STUDY - Technical - New Dacian's Medicine
Lymphadenopathy
and Splenomegaly (2)
Translation Draft
Let's start with a few elements about the structure and function of the spleen. The spleen is a reticuloendothelial organ that has its embryological origin in the dorsal mesogastrum at week 5 of gestation. It appears as small islands that migrate into the normal adult location of the left hypochondrium and attaches to the stomach through the gastrosplenic ligament and kidneys through the splenorenal ligament. When the islands do not unite into a single table, about 20% of people, spline accessories appear.
The function of the spleen was not well known. Galen believed that the spleen was the source of the "white ball" or melancholy, and the word "hypochondria" (literally below the ribs) and the expression "to let go of the spleen" attest to the belief that the spleen has an important influence on the psyche and emotions. Some of its secrets, but not all, have been discovered by science. in humans, its physiological functions seem to be as follows: 1. maintaining qualitative control of erythrocytes in the red pulp, by eliminating old or defective erythrocytes (the spleen achieves this by the unique organization of the parenchyma and its vascularization), 2. synthesis of antibodies in the white pulp and 3. elimination of bacteria and erythrocytes coated with antibodies.
An increase in its normal functions leads to splenomegaly, with or without hypersplenism. The spleen consists of red pulp and white pulp, which are terms used by Malpighi for sinuses filled with reticulocytes and for reticuloendothelial cell cords and white lymphoid follicles found abundantly in the red pulp matrix. The spleen participates in portal circulation. The reason for this is unknown, but it is assumed that the low pressure allows a less rapid flow and decreases the alteration of normal erythrocytes.
Blood flow to the spleen is approximately 150 ml/ min through the splenic artery, which branches into the central arteries. Some of the blood passes from the arterioles into the capillaries and then into the splenic veins and comes out of the spleen, but most of the blood of the central arterioles passes into the sinuses and cords bordered by macrophages. Blood that has entered the sinuses returns to circulation through the splenic veins, but the one that has entered the cords is subject to a quality check.
In order to return to circulation, the erythrocytes in the cords must slip through the cracks of their wall and pass into the sinuses leading to the venrules. Old erythrocytes are less deformable and are retained in cords, where they are destroyed and their components recycled. Cytoplasmic inclusions in erythrocytes, such as parasites, nuclear residues (Howell-Jolly bodies) or denatured hemoglobin (Heinz bodies) are removed after passing through cracks, a process called burial. The selection of dead or altered erythrocytes and the elimination of inclusions is done quickly, because the time during which blood passes through the spleen is only slightly higher than in other organs.
The spleen is also capable of helping the host to adapt to a hostile environment. It has at least three adaptive functions: 1. removal of bacteria and particles from the blood, 2. generation of a response to pathogens and 3. generation of cellular components of the blood if the marrow cannot cover the demand (i.e. extramedular hematopoiesis).
The last adaptive function is a resumption of the blood formation function, which the spleen performed during gestation. In some animals, the spleen plays a role in vascular adaptation to stress, as it stores erythrocytes (often hemoconcentrated with a higher than normal haematocrit) under normal conditions and contracts after beta-adrenergic stimulation, ensuring the animal a self-transfusion and improving oxygen transport capacity.
However, the normal human spleen does not seize or store erythrocytes or contract in response to sympathetic stimulation. The normal human spleen contains about one third of the total number of platelets in the body and a significant number of bordered neutrophils. these sequestered cells are available when response to an infection or bleeding is required.
As for the patient's approach let's start with the clinical evaluation! The most common symptoms caused by conditions of interest to the spleen are pain and feeling of weight in the left hypochondrium. The pain can be caused by acute edema of the spleen, the stretching of the capsule, the infarction or inflammation of the capsule. For many years it was thought that splenic infarction was clinically silent, which is sometimes true.
However, Soma Weiss, in his classic 1942 report on a Harvard medical student's self-observations of the clinical evolution of subacute bacterial endocarditis, states that pain in the left hypochondrium and severe pleuritic thoracic may accompany thromboembolic occlusion of blood flow in the spleen. Vascular occlusion, with heart attack and pain, is commonly found in children with bouts of sickle cell disease.
The rupture of the spleen, caused either by trauma or by an infiltrating disease that destroys the capsule, can lead to intraperitoneal bleeding, shock and death. The rupture itself can be painless. A palpable spleen is the major physical sign caused by the disease that affects the spleen and suggests that the organ is enlarged. Normal spleen weighs less than 250 g, decreases in volume with age, normally is entirely in the lower part of the chest, has a maximum cefaloaudal diameter of 13 cm at ultrasound or maximum length of 12 cm and/ or 7 cm when scanning with radioisotopes, and is usually non-palpable.
However, a palpable spleen was found in about 3% of "verified", young, asymptomatic males. The 3-year follow-up of these individuals revealed that 30% of these students still have a palpable spleen, with no increase in morbidity. After 10 years, no evidence of lymphoid malignancy was observed. Moreover, in some tropical countries the incidence of splenomegaly reaches 60%.
Thus, the presence of a palpable spline does not always indicate the existence of a disease. Even when a disease is present, splenomegaly may not be a sign of the primary disease, but rather a reaction to it. For example, in patients with Hodgkin's disease, only two-thirds of palpable spleens show an involvement of the neoplastic process.
Physical examination of the spleen is done first by palpation and percussion. The inspection may reveal a formation in the left hypochondrium that descends into the inhale, which corresponds to a very enlarged spline. Auscultation can cause a venous murmur or a rub. Palpation can be done bimanually, by baling and palpation from the top (Middleton maneuver). For bimanual palpation, which is at least as effective as other techniques, the patient is in clinostatism with his knees raised.
The examiner's left hand is placed at the bottom of the ribcage and pushes the spleen towards the costal rim, allowing the fingertips of the right hand to feel the tip of the spleen, which descends as the patient breathes slowly, quietly and deeply. The palpation begins with the right hand placed in the lower left quadrant with a gradual movement towards the left costal rim, thus identifying the lower edge of a much enlarged spline.
When the tip of the spleen is felt, its size is assessed as the number of centimeters below the left costal rim from an arbitrary point chosen, i.e. 10-15 cm from the navel or from the xyfosternal junction. This allows many examiners to compare the data found or the first examiner to determine the size changes that have occurred in the meantime. biannual palpation in the right lateral decubit does not bring anything in addition to the examination in clinostatism.
The percussion of splenic matteness is achieved by one of three techniques described by Nixon, Castell and Barkum: The Nixon method is characterized by placing the patient in the right lateral decubit, so that the spleen is above the colon and stomach. Percussion starts at the lowest level of pulmonary sound on the posterior axillary line and descends diagonally towards the anterior and medial costal rim. The upper edge of the matte is normally 6-8 cm above the costal rim. The matte ness greater than 8 cm in the adult is assumed to indicate the enlargement of the spleen. The Castell method "has" the patient placed in clinostatism, percussion in the lowest intercostal space (8 or 9) on the anterior axillary line causing a resonant area if the spleen has normal dimensions. This happens during exhalation or deep breath.
Matity to percussion in deep breath suggests splenomegaly. Percussion in the Traube semi-lunar space (the limits of the Traube space are the 6th upper rib, the average lateral axillary line and the lower left rib) "has" the patient placed in clinostatism with the right arm slightly raised. During normal breathing, this space is rotated from the medial to the external edge, producing a normal resonant sound. The mattity of percussion suggests splenomegaly.
Studies comparing percussion and palpation methods with data obtained by ultrasound and standard scintigraphy revealed a sensitivity of more than 50% for palpation and over 70% for percussion. Reproducibility between examiners is better for palpation than for percussion. Both techniques are less effective in obese patients or those who have just eaten. Thus, the techniques of the physical examination of palpation and percussion are at least imprecise.
It was recommended that the examiner first perform the percussion, and, if positive, continue with palpation (if the spleen is palpable, then there is a high probability that splenomegalia will be present). However, not all masses in the left hypochondrium are enlarged spline (gastric or colonic tumors and pancreatic and renal cysts or tumors can mimic splenomegalia).
All right, next time (when I complete the posts related to adenopathy and splenomegaly - then I'll do quite a few posts about nutrition)!!!
Let's start with a few elements about the structure and function of the spleen. The spleen is a reticuloendothelial organ that has its embryological origin in the dorsal mesogastrum at week 5 of gestation. It appears as small islands that migrate into the normal adult location of the left hypochondrium and attaches to the stomach through the gastrosplenic ligament and kidneys through the splenorenal ligament. When the islands do not unite into a single table, about 20% of people, spline accessories appear.
The function of the spleen was not well known. Galen believed that the spleen was the source of the "white ball" or melancholy, and the word "hypochondria" (literally below the ribs) and the expression "to let go of the spleen" attest to the belief that the spleen has an important influence on the psyche and emotions. Some of its secrets, but not all, have been discovered by science. in humans, its physiological functions seem to be as follows: 1. maintaining qualitative control of erythrocytes in the red pulp, by eliminating old or defective erythrocytes (the spleen achieves this by the unique organization of the parenchyma and its vascularization), 2. synthesis of antibodies in the white pulp and 3. elimination of bacteria and erythrocytes coated with antibodies.
An increase in its normal functions leads to splenomegaly, with or without hypersplenism. The spleen consists of red pulp and white pulp, which are terms used by Malpighi for sinuses filled with reticulocytes and for reticuloendothelial cell cords and white lymphoid follicles found abundantly in the red pulp matrix. The spleen participates in portal circulation. The reason for this is unknown, but it is assumed that the low pressure allows a less rapid flow and decreases the alteration of normal erythrocytes.
Blood flow to the spleen is approximately 150 ml/ min through the splenic artery, which branches into the central arteries. Some of the blood passes from the arterioles into the capillaries and then into the splenic veins and comes out of the spleen, but most of the blood of the central arterioles passes into the sinuses and cords bordered by macrophages. Blood that has entered the sinuses returns to circulation through the splenic veins, but the one that has entered the cords is subject to a quality check.
In order to return to circulation, the erythrocytes in the cords must slip through the cracks of their wall and pass into the sinuses leading to the venrules. Old erythrocytes are less deformable and are retained in cords, where they are destroyed and their components recycled. Cytoplasmic inclusions in erythrocytes, such as parasites, nuclear residues (Howell-Jolly bodies) or denatured hemoglobin (Heinz bodies) are removed after passing through cracks, a process called burial. The selection of dead or altered erythrocytes and the elimination of inclusions is done quickly, because the time during which blood passes through the spleen is only slightly higher than in other organs.
The spleen is also capable of helping the host to adapt to a hostile environment. It has at least three adaptive functions: 1. removal of bacteria and particles from the blood, 2. generation of a response to pathogens and 3. generation of cellular components of the blood if the marrow cannot cover the demand (i.e. extramedular hematopoiesis).
The last adaptive function is a resumption of the blood formation function, which the spleen performed during gestation. In some animals, the spleen plays a role in vascular adaptation to stress, as it stores erythrocytes (often hemoconcentrated with a higher than normal haematocrit) under normal conditions and contracts after beta-adrenergic stimulation, ensuring the animal a self-transfusion and improving oxygen transport capacity.
However, the normal human spleen does not seize or store erythrocytes or contract in response to sympathetic stimulation. The normal human spleen contains about one third of the total number of platelets in the body and a significant number of bordered neutrophils. these sequestered cells are available when response to an infection or bleeding is required.
As for the patient's approach let's start with the clinical evaluation! The most common symptoms caused by conditions of interest to the spleen are pain and feeling of weight in the left hypochondrium. The pain can be caused by acute edema of the spleen, the stretching of the capsule, the infarction or inflammation of the capsule. For many years it was thought that splenic infarction was clinically silent, which is sometimes true.
However, Soma Weiss, in his classic 1942 report on a Harvard medical student's self-observations of the clinical evolution of subacute bacterial endocarditis, states that pain in the left hypochondrium and severe pleuritic thoracic may accompany thromboembolic occlusion of blood flow in the spleen. Vascular occlusion, with heart attack and pain, is commonly found in children with bouts of sickle cell disease.
The rupture of the spleen, caused either by trauma or by an infiltrating disease that destroys the capsule, can lead to intraperitoneal bleeding, shock and death. The rupture itself can be painless. A palpable spleen is the major physical sign caused by the disease that affects the spleen and suggests that the organ is enlarged. Normal spleen weighs less than 250 g, decreases in volume with age, normally is entirely in the lower part of the chest, has a maximum cefaloaudal diameter of 13 cm at ultrasound or maximum length of 12 cm and/ or 7 cm when scanning with radioisotopes, and is usually non-palpable.
However, a palpable spleen was found in about 3% of "verified", young, asymptomatic males. The 3-year follow-up of these individuals revealed that 30% of these students still have a palpable spleen, with no increase in morbidity. After 10 years, no evidence of lymphoid malignancy was observed. Moreover, in some tropical countries the incidence of splenomegaly reaches 60%.
Thus, the presence of a palpable spline does not always indicate the existence of a disease. Even when a disease is present, splenomegaly may not be a sign of the primary disease, but rather a reaction to it. For example, in patients with Hodgkin's disease, only two-thirds of palpable spleens show an involvement of the neoplastic process.
Physical examination of the spleen is done first by palpation and percussion. The inspection may reveal a formation in the left hypochondrium that descends into the inhale, which corresponds to a very enlarged spline. Auscultation can cause a venous murmur or a rub. Palpation can be done bimanually, by baling and palpation from the top (Middleton maneuver). For bimanual palpation, which is at least as effective as other techniques, the patient is in clinostatism with his knees raised.
The examiner's left hand is placed at the bottom of the ribcage and pushes the spleen towards the costal rim, allowing the fingertips of the right hand to feel the tip of the spleen, which descends as the patient breathes slowly, quietly and deeply. The palpation begins with the right hand placed in the lower left quadrant with a gradual movement towards the left costal rim, thus identifying the lower edge of a much enlarged spline.
When the tip of the spleen is felt, its size is assessed as the number of centimeters below the left costal rim from an arbitrary point chosen, i.e. 10-15 cm from the navel or from the xyfosternal junction. This allows many examiners to compare the data found or the first examiner to determine the size changes that have occurred in the meantime. biannual palpation in the right lateral decubit does not bring anything in addition to the examination in clinostatism.
The percussion of splenic matteness is achieved by one of three techniques described by Nixon, Castell and Barkum: The Nixon method is characterized by placing the patient in the right lateral decubit, so that the spleen is above the colon and stomach. Percussion starts at the lowest level of pulmonary sound on the posterior axillary line and descends diagonally towards the anterior and medial costal rim. The upper edge of the matte is normally 6-8 cm above the costal rim. The matte ness greater than 8 cm in the adult is assumed to indicate the enlargement of the spleen. The Castell method "has" the patient placed in clinostatism, percussion in the lowest intercostal space (8 or 9) on the anterior axillary line causing a resonant area if the spleen has normal dimensions. This happens during exhalation or deep breath.
Matity to percussion in deep breath suggests splenomegaly. Percussion in the Traube semi-lunar space (the limits of the Traube space are the 6th upper rib, the average lateral axillary line and the lower left rib) "has" the patient placed in clinostatism with the right arm slightly raised. During normal breathing, this space is rotated from the medial to the external edge, producing a normal resonant sound. The mattity of percussion suggests splenomegaly.
Studies comparing percussion and palpation methods with data obtained by ultrasound and standard scintigraphy revealed a sensitivity of more than 50% for palpation and over 70% for percussion. Reproducibility between examiners is better for palpation than for percussion. Both techniques are less effective in obese patients or those who have just eaten. Thus, the techniques of the physical examination of palpation and percussion are at least imprecise.
It was recommended that the examiner first perform the percussion, and, if positive, continue with palpation (if the spleen is palpable, then there is a high probability that splenomegalia will be present). However, not all masses in the left hypochondrium are enlarged spline (gastric or colonic tumors and pancreatic and renal cysts or tumors can mimic splenomegalia).
All right, next time (when I complete the posts related to adenopathy and splenomegaly - then I'll do quite a few posts about nutrition)!!!
Pleasant weekend,
understanding, love and gratitude!
Dorin, Merticaru