Suggestion: If the inspiration is too deep, the lung (47) extends inferiorly into the diaphragmatic angle and obscures the subdiaphragmatic portion of the spleen (Fig. 47.3). In this situation, the "curtain trick" should be tried by asking the patient to exhale slowly following maximal inspiration until the spleen becomes visible (Fig. 47.4). Like a curtain, the lung frequently recedes before the spleen (37) moves back upward. During this asynchronous rate of retraction, the moment has to be watched for when the acoustic shadows (45) from the lung no longer interfere with visualization of the spleen. At that point, the patient has to be asked to hold his or her breath.
Occasionally, the spleen is better seen in the supine than in the right lateral decubitus position.
Many conditions are associated with diffuse enlargement of the spleen, and the differential diagnosis does not only include portal hypertension (Fig. 48.2) secondary to hepatic cirrhosis but also viral infections, such as mononucleosis. Furthermore, all diseases causing an increased turnover of erythrocytes, such as hemolytic anemia and polycythemia vera, can produce a splenomegaly (Fig. 48.3).
Splenomegaly typically accompanies systemic hematologic diseases, such as acute or chronic leukemia (Fig. 48.1 in CLL), but can be found in rheumatic, immunologic, and storage diseases. Not every splenomegaly is of pathologic relevance since many diseases heal by leaving behind a mild to moderate splenomegaly, for instance mononucleosis. The enlargement of the spleen (37) begins with a rounding of its normal crescentic configuration (Fig. 47.2) and can progress to the so-called "giant spleen/' The massively enlarged spleen can touch the left hepatic lobe and this is referred to as "kissing phenomenon." Occasionally, an accessory spleen can reach a considerable size. Accessory spleens (86)
(Fig. 48.1) are generally located at the splenic hilum or adjacent to the lower splenic pole and cannot always be differentiated from enlarged lymph nodes (55) (Fig. 48.3).
Suggestions: If the sonographic examination of the abdomen reveals a splenomegaly, a systemic hematologic condition must be considered and all node-bearing areas of the abdomen should be explored for any lymphadenopathy (see pp. 14 and 21). Furthermore, portal hypertension should be excluded by measuring the luminal diameter of the splenic vein (20), portal vein, and superior mesenteric vein and by searching for portocaval collaterals. The size of the spleen should be measured accurately. Only by having a baseline measurement of the splenic size can subsequent examinations determine any interval growth. Questions that subsequent examinations might address, such as possible interval growth during therapy, should already be kept in mind during the initial examination. Neither size nor echogenicity of the spleen allows any inference as to the nature of the underlying condition.
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