Imaging

Splenomegaly

Preliminary Diagnosis: Splenomegaly

I. What imaging technique is first-line for this diagnosis

  • Ultrasound (Gray scale and Doppler).

II. Describe the advantages and disadvantages of this technique for diagnosis of splenomegaly.

Advantages

  • Spleen is easily evaluated with ultrasound.

  • Able to provide accurate measurement of splenic volume.

  • May detail secondary pathology within the spleen and differentiate between focal lesions and diffuse splenomegaly.

  • Clinical information and additional radiographic findings may be helpful to determine a differential diagnosis for splenomegaly.

  • Relatively inexpensive and portable imaging modality.

  • Does not use ionizing radiation.

Disadvantages

  • Shadowing from ribs, overlying bowel gas and overlying lung can obscure visualization of the deeper structures.

  • Much longer imaging time compared to CT.

  • Quality of the exam is dependent upon the sonographer.

  • Lower resolution than CT or MRI.

III. What are the contraindications for the first-line imaging technique?

  • No significant contraindications exist.

IV. What alternative imaging techniques are available?

  • CT with intravenous (IV) contrast.

  • MRI with IV contrast.

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of splenomegaly.

CT with intravenous contrast

Advantages

  • Relatively quick imaging procedures that require minimal patient cooperation and are less susceptible to motion artifact.

  • Able to provide accurate measurement of splenic volume.

  • May detail secondary pathology as well as perfusion abnormalities within the spleen and differentiate between focal lesions and diffuse splenomegaly.

  • Clinical information and additional radiographic findings may be helpful to determine a differential diagnosis for splenomegaly.

Disadvantages

  • Exposure to ionizing radiation.

  • Contrast can cause renal injury and allergic reaction.

  • May not be able to fully characterize focal lesions, and ultrasound will be recommended.

MRI with IV contrast

Advantages

  • Able to provide accurate measurement of splenic volume.

  • May detail secondary pathology as well as perfusion abnormalities within the spleen and differentiate between focal lesions and diffuse splenomegaly.

  • Clinical information and additional findings may be helpful to determine a differential diagnosis for splenomegaly.

  • Does not utilize ionizing radiation.

Disadvantages

  • Expensive.

  • Time-consuming imaging modality that requires marked patient cooperation to limit motion artifact.

VI. What are the contraindications for the alternative imaging techniques?

CT

  • CT imaging is contraindicated in a pregnant patient, especially within the first two trimesters.

  • Contrast is contraindicated with Cr greater than 1.6.

  • Contrast is contraindicated with history of allergic reaction without premedication.

MR

  • MR imaging is contraindicated in patients with non-MR compatible metallic hardware or foreign bodies.

  • MR imaging with intravenous contrast requires that the patient have good renal function with a GFR greater than 60. Administration of intravenous contrast is decided individually on a case-by-case basis with a GFR greater than 30 and less than 60.

  • Nephrogenic systemic fibrosis (NSF) is a concern with gadolinium contrast agents if the patient has a GFR below 30 and a systemic inflammatory condition.

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