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Conferences and Reviews


The Clinical Diagnosis of Splenomegaly
JACK C. YANG, MD, MPH, and LELAND S. RICKMAN, MD, San Diego, Califomia, and SONYA K. BOSSER, MD, Bethesda, Maryland

Assessing for the presence of splenomegaly is an important component of the physical examination. Although several methods of palpation and percussion of the spleen have been described, until recently they have not been validated by noninvasive imaging techniques such as ultrasonography, radionuclide scanning, and computed tomography that offer objective means to assess splenomegaly. We review the literature comparing various physical examination techniques with noninvasive imaging modalities and conclude that palpation and percussion of the spleen are complementary but frequently insensitive and that further studies are needed to evaluate the efficacy of specific diagnostic methods.
(Yang JC, Rickman LS, Bosser SK: The clinical diagnosis of splenomegaly. West J Med 1991 Jul; 155:47-52)

Since the recent development of sophisticated imaging techniques, some might consider the clinical impression of splenic size to be obsolete. The initial evaluation of a patient, however, still depends largely on the physical examination. The spleen normally lies in the left hypochondrium situated between the gastric fundus and diaphragm along the long axis of the left tenth rib. Its lower pole extends forward only as far as the midaxillary line.' Normal spleen weight varies with age, sex, body weight, and body surface area and can range from 58 grams in a 79-year-old woman to 170 grams in a 20-year-old man.2 Insofar as its location should preclude palpation, a spleen that is detected on clinical examination may indicate the presence of disease and is likely to influence the choice of the differential diagnosis. Arkles and co-workers went to considerable length using scintigraphic scanning to conclude that "a palpable spleen is not necessarily enlarged or pathological" but conceded that "it is still important to exclude a pathological basis for this clinical finding."'3P17) Although the spleen was palpated in nearly 3% of healthy first-year college students,4 splenomegaly should suggest a variety of infectious, neoplastic, or congestive

be discussed. Also, although the physical examination may aid in staging a disease (such as the lymphomas), a definitive diagnosis of splenic involvement for therapeutic purposes should still come from the tissue examination. Methods of Physical Examination Palpation Three techniques for palpating the spleen are well known: bimanual palpation, ballottement, and palpation from above the patient. With bimanual palpation (Figure 1), the examiner's left hand is placed on the lower left rib cage and pulls the overlying skin toward the costal margin, allowing the fingertips of the right hand to sink under the ribs. The fingertips feel for the spleen's descent along the intercostal surface as the diaphragm contracts and descends with deep inspiration. The examination is repeated for the length of the costal margin and may be aided by having the patient lie partly on his or her right side. The second technique is ballottement (Figure 2), which may be accomplished in the same position as the first. The examiner's left hand reaches over and around to the patient's left posterior chest wall and lifts, using the right hand to receive impulses that may be transmitted by an enlarged organ. The third technique is done with the examiner at a supine patient's left shoulder (Figure 3). The patient places his or

disorders.5
Before the introduction of ultrasonography, radionuclide scintigraphic scanning, computed tomography (CT), and magnetic resonance imaging (MRI), physicians relied on examination techniques such as those described by Elmer and Rose in 1935. In Physical Diagnosis,6 they apply the traditional principles of inspection, auscultation, palpation, and percussion. For example, splenomegaly may manifest as a left upper quadrant bulge on inspection, auscultation might uncover a venous hum suggesting congestion, and palpation and percussion may reveal solid tissue filling a space normally occupied by hollow organs.
Many modern texts on the physical examination offer terse descriptions of physical diagnostic techniques and fail to correlate or compare the various clinical methods for evaluating splenic size.'`9 Because this information could affect the diagnosis and treatment, we review various clinical methods for detecting splenomegaly, noninvasive modalities for evaluating splenic size, and studies correlating the clinical assessment of splenomegaly with noninvasive imaging. Arteriography is considered an invasive modality and will not

Figure 1.-The spleen is palpated bimanually with the patient in a supine position and the examiner at the patient's right side. The examiner's left hand is placed on the lower left rib cage, and the right hand explores for the spleen.

From the Department of Surgery. University of California, San Diego, Medical Center (Dr Yang); the Division of Infectious Diseases, University of California, San Diego, Treatment Center (Dr Rickman); and the Department of Internal Medicine. National Naval Medical Center, Bethesda, Maryland (Dr Bosser). Reprint requests to Leland S. Rickman, MD. Division of Infectious Diseases, UCSD Treatment Center, 2760 5th Ave, Ste 300, San Diego. CA 92103.

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ABBREVIATIONS USED IN TEXT CT = computed tomography MRI = miagnetic resonance imiaging

I
her left fist beneath the back at the level of the 11 th rib to push the spleen forward. The examiner then reaches over, curling his or her fingertips under the left costal margin, and palpates with the patient taking deep breaths. Falsely abniormal ("false-positive") fiindings with palpation may occur in patients with flattened left hemidiaphragms due to chronic obstructive lung disease or in patients with prominent diaphragmatic excursions. Falsely normal ("false-negative") findings may occur in patients with obesity or ascites, narrow costal angles, a high diaphragm, or when another organ expands into the left upper quadrant.10 A special circumstance exists when palpation may be relatively contraindicated, as in patients with infectious mononucleosis, in whom there is a small risk of splenic rupture with vigorous palpation.
Percussion Nixon in 1954 described a method of detecting splenomegaly based on percussion (Figure 4).11 The patient is placed on the right side so that the spleen lies above both the stomach and colon, thus permitting determination of both its upper and lower border of dullness. According to Nixon:
Percussion is initiated at the lower level of pulmonary resonance in approximately the posterior axillary line and carried down obliquely on a general perpendicular line toward the lower midanterior costal margin. Normally the upper border of dullness is measured 6 to 8 centimeters above the costal margin. Dullness increased over 8 cm is indicative of splenic enlargement in the adult."

Figure 4.-The drawing depicts Nixon's method of percussing the spleen.'

In the original article, Nixon's method was confirmed in his experience '"by successful splenic aspiration biopsies in 60 cases." I 1 Castell in 1967 published another method of percussion to detect splenomegaly (Figure 5)12:
With the patient in the supine position, percussion in the lowest intercostal space (eighth or ninth) in the left anterior axillary line usually produces a resonant note if the spleen is normal in size. Furthermore, the resonance persists with full inspiration. As the spleen enlarges, the lower pole is displaced inferiorly and medially. This may produce a change in the percussion note in the lowest left interspace in the anterior axillary line from resonance to dullness with full inspiration. The percussion sign is considered positive, therefore, when such a change is noted between full expiration and full inspiration.

Figure 2.-The drawing shows the positioning of the examiner's hands during ballottement of the spleen.

Although Castell's article is widely cited, the method described was validated in only ten male patients who had a positive percussion sign and a nonpalpable spleen, these findings being compared with those of a radioisotope scan using erythrocytes labeled with chromium 51. His ten "normal" controls were male patients with diseases in which hepatosplenomegaly was "not expected." Castell found that the mean spleen size was greater in patients with a positive percussion sign than in controls. In another study, Castell and associates noted a difference in the estimation of liver size with light versus firm percussion, where light percussion correlated with the findings of a sonogram. but firm percussion tended to underestimate the liver size.'3 Whether, however, this difference in percussion technique is relevant to splenic examination is unknown. A third method is percussion of Traube's semilunar space (Figure 6). Barkun and colleagues studied the sensitivity of this technique (discussed later)'4 and defined the borders as the left sixth rib superiorly, the left midaxillary line laterally, and the left costal margin inferiorly. Traube (1818-1876) recognized dullness over the usually tympanitic gastric air bubble as a sign of left pleural thickening in association with a tuberculous empyema.'5 Traube never clearly delineated the space that bears his name, nor did he associate left upper quadrant dullness with splenomegaly. Physicians today recognize that an enlarged spleen may displace Traube's space to the right of its defined position. 16

Figure 3.-The spleen is palpated from above.

Imaging Studies Plaini Radiographs Roentgenographic examination can visualize the splenic shadow primarily because of its juxtaposition to gas in the stomach and the splenic flexure of the colon. Whitley and co-workers in 1966 studied 81 routinely

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taken abdominal films in which the spleen was seen and compared these with splenic weight by autopsy (done within eight weeks of the radiograph).17 The best estimator of spleen weight in their study was the vertical length times the width of the spleen shadow at midpoint, with a correlation coefficient of .91. In general, however, plain films do not dependably outline the spleen and are mostly helpful only in cases of gross splenomegaly. 18-20

Ultrasonography The abdominal ultrasonogram is a safe, quick, noninvasive, and mobile method for assessing the splenic volume. Kardel and associates in 1971 developed a method for calculating liver and spleen volumes based on parallel ultrasound scanning sections and compared these with the actual organ weights following splenectomy in nine patients suffering from hematologic diseases.21 The correlation coefficient for their calculations was .98. Niederau and colleagues in 1983 prospectively examined 915 healthy blood donors by ultrasonography.22 They concluded that "longitudinal and transverse diameters are sufficient to estimate the size of the spleen, since both measurements correlate well with the diagonal diameter and cross-sectional area."22"54'" Other studies using similar simplified calculations in lieu of a more complicated integration of cross sections have also shown good results.23-25 On transverse sonograms of the abdomen, a rule of thumb has been that a normal-sized spleen does not extend anterior to an imaginary line drawn tangentially to the anterior border of the aorta and parallel to the back (Figure 7). Leopold and Asher, in the evaluation of more than 3,000 patients,23 found this to be a generally reliable index in more than 90 % of their subjects for determining the presence of splenomegaly. False-positive studies occurred with long, thin spleens that extended more anteriorly but were of normal volume. Although results obtained are often operator dependent, most

Figure 6.-Traube's space is shown, as defined by Barkun et al.14

ultrasound studies have shown both high sensitivity and specificity for the detection of splenomegaly. Nuclear Scans Several studies have shown radionuclide scanning to be accurate in predicting and assessing spleen size, but this method is limited by its immobility, relatively long total acquisition time, and cost. Also, its accuracy depends on the vascular integrity and function of the spleen.26 Holzbach and co-workers in 1962 used 51Cr-labeled erythrocytes in 55 patients to determine splenic size.27 Their subjects were 22 patients with cirrhosis and 23 controls without evidence of hepatic or splenic disease. In the other 10 cases, the spleen was examined postoperatively or at autopsy and the findings showed "good" correlation with scan activity (a correlation coefficient was not calculated). Rollo and DeLand in 1970 estimated spleen mass from radionuclide images using technetium Tc 99m sulfur colloid and merisoprol Hg 197 in 21 patients, comparing the images with the actual mass obtained at postmortem examination.28 Both posterior and left lateral images and then only posterior images revealed less than 13% error in all cases (mean error, 7%). In a similar study, Larson and associates, using 99mTc-sulfur colloid, scanned 26 "normal" control subjects

Figure

5.-In

Castell's method"

of

percussing

the

spleen,

the examiner per-

cusses at

space

the intersection of the left anterior axillary line and 9th intercostal (marked). The lower diagonal line points to normal spleen.

Figure 7.-In evaluating for the presence of splenomegaly with ultrasonography, a normal-sized spleen should not extend anterior to an imaginary line drawn tangentially to the anterior border of the aorta and parallel to the back (from Leopold and Asher23).

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SPLENOMEGALY

and 17 patients who either would undergo splenectomy (n = 14) or their spleens would be examined at autopsy (n = 3). 29 In their calculations, posterior length correlated best with actual weight (r = .96). Using computed tomographs as standards, Strauss and colleagues found that the accuracy of in vivo nuclear scans was limited mostly by nonhomogenous tracer distribution and respiratory artifact caused by long acquisition times.30 One advantage unique to nuclear scanning has been in the detection of "ectopic," "aberrant," or "floating" spleensthat is, spleens that are not located in the left upper quadrant. In one case, both ultrasonography and CT scan delineated a large midabdominal mass that was thought to be a tumor until the colloidal uptake study showed the mass to be a congested, displaced spleen.31 Nuclear scanning has also been effective in detecting accessory spleens in patients with recurrent immune thrombocytopenia.32

Blendis and co-workers in 1970 also assessed observer variation in both clinical and radiologic examinations for hepatosplenomegaly.4" They concluded that a plain film is a helpful adjunct to palpation in the assessment of hepatosplenomegaly because it is less subject to observer variation and is more easily quantifiable. This was one of the last studies of its kind because the new imaging modalities were just around the corner.

Computed Tomography and Magnetic Resonance Imaging Neither CT nor MRI is limited by overlying ribs or aerated lungs and thus does not suffer some of the technical difficulties encountered with ultrasonography. In addition, the omental and mesenteric fat surrounding much of the spleen often permits a sharper demarcation of the capsule and hilar vasculature even without contrast media. Disadvantages with these methods include both that some patients cannot be transported to or placed on the scanner and the tests are expensive. Technical artifacts arise with motion and dynamic scanning. Heymsfield and co-workers in 1979 correlated the calculated mass from CT scans in two cadavers with the autopsy specimens of liver, kidney, or spleen34 and found a mean difference of less than 5%. Breiman and colleagues obtained CT scans in eight patients before splenectomy and predicted the spleen volumes using four mathematic integration techniques.35 Using 1-cm spaced scanning produced a mean error of 3.59% and 2-cm spaced scans only 3.65%. Cools and associates sought to simplify calculations and retrospectively studied 50 abdominal CT scans.36 Using only length and maximal width, they showed a correlation coefficient of .95 compared with previous methods of summing contiguous areas. Stark and Bradley in their text on MRI note that "The diagnosis of splenomegaly is based on imprecise morphologic criteria analogous to CT."'371t(23 In addition, "Patients with hematologic disorders and splenomegaly generally show no consistent pattern of signal intensity alteration, and, except for enlargement, the spleen is unchanged on MR images."37tp1123) At this point, most believe MRI offers no clear advantage over CT in assessing splenic size. Physical Examination Compared With Imaging Palpation and Radiography Dell and Klinefelter in 1946 and Blackburn in 1952 compared the results of physical examination with readings of plain abdominal radiographs, with the incorrect assumption that the radiograph would serve as a sensitive and objective standard.38.39 Riemenschneider and Whalen invalidated those studies when they examined 47 spleens at autopsy and compared these with medical records of the physical examination and abdominal radiographs.40 The authors concluded that neither palpation nor plain films were helpful in identifying splenomegaly.
33

Physical Examination and Nuclear Scans Holzbach and associates in their study of 55 patients using 5tCr-labeled erythrocytes found 16 with enlarged spleens." Of these patients, the spleen was palpated in 10, whereas the radiograph was judged to be abnormal in 8. Sullivan and Williams in 1976 prospectively studied 65 patients about to undergo a 9mTc-sulfur colloid liver scan.42 One examiner did percussion techniques described by Nixon and Castell,'1'12 as well as palpation with the patients in both the supine and right lateral positions. The criteria for splenomegaly on nuclear scan were longer than 12 cm and/or wider than 7 cm. Of 65 spleens, 17 were enlarged by scan. Of these, 12 were palpable (71% sensitivity), 10 were enlarged by Nixon's method of percussion (59% sensitivity), and 14 were enlarged by Castell's method of percussion (82% sensitivity). Overall, 14 of 17 cases of splenomegaly were detected by physical examination (88% sensitivity). The other 48 scans were considered normal, with 5 spleens palpable, 3 enlarged
by Nixon's method, and 8 enlarged by Castell's method, for a

cumulative false-positive rate of 16.6%. Halpem and colleagues studied 214 patients who underwent liver and spleen '9Tc-sulfur colloid scans and reviewed the results of physical examinations in the patients' medical records.43 In 92 cases of splenomegaly by scan, only 26 (28%) were detected on physical examination. False-positive
TABLE 1.-Various Clinical Methods for Detecting Splenomegaly Sensitivity, ecifcity,
9S

Palpation

Examination Reference Holzbach et al, 196227

9b

Comments

...

62

Halpern et al, 0197443

28
71

99 90

nuclide scan (n=16); palpation method not described Review of 214 patient charts; method not

Compared with radio-

Sullivan and Williams,


197642

described 65 patients examined by palpation, Nixon's method, and Castell's method before 99mTcsulfur colloid liver scan
65 patients examined by palpation, Nixon's method, and Castell's method before 99mTcsulfur colloid liver scan 65 patients examined by palpation, Nixon's method, and Castell's method before 99,Tcsulfur colloid liver scan As compared with 118 patients who had had an abdominal ultrasonogram within 2 mo

Percussion as described by Nixon* Sullivan and 59

94

Williams,
197642

Casttell

Sullivan and Williams,


197642 Barkun
et al, 198914

82

83

Traubet

62

72

*Nixon, 1954.11

tCastell, 1967.12 lAs defined by Barkun et al,

1989.14

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Examination

Refeine

TABLE 2.-The Nonclinical Methods for Detecting Splenomegaly Comments rt Sensitity.% Speiic
... ... -95 ... -93
...

Plain film Ultrasonogram

Whitley et al, 1966'7


Kardel et al, 197121 Koga and Morikawa, 197524 Leopold and Asher, 1975Z Rollo and DeLand, 197028

.91

...
...

.98
...

Nuclear scan

>90 ...
...

... ...

Compared with spleen weight at autopsy in films where the spleen was seen (n=81) Compared with spleen weight after splenectomy tn=9) Patients with known liver disease (n=96) "Observations in over 3,000 patients" Using 99mTc and 197Hg mean error=7%, compared with

CT

Larson et al, 197129 ... X f 0 : ... Strauss et al, 198430 >95 Heymsfield et al, 197934 Breiman et al, 198235
96.4
...

.96
.87 ... ...
.95

~~~~~~~~~(n=3)

postmortem weight (n=21) Compared with weight at splenectomy (n=14) or autopsy


Compared with CT in 47 patients In situ CT in cadavers, then compared with autopsy weights

... ...

...
...

Cools et al, 198336


CT-computed tomography

(n=2) Mean error=3.6% compared with weights after splenectomy (n=8) Estimate based on simple linear measurements compared with previous method by Heymsfield et al (n=50)t; no true weights in study

*r= Correlation coefficient tHeymsfield et al, 1979.34

results occurred in 3 cases (1.4%). This study is flawed, however, because a standardized method for physical examination was not established at the outset, which invalidates comparison with the scan. On the other hand, the chart data may reflect inadequately performed examinations, and many false-negatives could occur. Finally, nuclear scans are themselves subject to enough error (discussed earlier) to call their use into question as an objective standard.

Percussion and Ultrasonography Barkun and associates sought to assess the clinical reliability of percussing Traube's space compared with ultrasonography.14 Patients with known splenomegaly by ultrasonogram were matched with controls. By ultrasound examination, 43 of 118 subjects had enlarged spleens (length greater than 13 cm). Percussion of Traube's space yielded a 62% sensitivity and 72% specificity for the detection of splenomegaly. Discussion The clinical detection of splenic enlargement may be of great value in forming a differential diagnosis, whereas the erroneous assessment of splenomegaly may initiate an unnecessarily involved and invasive evaluation. Establishing the value of various clinical methods for detecting splenic enlargement has, in the past, been hindered by a lack of objective in vivo imaging. A summary of the various clinical methods for detecting splenography is given in Table 1. Although plain radiographs of the abdomen have been accessible for decades and may detect splenomegaly, the splenic outline is often difficult to visualize. The development of radionuclide scans and, more recently, of ultrasonography and computed tomography has made available more objective methods by which to evaluate the techniques of physical examination. The strongest of the early studies showed the relative accuracy of CT and ultrasonography compared with true weights obtained at splenectomy or autopsy. Various noninvasive modalities for the detection of splenomegaly are summarized in Table 2. Both palpating and percussing the abdomen may detect splenomegaly. These techniques appear to be complementary, as each may fail to detect splenic enlargement. Ultra-

sonographic imaging is a noninvasive method well suited for the detection of splenic enlargement. Nuclear medicine scans appear to be fairly sensitive and specific for detecting splenomegaly, but these scans are more expensive and use radionuclides, which are prone to imprecisions. Computed tomography, although useful in evaluating splenic size and structure, exposes patients to ionizing radiation and sometimes contrast agents and is expensive. Both nuclear scans and CT suffer difficulties such as patient access and motion artifact causing distortion. Detecting splenic enlargement is an important reason for doing a physical examination, but information on the relative efficacy of various clinical methods is either lacking or inadequate. With a low-cost, noninvasive, and accurate imaging technique such as ultrasonography, the techniques for splenic palpation and percussion can be readily evaluated in a controlled prospective study.
REFERENCES

1. Williams PL, Warwick R (Eds): Gray's Anatomy, 37th edition. Edinburgh, Churchill Livingstone, 1989 2. DeLand FH: Normal spleen size. Radiology 1970; 97:589-592 3. Arkles LB, Gill GD, Molan MP: A palpable spleen is not necessarily enlarged or pathological. Med J Aust 1986; 145:15-17 4. McIntyre R, Ebaugh FG: Palpable spleens in college freshmen. Ann Intem Med 1967; 66:301-306 5. Eichner ER: Splenic function: Normal, too much and too little. Am J Med 1979;
66:311-320 6. Elmer WP, Rose WD: Physical Diagnosis. St Louis, Mo, CV Mosby, 1935 7. Clain A (Ed): Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery, 17th edition. London, IOP Publ Ltd, 1986 8. Bates B: Guide to Physical Examination and History Taking, 4th edition. Philadelphia, Pa. JB Lippincott, 1987 9. DeGowin EL, DeGowin RL: Bedside Physical Examination, 4th edition. New York, NY, Macmillan, 1981 10. Zhang B, Lewis SM: A study of the reliability of clinical palpation of the spleen. Clin Lab Haematol 1989; 11:7-10 I 1. Nixon RK: The detection of splenomegaly by percussion. N EngI J Med 1954; 250:166-167 12. Castell DO: The spleen percussion sign, a useful diagnostic technique. Ann Intern Med 1967; 67:1265-1267 13. Castell DO, O'Brien KD, Muench H, et al: Estimation of liver size by percussion in normal individuals. Ann Intern Med 1969; 70:1183-1189 14. Barkun AN. Camus M, Meagher T, et al: Splenic enlargement and Traube's space: How useful is percussion? Am I Med 1989; 87:562-566 15. Talbott JE: A Biographical History of Medicine; Excerpts and Essays on the Men and Their Work. New York, NY, Grune & Stratton, 1970 16. Parrino TA: The art and science of percussion. Hosp Pract 1987; 30:25-36 17. Whitley JE, Maynard CD, Rhyne AL: A computer approach to the prediction of spleen weight from routine films. Radiology 1966: 86:73-75

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18. Wyman AC: Traumatic rupture of the spleen. AJR Am J Roentgenol 1954; 72:51-63 19. Brogden BG, Crow NE: Observations on the 'normal' spleen. Radiology 1959; 72:412-413 20. Rosenbaum HD, Lieber A, Hanson DJ, et al: A routine survey roentgenogram of the abdomen on 500 consecutive patients over 40 years of age. AJR Am J Roentgenol 1964; 91:903-909 21. Kardel T, Holm HH, Rasmussen SN, et al: Ultrasonic determination of liver and spleen volumes. Scand J Clin Lab Invest 1971; 27:123-128 22. Niederau C, Sonnenberg A, Muller JE, Erckenbrecht JF, Scholten T, Fritsch WP: Sonographic measurements of the normal liver, spleen, pancreas, and portal vein. Radiology 1983; 149:537-540 23. Leopold GR, Asher WM: Fundamentals of Abdominal and Pelvic Ultrasound. Philadelphia, Pa, WB Saunders, 1975 24. Koga T, Morikawa Y: Ultrasonic determination of the splenic size and its clinical usefulness in various liver diseases. Radiology 1975; 115:1073-1077 25. Pietri H, Boscaini M: Determination of a spleen volumetric index by ultrasound scanning. J Ultrasound Med 1984; 3:19-23 26. Margulis AR, Burhenne HJ (Eds): Alimentary Tract Radiology. St Louis, Mo, CV Mosby, 1989 27. Holzbach RT, Clark RE, Shipley RA, et al: Evaluation of spleen size by radioactive scanning. J Lab Clin Med 1962; 60:902-913 28. Rollo FD, DeLand FH: The determination of spleen mass from radionuclide images. Radiology 1970; 97:583-587 29. Larson SM, Tuell SH, Moores KD, et al: Dimensions of the normal adult spleen scan and prediction of spleen weight. J Nucl Med 1971; 12:123-126 30. Strauss LG, Clorius JH, Frank T, van Kaick G: Single proton emission computerized tomography (SPECT) for estimates of liver and spleen volume. J NucI Med 1984; 25:81-85

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31. Groshar D, Israel 0, Front D: Spleen imaging-Enlargement of the spleen. Semin Nucl Med 1983; 8:295-297 32. Davis HH II, Varki A, Heaton WA, Siegel BA: Detection of accessory spleens with indium 11I-labeled autologous platelets. Am J Hematol 1980; 8:81-86 33. Friedman AC (Ed): Radiology of the Liver, Biliary Tract, Pancreas and Spleen. Baltimore, Md, Williams & Wilkins, 1987 34. Heymsfield SB, Fulenwider T, Nordlinger B, Barlow R, Sones P, Kutner M: Accurate measurement of liver, kidney, and spleen volume and mass by computerized axial tomography. Ann Intern Med 1979; 90:185-187 35. Breiman RS, Beck JW, Korobkin M, et al: Volume determinations using computed tomography. AJR Am J Roentgenol 1982; 138:329-333 36. Cools L, Osteaux M, Divano L, Jeanmart L: Prediction of splenic volume by a simple CT measurement: A statistical study. J Comput Assist Tomogr 1983; 7:426-430 37. Stark DD, Bradley WG: Magnetic Resonance Imaging. St Louis, Mo, CV Mosby, 1988 38. Dell JM, Klinefelter HF: Roentgen studies of the spleen. Am J Med Sci 1946; 211:437-442 39. Blackburn CRB: On the clinical detection of enlargement of the spleen. Aust Ann Med 1953; 2:78-80 40. Riemenschneider PA, Whalen JP: The relative accuracy of estimation of enlargement of the liver and spleen by radiologic and clinical methods. AJR Am J Roentgenol 1965; 94:462-468 41. Blendis LM, McNeilly WJ, Sheppard L, et al: Observer variation in the clinical and radiological assessment of hepatosplenomegaly. Br Med J 1970; 1:727-730 42. Sullivan S, Williams R: Reliability of clinical techniques for detecting splenic enlargement. Br Med J 1976; 30: 1043-1044 43. Halpern S, Coel M, Ashburn W, et al: Correlation of liver and spleen sizeDeterminations by nuclear medicine studies and physical examination. Arch Intern Med 1974; 134:123-124