Causes and differential diagnosis of the swellings in the Left Hypochondrium

A. Parietal Swellings- As on the right side.

B. Intra-Abdominal Swellings- These swellings occur in connection with the (1) spleen (2) stomach (3) left lobe of the liver (4) splenic flexure of the colon (5) tail of the pancreas (6) left subphrenic space (7) Left kidney and (8) Left suprarenal gland.

(1) spleen- An enlarged spleen is differentiated from a renal swelling by the following points: (i) The spleen enlarges towards the umbilicus i.e. downwards, forwards and inwards, whereas the kidney enlarges forwards and directly downwards towards the iliac fossa. (ii) A splenic swelling is smooth and uniform, its anterior border is sharp with one or more notches- the characteristic feature of this organ. (iii) On inspection, a splenic swelling moves more freely with respiration than a renal swelling, (iv) in Palpation, the spleen is palpated more easily from the anterior aspect and the kidney from the posterior aspect, as the spleen lies just under the anterior abdominal wall and the kidney on the posterior abdominal wall. (v) Further, for the same reason the hand can be insinuated between the swelling and the costal margin in case of the kidney but not in the case of the spleen. (vi) Always look for the notches while palpating a splenic swelling. (vii) On percussion on anterior abdominal wall, the splenic swelling is dull all throughout but in case of renal swelling a band of colonic resonance is obtained. (viii) The loin just lateral to the erector spinae is resonant in splenic swelling but dull in renal swelling.

Causes of enlargement of the spleen are many. Malaria and kala-azar are common in this country but are of little surgical importance. Only the conditions of surgical importance are described below:

(a) HAEMOLYTIC ANAEMIA- There are two forms of this disorder: (i) congenital (hereditary spherocytosis) and (ii) acquired.

(i) HEREDITARY SPHEROCYTOSIS - The main pathology is congenital increase in permeability of the red cell membrane to sodium. As sodium leaks into the cell its osmotic pessure rises, the cell swells, becomes spherical and more fragile. In this condition the energy and oxygen requirement of the red cells increase. In the spleen there is deficiency of both glucose and oxygen in the pulp and therefore a large number of red cells are destroyed. Splenectomy reduces red cell destruction. Though it does not cure the congenital red cell membranedefect yet it makes the red cell survival time normal and thus lessens anaemia. This defect is transmitted as a Mendelian autosomal dominant. The circulating excess bilirubin remains unconjugated with glycuronic acid and is attached to albumin. This is not excreted through urine. Hence it is called acholuric jaundice.

The patients present with anaemia and jaundice . A family history may be elicited. Though it is a congenital condition yet it may not be manifested before puberty or even adult life. In adult cases there is often a history of biliary colic. In fact about 70% of untreated cases may show pigment stone in the gallbladder. Sometimes a severe crisis of red cell destruction is come across. The RBC count may fall down to 2 millions during the attack. Such attacks are characterised by abdominal pain,nausea, vomiting and pyrexia besides usual extreme pallor and jaundice.