The abnormal enlargement of the spleen (subdivided into mild, moderate and massive splenomegaly)

Mild: just palpable (1-3cm below the costal margin)

Moderate: between the costal margin and umbilicus (4-8cm below the costal margin)

Massive: crosses umbilicus and midline (>8cm)





A spleen should be palpable as a mass originating in the LUQ, with palpable splenic notch, moves inferomedially with inspiration, is not ballotable and which you are unable to get above


Other signs may be present depending on the underlying condition causing splenomegaly, for example:

Myeloproliferative causes such as chronic myeloid leukaemia and myelofibrosis may be associated with massive splenomegaly.

Patient may appear anaemic

Lymphadenopathy may be present due to an underlying lymphoproliferative process or associated infection


Chronic liver disease signs may be present as portal hypertension is a common cause of splenomegaly

Look for stigmata of infective endocarditis such as Oslers nodes, janeway lesions, finger clubbing and splinter haemorrhages

Look for features of rheumatoid arthritis suggesting Felty’s syndrome

Jaundice may be present – this could imply haemolytic anaemia



Very varied and depend on underling cause:

Splenomegaly can be an incidental finding or present with:

Weight loss


Noticeable lymphadenopathy


Night sweats – from haematological malignancy or infection


Abdominal pain – particularly if massive


Causes: It is often helpful to break causes of splenomegaly down into those which cause massive, moderate or mild splenomegaly.


Causes of Massive splenomegaly include: myeloproliferative disorders such as chronic myeloid leukaemia, acute myeloid leukaemia and myelofibrosis

Tropical infections such as malaria and visceral leishmaniasis



Causes of Moderate splenomegaly include: myeloproliferative disorders,

lymphoproliferative disorders such as chronic lymphocytic leukaemia and lymphoma, infiltrative conditions such as Gauchers disease and amyloidosis


Causes of Mild splenomegaly include: myelo and lymphoproliferative disorders, portal hypertension, infections such as infective endocarditis, Epstein Barr virus infection and viral hepatitis, haemolytic anaemia and autoimmune causes e.g. SLE.




Investigations for splenomegaly should be targeted to the most likely underlying cause and include:

Blood tests: FBC/blood film/U+E/LFTs/LDH/autoimmune screen/blood cultures

HIV test

Viral serology

CXR – looking for bihilar lymphadenopathy which may suggest an underlying lymphoproliferative process or infection

Malaria film if recent foreign travel to a malaria endemic area

Echo if infective endocarditis is suspected

CT thorax/abdo/pelvis if underlying malignancy suspected

Bone marrow aspirate and trephine if an underlying haematological process is likely

Lymph node biopsy



Depends on the underlying condition:

Myelo/lymphoproliferative conditions require referral to haematology for consideration of chemotherapy

Infective endocarditis suspected: TTE (transthoracic) +/- TOE (transoesophageal) for vegetations, at least 3 different sets of blood cultures from different sites at different time should be sent and discuss with cardiology and microbiology for appropriate treatment

If there is associated hypersplenism then patient may sometimes require splenectomy if treatment of underlying condition fails



Top tip: Splenomegaly patients appear in the exam frequently and the enlarged spleen may be the only sign to elicit. It is worth spending time practising spleen palpation technique as it is fairly obvious when candidates are not confident in this. However if you have been unable to pick up any signs including a spleen DONT MAKE IT UP as it is not uncommon for the examiners to use a normal abdomen in this station to throw candidates.

Written by Jo Corrado

Resources used to write this document are listed in the references section of this webpage