous chronic or pseudo-leukemia), malaria, cysts and endothelium.

That is, when performing a palpation of the spleen, the doctor has the opportunity to assess the condition of its surface, to detect fibrin deposition (as, for example, in perisplenitis), various protrusions (which happens, for example, with abscesses, hemorrhagic and serous cysts, echinococcosis) and determine tissue density. When abscesses are often detected and swelling. All the information determined by palpation is extremely valuable, both for diagnosing the disease of the spleen itself, and for determining the diseases that could lead to splenomegaly.

Normally, the spleen is located in the region of the left hypochondrium, its long axis is located along the tenth rib. The organ has an oval (bean-shaped) shape.

Spleen in childhood

Spleen sizes are normal, depending on age:

• Newborns: width - up to 38 millimeters, length - up to 40 millimeters.
• 1-3 years: length - up to 68 millimeters, width - up to 50 millimeters.
• 7 years: length - up to 80 millimeters, width - up to 55 millimeters.
• 8-12 years: width - up to 60 millimeters, length - up to 90 millimeters.
• 15 years: width - up to 60 millimeters, and length - 100-120 millimeters.

It should be remembered that palpation of the spleen in children, as well as in adults, should be painless, in addition, the normal spleen in the child is not determined. The dimensions described above are not absolute, that is, small deviations in the direction of decreasing / increasing the size of the organ should not be regarded as a pathology.

Percussion of the spleen

This method is used to assess the size (boundaries) of the organ.

The patient is placed in the right semi-sideways position with hands above his head, while the legs are hardly bent in the hip and knee joints. Percussion follows, moving from clear to blunt sound, applying quiet percussion beats.

Conducting percussion

1. The finger-plessimeter should be installed on the edge of the costal arch from the left side of the body, perpendicular to the 10th rib.
2. Conduct a weak percussion along the 10th rib, first from the costal arch (left) to the appearance of a dull sound (dullness). In the place of transition of a sound do on a mark a mark. Then percussion from the axillary line (posterior) anteriorly to the appearance of blunting sound and also put a mark on the skin.
3. The length of the interval between the marks is the length of the spleen (corresponding to the 10th rib). Normally, this indicator is 6-8 centimeters.
4. From the middle of the longest, perpendiculars are drawn to the tenth edge and they produce further percussion to determine the diameter of the spleen, which normally ranges from 4 to 6 centimeters.
5. Normally, the anterior part of the spleen (that is, its edge) should not be medial to the line, which connects the free end of the 11th rib and the sternoclavicular junction. It should be noted that calculating the size of the spleen with percussion is a very approximate indicator. The dimensions of the organ are recorded as a fraction, where the numerator is the longest, and the denominator is the diameter of the spleen.