Chapter 17-8: Hypersplenism

TEXTBOOK PRESENTATION

Cytopenias are found on routine blood testing in a patient with cirrhosis.

DISEASE HIGHLIGHTS

1. Splenomegaly is found in 36–92% of patients with cirrhosis; 11–55% have the clinical syndrome of hypersplenism, defined as the presence of splenomegaly with a reduction of 1 or more cellular elements of the blood

2. There is a rough correlation between spleen size and degree of decrease in blood cells.

3. Blood cell abnormalities in liver disease

   1. Thrombocytopenia is due to

      1. Platelet sequestration in the spleen

      2. Impaired bone marrow production

      3. Decreased platelet survival

   2. Leukopenia is

      1. Due to sequestration in the spleen

      2. Rare compared with thrombocytopenia (1 series found 64% of cirrhotic patients had thrombocytopenia, but only 5% had leukopenia)

   3. Etiology of anemia in patients with liver disease

      1. Often multifactorial

      2. Sometimes not included in discussions of hypersplenism

      3. Common mechanisms include:

         1. Increased destruction in the spleen

         2. Iron and folate deficiency

         3. Reduced erythropoietin production

EVIDENCE-BASED DIAGNOSIS

1. Hypersplenism is a clinical syndrome without a specific set of diagnostic criteria.

2. Hypersplenism is based on physical exam or radiologic findings of splenomegaly and the presence of cytopenia on laboratory results.

TREATMENT

1. Treatment is usually not necessary.

2. Splenectomy or partial splenic embolization is sometimes done for severe thrombocytopenia with bleeding complications.

3. Granulocyte-macrophage colony-stimulating factor and erythropoietin are rarely used.

4. TIPS does not correct thrombocytopenia.