Visually, I find the spleen to be a treat. It's a handsome crescent shaped organ nestled just behind the ribs. Occasionally you'll find it partnered with a view of the elusive pancreatic tail, cute little splenunculous or even a glimpse of
an adrenal gland.
However, some spleens are just plain difficult to see. The combination of rib shadowing, body habitus, and overlying lung or bowel gas can all conspire to make the spleen one of the shyest organs I’ve ever encountered.
Sometimes the first trick works, and sometimes I go through the whole list before finally getting a glimpse of the elusive spleen.
This is the order in which I use my tricks for best spleen visualization.
1. Right lateral decubitus (RLD) Scanning
I start with them turned over all the way onto their side (about 90 degrees) then lean them back bit by bit to about a 45 degree angle, keeping my transducer in contact with their skin to be able to watch when the spleen comes into view. Keeping skin contact is crucial to best see when the spleen comes into view.
For best ergonomics rest your arm or wrist lightly on your patient's side and sit nice and close to them. This is also a great opportunity to answer any questions they may have or let them see what a spleen looks like. Some people are very curious about their body and I like to reward curiosity. Bu that's just me.
2. Breathe in and hold
Often a small breath in works best to bring the spleen down just a couple of inches into the field of view between the ribs without over-inflating the lungs, which can move down to cover the spleen.
However, in some cases (where the small breath failed to reveal the spleen) a big breath in will work better, mostly in the 45 degree RLD position. Keep your transducer on the skin as you have your patient breath to best catch that perfect moment of full spleen exposure.
If your patient struggles with holding their breath let them breath out and then encourage them to breath in again and hold, hold, hold! Okay, breath out, good job! Sometimes just a bit of encouragement is all that is needed to get the perfect picture.
3. Breathe alllllll the way out
This can work really well to pull larger overlying lung up and out of the way, but you often only have a few seconds of good view since it seems more difficult for people to hold the air out.
This is another time when a little verbal encouragement goes a long way. Patients want to help you out and will really try their best if you only ask them to.
Sometimes i even hold my breath with them and we both gasp for air together with laugh at the end. It's just another way to build rapport and partnership with your patients.
4. Supine Scanning
This is a last resort trick that I only use on really stubborn spleens since leaning over the patient in this position is not particularly ergonomic or comfortable.
Be sure to have the patient move to the edge of the bed, if possible, and you move over nice and close to them to ensure that you do not injure yourself with this position.
In a situation of non-visualization of the spleen I do 2 things:
ONE: Do a quick scan down the patients’ left side to check for the possibility of a Wandering Spleen.
TWO: Ask the patient if they have had any abdominal surgery (to see if the spleen has been surgically removed) or if they have ever had a CT scan (which would be better able to see the spleen and a copy of that report will reveal the spleens’ presence or absence).
Only once I have done these two things am I able to comment that the spleen was NWS, or not visualized, on my report. It’s important to me to be sure that I am making that comment with the knowledge that I did all I could to establish it’s presence.
These are my experiences with spleens, but I know that there must be others! If you have any tips, tricks or useful stories to share about your adventures with the spleen please comment on them below. Let’s share the knowledge and continue making ultrasound awesome.