Splenomegaly: Likelihood Ratios

Introduction: Splenomegaly, an enlarged spleen, may be found in many diagnoses, including infectious mononucleosis, lymphoma, and cirrhosis. Generally accepted cutoffs for an enlarged spleen are >250g, 12-13cm in length, 7cm in width, or 250cc in volume (PMID 8411607).

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The likelihood ratios of findings for Splenomegaly are listed below. See the left navigation bar to change the display.

Good Positive and Negative Likelihood Ratios

Finding	+LR	-LR	Comments, Study
Percussion Duplicate	4.8	0.2	Castell's method: The patient is placed in the supine position. Percussion is carried out in the lowest intercostal space in the left anterior axillary line in both expiration and full inspiration (Fig 4). In a normal examination, the percussion note re-mains resonant throughout this maneuver. Splenomegaly is diagnosed when the percussion note is dull or becomes dull on full inspiration. Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607
Palpation Duplicate	7.1	0.3	right lateral decubitus and supine With the patient in the right lateral decubitus position, the examiner's left hand is slipped from front to back around the left lower thorax, gently lifting the left lowermost rib cage anteriorly and medially. The tips of the fingers of the examiner's right hand are pressed gently just beneath the left costal margin, and the patient is asked to take a long, deep breath as the palpation of a descending spleen is sought. If none is felt, the procedureis repeated, lowering the right hand 2 cm toward the umbilicus each cycle, until the examiner is confident that a massive spleen has not been missed. (Some authorities suggest starting palpation over the lower abdomen and moving up toward the costal margin.) The same procedure can be carried out with the patient supine. Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607
Percussion Duplicate	9.8	0.4	Nixon's Method: The patient is placed in the right lateraldecubitus position. Percussion is initiated midway along the left costal margin and continued upward along a line perpendicular to the costal margin (Fig 3). In a normal examination, dullness extends no further than 8 cm above the costal margin. Splenomegaly is diagnosed when the upper limit of dullness extends more than 8 cm above the costal margin. Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607
Middleton's Maneuver	8	0.5	The patient is asked to lie flat with his or her left fist under the left costovertebral angle. The examiner is positioned to the patient's left, facing the patient's feet. The fingers of both the examiner's hands are curled under the left costal margin, and the patient is asked to take a long, deep breath as the palpation of a descending spleen is sought. Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607
Palpation Duplicate	7.3	0.5	all techinques Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607
Percussion Duplicate	2.2	0.5	Percussion of Traube's space: The patient is supine with the left arm slightly abducted for access to the entire Traube's space (after its description by Ludwig Traube who ascribed its disappearance to pleural effusion, not an enlarged spleen), defined by the sixth rib superiorly, the midaxillary line laterally, and the left costal margin inferiorly (see figure in paper). With the patient breathing normally, this triangle is percussed across one or more levels from its medial to lateral margins. Normal percussion yields a resonant or tympanitic note. Splenomegaly is diagnosed when the percussion note is dull. Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607

Good Positive Likelihood Ratio

Physical Exam

inf

0.8

i.e. routine physical exam

Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607

Poorly Diagnostic Findings

Palpation
Duplicate

1.8

0.6

supine, two-handed

Study: JAMA. 1993 Nov 10;270(18):2218-21. PMID 8411607