Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Abordaje de esplenomegalia
1. 266 Historical Review
Abordaje
de
Esplenomegalia
Fig 1. Hippocrates examining the upper abdomen (possibly pal-
pating the spleen?) of a patient. Photograph courtesy of Dr Barbara
Bain, St Mary’s Hospital, London.
golden age of lifeÕ (Stukeley, 1722; Fig 2). The prevailing
view for many centuries was, however, one of gloomy and
2. Introducción
• Se origina del mesodermo esplácnico a la 11ª SDG.
• Peso: 50 - 250 gr.
• Medidas:
• Largo: 11 a 13 cm.
• Ancho: 6 - 8 cm.
• Espesor: 3 - 4 cm.
• Situación: 9ª - 11ª costillas.
TRATADO DE ANTOMÍA HUMANA
Editorial Salval S.A. Tomo IV
Testut. L. Latarget A
3. Introducción
• Irrigación:
• Arterial: tronco celíaco.
• Venosa: forma la vena porta con la vena mesentérica
inferior.
• Linfática: hacia cadena esplénica.
• Inervación: plexo solar.
ANATOMÍA PARA ESTUDIANTES
Editorial El Sevier Gray España 2005
Richarch L. Drake
4. Funciones
• Reservorio de Sangre.
• Hematopoyética.
• Hematodestructora.
• Inmunológica.
• De depósito.
ANATOMÍA CON ORIENTACIÓN CLÍNICA
Keith L. Moore, 4a edición
Editorial Panamericana 2002
6. Exploración Física
Exactitud
• Comparación vs US:
• La palpación es más exacta en sujetos delgados.
• E: 92%; VPP: 92%.
• Percusión: S: 62%; E: 72%.
• Combinación de resultados positivos: S: 46%; E:
97%.
7. Esplenomegalia
• Definición “estándar de referencia”: peso mayor a 250 gr.
• Clínicamente palpable: 16% muestran un tamaño normal.
• Radiológica, US:
• Longitud craneocaudal ≥13 cm.
• Díametro AP ≥2/3 de la distancia entre la pared abdominal
anterior y la posterior.
• TC: Longitud ≥10cm. S: 81%; E: 90%.
Splenomegaly: Investigation, diagnosis and management Determination of splenomegaly by CT: is there a place for a single measurement?
Bezerra AS.
A.L. Pozo et al. / Blood Reviews 23 (2009) 105–111 AJR Am J Roentgenol. 2005;184(5):1510
9. Splenomegaly in 2,505 Patients at a Large University
Medical Center From 1913 to 1995
1963 to 1995: 449 Patients
ROBERT A. O'REILLY, MD, San Francisco, California
WIM, August
1998-Vol No. 2
Splenomegaly was studied retrospectively at the University of California, San Francisco (UCSF), School
-A WIM
of Medicine in 301 patients from 1963 to 1995 and compared with the UCSF service of the San Fran-
169,
Causas más comunes cisco General Hospital Medical Center (SFGH) in 148 patients from 1979 to 1994. The combined 449
patients were classified into several diagnostic groups and were studied by means of several clinical
and laboratory associations. Hepatic disease in the percentage of patients at UCSF (with those at SFGH
given in parentheses) was associated with splenomegaly in 290/o (41%), hematologic disease, 32%
diseases, 10% (4%); USED
(16%); infectious diseases, 16% (36%); congestive or inflammatoryABBREVIATIONSprimary IN TEXT
splenic disease, 6% (1%); other, 5% (1%); and cause unknown, 2% (1%). Massive splenomegaly oc-
curred in 27% of the patients of the combined series, particularly= acquired immunodeficiency syndrome
AIDS in patients with hematologic dis-
eases. The acquired immunodeficiency syndrome (AIDS) occurred in more than half of the patients
with infectious diseases at SFGH and was four times more frequent chronic lymphocytic leukemia
CLL = than in the patients at UCSF. The
• Enfermedad hepática (cirrosis): 33 % CML = chronic myelocytic (chronic
commonest diseases associated with splenomegaly were hematologic (lymphoma), hepatic leukemia
liver disease), infectious diseases (AIDS and endocarditis), congestive (congestive heart failure), pri-
HIV = human to the spleen). In 11 pa-
mary splenic (splenic vein thrombosis), and other (malignancy not metastaticimmunodeficiency virus
1ITP = idiopathic thrombocytopenic
tients with AIDS and massive splenomegaly, Mycobacterium avium complex occurred in 8 (73%). purpura
Splenectomy was performed in 117 patients (26%), primarily for hematologic amelioration. I conclude
PVT = choice vein thrombosis
that for splenomegaly of unknown origin, the invasive procedure ofportal for patients with hemato-
• Malignidad hematológica (linfoma) : 27% SFGH = San liver biopsy; and for infec-
logic associations may be a bone marrow biopsy; for hepatic associations, a Francisco General Hospital Medi
tious disease associations, a lymph node biopsy, before any SVT = splenic vein thrombosis
consideration of a diagnostic splenectomy.
(O'Reilly RA. Splenomegaly in 2,505 patients at a large university medical center from 1913 to 1995. 1963 to 1995: 449
patients. West j Med 1998; 169:88-97) UCSF = University of Califomia, San Francis
• Infección (VIH, Endocarditis): 23%. spleen from a surgical procedure
excised
Splenomegaly presents a diagnostic challenge because
nearly always it is due to another primary disorder.'
northern California. The centering of AIDS patients at the
SFGH and to a lesser extent at UCSF allowed the assess-
The only analyses from a developed country on ment of the development of AIDS on the diagnostic eval-
total of 331 patients
splenomegaly in general were two office-based studies coded having sp were
uation of splenomegaly and massive splenomegaly. as
•
performed decades ago in which no diagnosis was estab-
Congestión (ICC): 8%. UCSF for the
lished in more than 25% of the patients.23 Only a single
study of hospital-based patients in the United States has
could
been reported.4 Now, a second municipal hospital has
1963 1995; 30 medical
Patients and Methods
years
be found. Therefore, the study was
not
to
Patient Demographics
remaining 301 patients. A total of 193 pati
been studied, San Francisco General Hospital Medical
Center (SFGH), which has been compared with and con- All hospital records at SFGH for patients of any age diag-
coded having splenomegaly; 45 me
trasted to a university medical center at the University of were
nostically coded asas
splenomegaly from 1979 through 1994
• Enfermedad propia del bazo (trombosis): 4 be found. Therefore, the st
California, San Francisco (UCSF), School of Medicine
(23%) could
for about the same period. Infections with the human
immunodeficiency virus (HIV) and with diseases related
%.
were reviewed retrospectively. Splenomegaly was defined
not
as an enlarged spleen determined by one of the following:
palpable by at least two clinicians or noted on two written
the remaining 148 patients. The
to the acquired immunodeficiency syndrome (AIDS) are on observations, greater than 12 cm in length on radiologic
prevalent in the young male homosexual community of imaging study, or more than 250 grams wet weight on an
splenomegaly for these years at UCSF was
• Otras o desconocidas: Departments ofJose,A.California.MD, ofSCalifornia, Francisco,CAfrom about 90,000 admissions, or 0.3%.
the
5%.O'Reilly,University Bascom
Valley Medical Center, San
Reprint Robert
From
Medicine,
requests to 751
San
Stanford
Ave, San Jose,
School of Medicine;
Medical
95128.
Alto; University Center, Palo and the Santa Clara
Clinical and Laboratory Features
The detailed criteria for the analysis of th
laboratory features of the patients are all
first part of this study.5
Results
10. Esplenomegalia Masiva
• El polo inferior se encuentra dentro de la
pelvis o cruza la línea media hacia el
hemiabdomen derecho.
• Causas:
•LMC
•Mielofibrosis, idopática o postpolicitémica
•Enfermedad de Gaucher.
•Linfoma (incluída Leucemia de células peludas)
•Kala-azar
•Síndrome tropical esplenomegálico
•Talasemia mayor
•SIDA con complejo Mycobacterium avium
O’ReillyRA.Splenomegalyin2505patientsatalargeuniversitymedicalcentre
from 1913 to 1995. 1963 to 1995:449 patients. West J Med 1998;169:88–97
11. Síntomas
•Dolor en CSI
•Sensación de plenitud postprandial precoz
•Dolor referido a hombro ipsilateral
•Dolor tipo pleurítico agudo + dolor en CSI
sugiere absceso esplénico
12. including bone marrow, liver and rectal
y of these patients remained well for over
Table 2
eem to be a group of individuals with benign
Initial investigations in the patient with splenomegaly.
prevalence is not clear.
Abordaje
causes of splenomegaly have now been stud- In most patients In selected patients (depending on clinical
features)
US hospital inpatients.11–13 The estimated
o 1995 was 0.3% of admissions and a diagno- Haematology
Full blood count Direct antiglobulin test
Inicial
8%, but 12% required a diagnostic splenec-
Peripheral blood film Reticulocyte count
ents with splenomegaly, haematological ESR Malaria blood film
16–66%, hepatic disease in 9–41%, infectious Clotting screen Haemoglobin electrophoresis/HPLC
estive or inflammatory disease in 4–10% and Biochemistry
e (e.g. storage disease) in 1–6%.11–13 Within Urea and electrolytes Serum ACE
sorders, the most common diagnoses were Liver function tests Serum protein electrophoresis
all splenomegaly), CML (8–29%), haemoglo- C-reactive protein Urine Bence Jones protein
Bone biochemistry
L (0–20%) and myelofibrosis (9–16%).
•Historia Clínica
omegaly vary between hospitals in the same
ences between developing and developed
Serum LDH
Vitamin B12, red cell folate
Microbiology
re striking. 11–45% of massive splenomegaly Monospot test Peripheral blood cultures
•Exploración
opical Splenomegaly Syndrome of malarial
is due to schistosomiasis.14
Serology: hepatitis B/C Sputum microscopy, culture and AAFB
Mantoux test
Física Immunology
Serology: HIV, CMV, toxoplasmosis, brucella
tient with splenomegaly
Auto-antibodies incl. ANA
Rheumatoid factor
begins with a thorough history and exami-
Radiology
ay elicit symptoms of pressure effects from Ultrasound/CT abdomen Ultrasound abdomen with duplex-Doppler studies
uch as left hypochondrial discomfort or early Plain chest radiograph CT chest, abdomen and pelvis
symptoms of cytopenias due to hypersplen- Transthoracic/transoesophageal echocardiogram
prising splenomegaly; anaemia, leucopenia Bedside
enia; compensatory bone marrow hyperpla- Urine dipstick (protein,
t after splenectomy (if performed). General blood)
uch as fever, sweats, weight loss or lymphad- ESR: erythrocyte sedimentation rate; HPLC: high-performance liquid chromatog-
matological, malignant, infectious or inflam- raphy; LDH: lactate dehydrogenase; ACE: angiotensin-converting enzyme; AAFB:
horough systemic enquiry is essential to acid and alcohol-fast bacilli; and ANA: anti-nuclear antibodies.
13. Abordaje Adicional
Esplenectomía Why does my patient have Lymphadenopathy or splenomegaly?
Motyckova & Steensma
Hematol Oncol Clin N Am 26 (2012) 395–408
•Causa aún desconocida.
•Crecimiento refreactario a tratamiento
•Persistencia de síntomas.
•Paliativa: mielofibrosis, LCP.
•Víalaparoscópica: complicaciones del 6-22%.
Mortalidad 1.4%
14. Abordaje Adicional
Biopsia
•No recomendada actualmente.
•Poca utilidad clínica.
Why does my patient have Lymphadenopathy or splenomegaly?
Motyckova & Steensma
Hematol Oncol Clin N Am 26 (2012) 395–408
