The spleen should enlarge more than 2 times to become palpable.
For Conventional palpation 2 handed technique is recommended
- The patient is asked to lie in supine position
- The left hand of examiner is placed posterolaterally over the left lower ribs.
- The right hand of examiner is placed on the abdomen with finger tips directing to left hypochondrium.
- Start palpating from the right iliac fossa towards left hypochondrium.
- Don't start palpating too close to the costal margin, a large spleen will be missed.
- As the Right hand is advanced closer to the left costal margin the left hand compresses firmly over the rib cage so as to enable a slightly enlarged soft spleen to be felt as it moves downwards at the end of inspiration.
- If the spleen is not palpable in the supine position, the patient must be rolled onto the right side towards the examiner with the left hip and knee flexed and palpation repeated.Place the other hand posteriorly to support the lower rib cage and repeat the examination. Here one begins to palpate close to the Left costal margin
Middletons maneuver for palpation of spleen
In this method the examiner stands on the left side of the patient facing the foot of the bed. The hooked fingers of the left hand are placed under the costal margin and with right hand pressure is exerted over the posterolateral aspect of the lower thorax. The patient is then asked to take a deep breath and spleen is felt at the end of deep inspiration
Note the following features if the spleen is palpable
- Measure the enlargement from the tip of the 10th costal cartilage on the Left side towards the right iliac fossa. (10th rib is in line with the long axis of the spleen)
- Movement with respiration - Well moving with respiration
- Consistency - Soft / firm
- Tenderness
- Notch
- Insinuation of the fingers between the mass and the costal margin is not possible.
- Not bimanually palpable and upper border cannot be felt.
Mild -1-2 cm
Moderate - 3-7 cm
Massive > 7 cm
Huge spleen can be bimanually palpable and becomes ballotable if ascites is present with splenomegaly.
Difference between spleen and left kidney
Features Spleen Lateral kidney
Movement with respiration Well moving Restricted movement
Notch Absent Present
Insinuation of the fingers Not Possible possible
Between costal margin and the organ
Direction of enlargement Towards RIF Towards lumbar region
Band of colonic resonance Present Absent
Bimanual palpation Not palpable Palpable
Ballotability Not ballotable Ballotable
Midline crossing Crosses Does not cross
