Wednesday, November 10, 2010

Cirrhosis: What Happens When The Spleen Is Enlarged ?

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Some patients with cirrhosis have enlarged livers and/or spleens.
The obstructed flow of blood through the portal vein (portal hypertension) causes the spleen to enlarge by causing an increase in pressure inside the vessels of the spleen. The spleen stores red and white blood cells and platelets (fragment of cells that are used to clot blood). An enlarged spleen traps platelets lowering levels in the blood which can lead to the inability of blood to clot. This is called Thrombocytopenia and is common in people with cirrhosis. Thrombocytopenia or thrombopenia in short is the presence of relatively few platelets in blood. Generally speaking, in human beings a normal platelet count ranges from 750,000 to 800,000 platelets per microliter of blood. These limits are determined by the 2.5th lower and upper percentile, so values outside this range do not necessarily indicate disease. One common definition of thrombocytopenia is a platelet count below 50,000 per microliter

A doctor can often feel (palpate) the lower edge of an enlarged liver below the right rib cage and feel the tip of the enlarged spleen below the left rib cage. However, x-rays and other imaging tests may be used to determine how large the spleen is. A cirrhotic liver also feels firmer and more irregular than a normal liver.
Q- What happens when the spleen is enlarged ?
Spleen is an important organ of the lymphatic system. It is found on the left upper side of the abdomen, between the 9th and 12th rib. The primary function of the spleen is to produce lymphocytes and plasma cells, which are used in humoral and cellular immune defense. Approximately half of the body’s monocytes are stored in this organ. These cells can easily transform into macrophages and dendritic cells, and assist in wound repair. Additionally, the spleen filters the blood and removes all the unwanted materials like cell debris and microorganisms as bacteria, viruses and fungi.

Furthermore, it monitors the red blood cells, eliminating those that are abnormal, damaged or too old to function properly. It also serves as a storehouse for various elements of the blood like platelets and white blood cells. In the absence of the spleen, the body becomes susceptible to diseases caused by bacteria and protozoa, and responsiveness to certain vaccines also decreases.Whenever the normal functioning of the body is hampered by disorders like cancer, anemia, malaria, tuberculosis, amyloidosis, cirrhosis, hepatitis and the like, the spleen becomes hyperactive, and starts entrapping and storing a large number of blood cells and platelets.

As the result, the platelet and blood cell count in the bloodstream begins to fall dramatically. Due to entrapment, the spleen grows in size, and as it grows, it traps in more and more blood cells and platelets. Eventually the overgrown spleen starts capturing and destroying the normal blood cells together with the abnormal ones. These blood cells and platelets clog the spleen and interfere with its normal function.

The characteristic symptom of spleen enlargement is severe pain in the abdomen and back. At times, the pain shoots up to the left shoulder. This happens when certain parts of the spleen begin to bleed and die due to inadequate supply of blood. The enlarged spleen also starts pressing the stomach, which leads to the feeling of fullness after eating a small amount of food or even without eating anything. Furthermore, as too many blood cells and platelets have been removed from the bloodstream, the body’s immune response begins to dwindle, symptoms of anemia emerge, and normal blood clotting process is also slows down.

Viral Hepat. 2010 Jul;17(7):488-92. Epub 2009 Oct 13.

Splenectomy and antiviral treatment for thrombocytopenic patients with chronic hepatitis C virus infection.

Department of Internal Medicine, Osaka Koseinenkin Hospital, Osaka, Japan.
Thrombocytopenic patients with chronic hepatitis C virus (HCV) infection are poor candidates for antiviral treatment with interferon (IFN), but no standard treatment for thrombocytopenia has yet been established. We evaluated the safety of splenectomy and its efficacy for the initiation and continuation of antiviral therapy.

From March 2003 to April 2006, 10 patients (mean age 62.5 years) with HCV-related cirrhosis, low platelet count (<==106 000/mm(3)) and splenomegaly (spleen size >==10 cm) underwent splenectomy.
Platelet counts significantly increased at 4-8 weeks after splenectomy [pre: 64 200 +/- 6900/mm(3)vs post 209 000 +/- 40 600/mm(3) (P = 0.004)].

No severe operative complications were observed.
All patients subsequently received antiviral therapy. Of the eight patients who were infected with HCV genotype 1 and had a high viral load (>==100 KIU/mL), four received combination therapy with pegylated IFNalpha-2b plus ribavirin, and the other four received standard IFNalpha-2b plus ribavirin.

One patient infected with HCV genotype 2 and another with HCV genotype 1 and a low viral load (less then 100 KIU/mL) were treated with pegylated IFNalpha-2a. Six patients achieved sustained virologic response (SVR).
Six patients achieved sustained virologic response (SVR). Among four patients who failed to achieve SVR, one was given retreatment with pegylated IFN plus ribavirin, and the other three received low-dose long-term IFN therapy.
Although this study was small, the treatment results were similar to those for patients without thrombocytopenia and suggested that splenectomy would not reduce the antiviral efficacy of IFNalpha-based treatment.

PMID: 19840366 [PubMed - indexed for MEDLINE]

Spleen Enlargement on Follow-Up Evaluation: A Noninvasive Predictor of Complications of Portal Hypertension in Cirrhosis
Annalisa Berzigotti
Address requests for reprints to: Annalisa Berzigotti, MD, Dipartimento di Medicina Interna, Cardioangiologia, Epatologia, Università di Bologna, Policlinico S. Orsola-Malpighi, Via Albertoni 15, 40138 Bologna, Italy. fax: (39) 051-6362210,
Paola Zappoli, Donatella Magalotti, Carolina Tiani, Valentina Rossi, Marco Zoli
Background & AimsSplenomegaly is observed in most but not all patients with cirrhosis, and has been detected more often in patients showing complications of portal hypertension. We aimed to test the hypotheses that spleen enlarges over time in cirrhosis, and that a progressive enlargement may be associated with portal hypertension–related events.
A total of 127 cirrhotic patients (Child–Pugh, 6.7 ± 1.7; range, 5–11), observed at our center and followed-up clinically, endoscopically, and with periodic abdominal ultrasound for at least 1 year, were included. Spleen diameter was recorded at each ultrasound examination. The change of spleen diameter over time was calculated. The occurrence of clinical complications of cirrhosis on follow-up evaluation was recorded.
ResultsAt inclusion, spleen diameter was 14.9 ± 3.1 cm; 83% of the patients had splenomegaly. Spleen was larger in patients with decompensated disease (n = 39) versus patients with compensated disease (n = 88) (16.1 ± 3.5 vs 14.5 ± 2.7; P = .012).
The mean follow-up period was 53 ± 37 months.
Spleen progressively enlarged over time (analysis of variance, P < .0001). A total of 46.4% of patients showed a spleen enlargement of 1 cm or more at 1 year. Over 5 years of follow-up evaluation patients showing spleen enlargement showed a higher actuarial probability of esophageal varices formation (84.6% vs 16.6%; P = .001) and growth (63.3% vs 20.6%; P = .001).
Among patients with compensated cirrhosis at inclusion, those showing a spleen enlargement had a higher actuarial probability of developing the first clinical decompensation of cirrhosis (51.1% vs 19.5%, P = .002).
Spleen enlargement at follow-up evaluation outlines a subgroup of cirrhotic patients at higher risk of complications of portal hypertension. Noninvasive monitoring of spleen diameter allows a prognostic stratification of cirrhotic patients.
.Abbreviations used in this paper: ANOVA, analysis of variance, CI, confidence interval, HVPG, hepatic venous pressure gradient, MELD, Model for End-Stage Liver Disease, OR, odds ratio, US, ultrasound.

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