Splenomegaly

Last revised by Mohammadtaghi Niknejad on 21 Nov 2022

Splenomegaly refers to enlargement of the spleen. The upper limit of the normal adult splenic length is traditionally cited at 12 cm, but lengths upwards of 14 cm can be seen in normal, taller males 7.

Massive splenomegaly is variably defined, including when the spleen is 5 standard deviations above the mean normal volume (~943 cm34, heavier than 1.0 kg 5 or 1.5 kg 8, >14.5 cm true craniocaudal measurement on coronal CT 4, >15 cm on clinical exam 8, or at/below the umbilicus, extending into the pelvis and/or across the midline 4,8.

The causes of splenomegaly are protean, and can be thought of under several headings 3,8:

  • hematological disease
  • hemodynamic
  • infectious
  • storage diseases/metabolic/infiltrative disorders
  • neoplastic (non-hematologic)
  • traumatic
  • connective tissue disorders

It is sometimes helpful to consider those etiologies that may cause the spleen to grow especially large as a separate group 3,8:

The shape and orientation of a spleen make accurate linear measurement difficult. Since single length measurements are relatively inaccurate many volume-based approaches have been proposed. True volumetry is the most accurate but is rarely feasible in routine clinical practice. 

On sonographic assessment, a length of 12 cm is generally considered the upper limit of normal 15

On ultrasound the prolate ellipsoid formula is used most commonly 13

  • spleen volume (cm3) = 0.52 × length × anteroposterior dimension × width (cm)

A modified formula has been proposed to improve accuracy 14

  • spleen volume (cm3) = 0.524 × width × thickness × (maximum length + craniocaudal length) / 2

Single splenic measurements can be used to identify splenomegaly:

  • width (largest AP axial measurement) >10.6 cm 15
  • craniocaudal length
    • >9.5-10.5 cm for splenomegaly 4,15
    • >14.5 cm for massive splenomegaly 4
  • coronal oblique length >12 cm

The splenic index was first proposed to express splenic volume 10:

  • splenic index = length × width × thickness (cm)

The normal range of the index is 120-480 and this is considered the most reliable measurement for splenomegaly 15. Since the index does not have a unit, other formulas have been proposed for estimating splenic volume on cross-sectional imaging 5

  • spleen volume (cm3) = 30 + 0.58 × craniocaudal length × diameter × thickness (cm)

Where:

  • length is defined as the craniocaudal distance between the first and last slices in the axial plane where the spleen is depicted
  • diameter is the largest measurable long axis distance in the axial plane
  • thickness is the largest perpendicular dimension to the diameter in the axial plane

The normal range of the estimated volume in healthy individuals with this formula is 107.2 – 314.5 cm3 (mean: 214.6 cm3) 5.

The normal spleen size for any individual is substantially influenced by demographic factors, sex, and body habitus; e.g. a study using volumetry found a 236.89 ± 77.58 cm3 average normal spleen size, whilst thresholds of 314.47 and 430.84 cm3 were determined for mild and massive splenomegaly respectively 11. In contrast, a study done by Japanese researchers has found much lower values in a different patient population for average spleen volume (112 cm3) and normal range (32-209 cm3) 12. Furthermore, it has been also shown that normal spleen size is influenced by sex and body habitus, with men, and taller or heavier individuals having longer and larger spleens 13

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Cases and figures

  • Figure 1: splenic deposits in CLL
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  • Case 1
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  • Case 2
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  • Case 3
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  • Case 4 : with splenic infarct
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  • Case 5 : CML with splenic Infarction
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  • Case 6 : CML with massive splenommegaly
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  • Case 7: infectious mononucleosis
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  •  Case 8 : lymphoma
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  • Case 9: myelofibrosis
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  • Case 10: on abdominal x-ray
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  • Case 11: with sickle cell disease
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  • Case 12: with leukemia
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  • Case 13: Lymphoma: Lugano classification
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  • Case 14 : Gaucher disease
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  • Case 15 : Wilson's disease and cirrhosis
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  • Case 16
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  • Case 17
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  • Case 18: cirrhosis
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  • Case 19: cirrhosis
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  • Case 20: non-Hodgkin lymphoma
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  • Case 21
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