Splenomegaly: Remember the 3 primary causes with CIP


An
enlarged spleen is a physical exam finding that has a broad differential. Let’s investigate the three primary causes;
congestion, infiltration, and proliferation: we can remember it as C-I-P. First let’s look at congestion. Increased blood pressure in the splenic vein
can cause a cascade of congestion, hyperplasia and fibrosis in the spleen. This can be due to direct occlusion of the
splenic vein such as in a splenic vein thrombosis (a complication of pancreatitis) or any pathology
that causes portal hypertension – such as cirrhosis or right heart failure. Remember to look for signs and symptoms of
these diseases. In cirrhosis, we see jaundice, varices, and
spider angiomas. Pancreatitis can present with severe epigastric
pain radiating to the back. Identifying an enlarged spleen in this case
can point towards an increased risk for thrombotic complications. Next let’s look at infiltration. The spleen is highly vascularized and plays
a central role as a peripheral lymphatic organ. As such, it is prone to invasion by malignant
and non-malignant causes. Malignancies include lymphomas and leukemias,
as well as metastatic solid tumours. Depository diseases such as amyloidosis and
sarcoidosis will likely manifest in other organs as well. Also, the spleen is often one of the primary
sites of extramedullary hematopoiesis in myeloproliferative disorders. That brings us to proliferation. The spleen is a lymphatic organ which, instead
of filtering lymph; filters blood. In doing so, it is a major source of protection
against blood borne pathogens as well as other blood abnormalities which can cause the spleen
to become hyperfunctioning. This can be the result of acute infections,
which can be viral (CMV, HIV, EBV), bacterial (TB), fungal (histoplasmosis) as well as parasitic
(malaria, visceral leishmaniasis) in nature. Filtering the blood of abnormal cells / structures
can cause hyperplasia of the spleen. These include spherocytosis, hemoglobinopathies,
and sickle cell disease. An enlarged spleen should never be ignored
and a proper history and physical can make this broad differential much easier to stratify. Remember it’s a simple as C-I-P.

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