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Diagnosis

Bedside assessments of splenic enlargement were clinically useful

ACP J Club. 1992 Mar-April;116:56. doi:10.7326/ACPJC-1992-116-2-056


Source Citation

Barkun AN, Camus M, Green L, et al. The bedside assessment of splenic enlargement. Am J Med. 1991 Nov; 91:512-8.


Abstract

Objective

To evaluate clinical assessment of splenic enlargement.

Design

Assessment of the physical examination of the spleen using specific bedside maneuvers compared with the results of abdominal ultrasonographic examination.

Setting

A university-affiliated hospital.

Patients

All inpatients who had abdominal ultrasound examination were eligible. Patients with splenomegaly and control patients matched for age, sex, height, and weight were selected over a 4-month period by a weekly review of ultrasound examination reports. 180 patients were eligible; 62 (34%) were excluded; and 245 (69%) of 345 possible examinations were completed.

Description of tests and diagnostic standard

3 internists did an abdominal examination of each patient consisting of the Traube space percussion and splenic percussion sign. After percussion, patients were sequentially assigned to undergo either the Middleton maneuver or the combination of supine palpation followed by right lateral decubitus palpation. The assessors were blinded to the patients' diagnoses. Ultrasound examinations were done by 1 physician blinded to initial ultrasound interpretations and the results of the clinical assessments. Splenic enlargement was defined as a sonographic cephalocaudad diameter ≥ 13 cm.

Main results

94 examinations of enlarged spleens were done in 43 patients and 151 examinations of normal spleens in 75 patients. Sensitivity and specificity of the splenic percussion sign were 79% (95% CI 64% to 90%) and 46% (CI 35% to 55%) {The likelihood ratio of a positive test (+LR) was 1.48 and of a negative test (-LR) was 0.45.}* The Traube space percussion had a sensitivity of 62% (CI 47% to 77%) and specificity of 72% (CI 60% to 82%) {+LR 2.24 and -LR 0.52}*. The Traube space percussion had greater diagnostic accuracy than the splenic percussion (68% vs 59%, P < 0.05). The Middleton, supine, and right lateral decubitus palpations were equally good discriminators for splenic enlargement, with areas under the receiver operating characteristic (ROC) curves of 0.73 ± 0.06, 0.79 ± 0.05, and 0.76 ± 0.06, respectively. The areas under the ROC curves for the Traube space percussion and for the 3 palpation maneuvers combined were similar. Palpation performed better among patients with percussion dullness than among those with percussion tympany (areas under the ROC curves 0.87 ± 0.04 and 0.55 ± 0.08, respectively; P < 0.001). Sensitivity and specificity for positive tests defined as those positive for both the Traube space percussion and palpation were 46% and 97%, respectively.

Conclusions

The Traube space percussion was as accurate as the splenic percussion sign, and took less time to do. The Middleton, supine, and right lateral decubitus palpations did equally well. Palpation was most useful in patients with percussion dullness.

Source of funding: Not stated.

Address for article reprint: Dr. S.A. Grover, Division of Clinical Epidemiology, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.

*Numbers calculated from data in article.


Commentary

Estimating spleen size is difficult. The spleen moves and slips away from the examiner's fingers. Because it enlarges anteriorly and posteriorly, spleen size must increase by 40% before becoming palpable. Only a small portion of the spleen protrudes beneath the costal margin, even when considerably enlarged. One text identified 12 methods of spleen examination dating to the early 19th century (1).

The Traube space is the area of resonance over the stomach. Older textbooks affirm that the Traube space dullness is useful in diagnosing pericardial effusion, left pleural effusion, left lower-lobe pneumonia, and massive cardiomegaly. Disagreement exists over its reliability in the diagnosis of splenomegaly.

Barkun and colleagues have used ROC analysis to assess various methods for detecting splenomegaly, including the Traube space percussion (TSP). ROC analysis is useful for assessing diagnostic accuracy when "threshold of perception" is unknown (2) and for allowing observers to quantitate their notion that a particular finding is "significant." TSP was as good as the most frequently used maneuvers for spleen examination, including orthodox palpation and percussion. Its value increased when combined with palpation.

TSP is a simple, rapid maneuver that is easily incorporated in the screening physical examination. I include TSP as part of my screening routine and use palpation as a confirmatory test if TSP reveals left upper quadrant dullness. I await a follow-up study on the value of auscultatory ("scratch") percussion, which I use frequently to detect organomegaly.

Thomas A. Parrino, MD
Veterans Affairs Medical CenterProvidence, Rhode Island, USA


References

1. Sapira JD. The art and science of bedside diagnosis. Baltimore: Urban and Schwarzenberg; 1990.

2. Barkun AN, Camus M, Meagher T, et al. Splenic enlargement and Traube's space: how useful is percussion? Am J Med. 1989;87:562-6.