Kurdistan Regional Government- Iraq Ministry of Higher Education and Scientific Research University of Sulaimani-Faculty of Medical Science School of Medicine-Department of Radiology
Sonographic Measurement of Splenic Size and its Correlation with Body Parameters in Sulaimani Region A Thesis Submitted to School of Medicine, Faculty of Medical Sciences University of Sulaimani in partial fulfillment of the requirements for the Degree of High Diploma (Two Years) in Radiology 2014-2016
Prepared by
Ali Hussein Hasan M.B.Ch.B
Supervised by
Dr. Salah Mohammed Fateh M.B.Ch.B, DMRD, FIBMS (Radiology)
2016 AD
2716 Kurdish
1439 Hijri
ﺍﻟﺮ ِﺣ ِﻴﻢ ﺍﻟﺮ ْﺣ َﻤ ِﻦ ﱠ ﺑﺴﻢ ﷲ ﱠ
ﻋﻠﱠ ْﻣﺗَﻧَﺎ ٓ ۖ ِﺇﻧﱠ َﻙ ﺳ ْﺑ ٰ َﺣﻧَ َﻙ َﻻ ِﻋ ْﻠ َﻡ ﻟَﻧَﺎ ٓ ﺇِ ﱠﻻ َﻣﺎ َ ﻗﺎﻟُﻭﺍْ ُ ﺃَﻧﺕَ ٱ ْﻟﻌَ ِﻠﻳ ُﻡ ٱ ْﻟ َﺣ ِﻛﻳ ُﻡ
) ﺻ َﺩﻕَ ﺁﻪﻠﻟ ﺁﻟﻌﻅﻳْﻡ( ﺳﻭﺭﺓ ﺍﻟﺑﻘﺭﺓ/ﺍﻻ ﻳﺔ ٣٢
DEDICATION This thesis dedicated to: My father. My mother. My supportive wife and my cute daughters. My capable mentor Dr. Salah M. Fateh All of my family.
ACKNOWLEDGEMENTS
In the name of Allah, the first who deserves all thanks, and appreciation for providing me the strength and willingness to establish this study. My deep gratitude and endless appreciation to my teacher and my supervisor, Dr. Salah M. Fateh for his patience and guidance he provided during the supervision of this research. I offer my sincere gratitude to Dr. Kawa A. Mahmood head of Radiology department, for continuously supporting the postgraduate students. To Dr. Nasr A. Mohammed, sincere thanks for his support and encouragement. My gratitude and appreciation goes to the Ministry of Higher Education and Scientific Research, Ministry of Health, Sulaimani Teaching Hospitals and their doctors and the medical staff; they were truly instrumental in bringing this effort to fruition. Thanks for the entire participating subjects. Without their cooperation and agreement to condition of my research, this effort would not have been possible. My sincere gratitude to my family. This thesis would not have been possible without their love, patience and support. Last but not least, I would like to thank those who helped me to complete this work.
ABSTRACT o Background. Sonographically no information is available about the spleen parameters in our populations and there are conflicting data regarding the normal size of the adult spleen and also in its relation with gender, age, different body parameters (body -weight, height and BMI) and ethnicity. o Aim of the Study. To establish reference value of splenic dimensions and volume in a healthy adult Kurdish population in Sulaimani region and its correlation with age, gender, height, weight and BMI. o Methods. This cross-sectional study was performed in Sulaimani Teaching Hospitals, Sulaimani Province. Study was Conducted on 300 healthy adult Kurdish volunteers of both gender (145 males and 155 females). Age, gender, body height, weight and BMI were recorded. Ultrasound-measure of spleen parameters include length, thickness and width. Spleen volume calculated using standard prolated ellipsoid formula (length x thickness x width x 0.523). o Results. The mean age, height, weight & BMI were 38±14 years, 166 ± 9 cm, 75 ±15.8 kg & 27 ± 5 kg/m2 respectively. The means of spleen length, thickness, width & volume were 10.7 ± 1.3 cm, 4.1 ± 0.6 cm, 7.3 ± 0.9 cm & 174.4 ± 52.4 ml respectively. Male had larger spleen parameters than Female. Spleen volume significantly correlate with subject height (r = 0.655 p < 0.001) and weight (r = 0.643 p <0.001) while weak correlations were detected between age and BMI with recorded spleen volume. Significant positive correlation was found between spleen length, thickness & width with spleen volume (more for spleen length). I
o Conclusion. We have provided the normative data of splenic dimensions and volume in normal Kurdish adults which can be used in certain clinical situation in which objective measurement of splenic dimensions and comparisons with standard of normal splenic volume would be useful.
Key word: Ultrasound Spleen Volume Spleen Length
II
LIST OF CONTENTS
Title
Page
Abstract
I
List of Contents
III
List of Tables
V
List of Figures
VI
List of Abbreviation
VII
CHAPTER ONE :INTRODUCTION 1.1. Anatomy
1-4
1.2. Splenic Functions
4
1.3. Normal Variants and Congenital Anomalies
4
1.3.1 Septation, Clefts and Notches
4
1.3.2 Splenunculus
4
1.3.3 Wandering Spleen
5
1.3.4 Heterotaxy Syndrome
5
1.3.5 Splenogonadal Fusion
5
1.3.6 Retrorenal Spleen
5
1.4. Pathological Conditions of the Spleen 1.4.1 Splenomegaly
6
1.4.2 Focal Abnormalities
7 III
6
1.5. Sonographic Appearance of the Normal Spleen
7
1.6. Measurement of the Spleen
8-12
1.7. Objectives
12
CHAPTER TWO: MATERIALS AND METHODS 2.1. Subject Selection
13
2.1.1 Inclusion Criteria
13
2.1.2 Exclusion Criteria
13-14
2.2. Study Design and Ultrasonographic Examinations
15-17
2.3. Ethical Approval
18
2. Statistical Analysis
18
CHAPTER THREE: RESULTS
19-27
CHAPTER FOUR: DISCUSSION
28-33
CHAPTER FIVE: CONCLUSION AND RECOMMENDATIOS
34-35
REFERENCES
36-41
IV
LIST OF TABLES
NO.
Title
1.1
Some Causes of Splenic Enlargement
6
3.1
Distribution of Sample by Age, Gender & BMI
19
3.2
Anthropometric Data of the Whole Sample & for Males & Females
21
3.3
Spleen Parameters of the Whole Sample & Comparison Between Males and Females
22
3.4
Means of Spleen Parameters by Age Groups
23
3.5
Means of Spleen Parameters by Age & Gender
24
3.6
Correlation Between Age, Weight, Height & BMI with Each of the Studied Spleen Parameters
25
3.7
Spleen Length Categories Among Males and Females
27
V
Page
LIST OF FIGURES
Title
NO. 1.1
The Surface Anatomy of spleen
2
1.2
The Visceral Surface of the Spleen
3
1.3
Coronal Sonogram of Spleen. Maximal Splenic Length, is Measured in Longitudinal Coronal Plane, with Splenic Hilum Visualized
9
1.4
a. Longitudinal Section b. Transverse Sections, Through the Spleen, at the Level of the Hilum Measure Length, Thickness & Width
10
1.5
Diagram Illustrating the Sonographic Measurement Technique
11
2.1
Spleen Diameters at the Level of the Hilum in a Longitudinal & Transverse Sections
16
2.2
Longitudinal Flank Scans of the Spleen
17
2.3
Transverse Flank Scans of the Spleen
17
3.1
Age Distribution by Gender.
20
3.2
Correlation Between Spleen Length & Spleen Volume
26
3.3
Correlation Between Spleen Thickness & Spleen Volume
26
3.4
Correlation Between Spleen Width & Spleen Volume
27
VI
Page
LIST OF ABBREVIATION
Abbrev.
Key
BMI
Body Mass Index
CBC
Complete Blood Count
CM
Centimeter
CT
Computerized Tomography
Kg
Kilogram
LSD
Fisher’s Least Significant Difference
LUQ
Left Upper Quadrant
M MHZ
Meter Mega Hertz
ML
Milliliter
MRI
Magnetic Resonance Imaging
RBC
Red Blood Cell
RLD
Right Lateral Decubitus
SD
Standard Deviation
US
Ultrasound
2D
Two Dimensional
3D
Three Dimensional
VII
CHAPTER ONE
INTRODUCTION
INTRODUCTION
Ultrasound (US) is a very useful imaging modality to diagnose or exclude splenic abnormalities and is also extremely helpful in the follow-up of patients with known splenic abnormalities. In general, the spleen can be examined by US without difficulty. Because the normal spleen is uniform in echogenicity, focal abnormalities are usually easily identified, but because spleen is located high in the left upper quadrant (LUQ) of abdomen, sometime difficulties can be encountered with proper US examination due to shadowing from ribs, bowel gas, and overlying lung. Expertise and persistence may be required to overcome these obstacles.1
1.1
Anatomy
The spleen is the largest single lymphatic organ, lies intraperitoneally in the superolateral part of the LUQ or hypochondrium. It is relatively delicate and considered the most vulnerable abdominal organ. It is a mobile organ although usually it does not descend inferior to the costal (rib) region; it rests on the left colic flexure (Figs. 1.1, A & B). It is associated posteriorly with the left 9th through 11th ribs. In the supine position, the long axis of the spleen is roughly parallel to the long axis of the 10th rib .2
1
Figure 1.1, The Surface Anatomy of Spleen2
The spleen varies considerably in size, weight, and shape; however, it is usually about 12 cm long, 3-4 cm thick and 7 cm wide, roughly the size and shape of a one clenched fist and its weight is related to the patient’s age and gender. The spleen usually weighs around 150 g .2 The Relations of the Spleen are: • Anteriorly, the stomach. • Posteriorly, the left part of the diaphragm, which separates it from the pleura, lung, and ribs 9–11. • Inferiorly, the left colic flexure. • Medially, the left kidney.2 Spleen connected to the greater curvature of stomach by the gastrosplenic ligament and to the left kidney by the splenorenal ligament. These ligaments, containing splenic vessels, are attached to the hilum of the spleen on its medial aspect. Except at the hilum, where peritoneal reflections occur, the spleen is intimately covered
2
with peritoneum. The hilum of the spleen is often in contact with the tail of the pancreas and constitutes the left boundary of the omental bursa.3
Figure 1.2, The Visceral Surface of the Spleen3
Arterial supply of the spleen is from the splenic artery, the largest branch of the celiac trunk, the splenic artery divides into five or more branches that enter the hilum. Lack of anastomosis of these arterial vessels within the spleen results in the formation of vascular segments of the spleen enabling subtotal splenectomy.3
Venous drainage from the spleen flows via the splenic vein, formed by several tributaries that emerge from the hilum. It is joined by the inferior mesenteric vein, then the splenic vein unites with the superior mesenteric vein posterior to the pancreatic neck to form the portal vein.3
3
Splenic lymphatic vessels leave the lymph nodes in the splenic hilum to the pancreaticosplenic lymph nodes then to celiac nodes.3
1.2 Splenic Functions Spleen is the largest lymphatic organs, it participates in the body’s defense system as a site of lymphocyte proliferation and of immune surveillance and response. The spleen serves as a blood reservoir, storing red blood cells (RBCs) and platelets, and, to a limited degree, can provide a sort of “self-transfusion” as a response to the stress imposed by hemorrhage. In spite of its size and the many useful and important functions it provides, it is not a vital organ (not necessary to sustain life).2
1.3 Normal Variants and Congenital Anomalies A great variety exists in the normal shape and position of the spleen in the normal individual. These normal variations may cause difficulties in measuring the exact size of the spleen or interpreting splenic disease on different imaging modalities.4 1.3.1 Septation, Clefts and Notches: incomplete fusion of the splenic lobules may result in clefts or notches in the normally smooth superolateral surface.5 1.3.2 Accessory Spleens: is congenital ectopic splenic tissue occurring in l0 - 30% of the population. Most are seen as small well-defined nodules of tissue of identical reflectivity to the normal spleen lying near the splenic hilum. Eighty-eight percent of patients have a single focus, with 9% having two foci, and 3% having multiple foci which are usually clustered.6 Sonographically accessory spleens are usually homogeneous round, smaller than 2 cm in diameter and identical in echogenicity to the spleen.5 4
1.3.3 Wandering Spleen: it is a rare condition (incidence < 0.5%) in which the spleen is excessively mobile and migrates from its expected position to ectopic sites in the abdomen or pelvis. 5,7 1.3.4 Heterotaxy Syndrome: The true incidence is not known, but some sources have estimated it to be around 1 per 8,000-25,000 live births.7 1. Asplenia (right isomerism, bilateral right-sidedness) an absent spleen. Seen in 3% of neonates with structural heart disease and in 30% of patients who die from cardiac malposition. The male-to-female ratio is 2:1.7 2. Polysplenia (bilateral left-sidedness), the spleen is divided into 2–16 masses located along the greater curve of the stomach. Death occurs in the first year of life in 60%.5
1.3.5 Splenogonadal Fusion: congenital fusion of splenic tissue and the gonad. More common in male patients (~95%). Has been found in patients from birth to 81 years old. The fusion of the two tissue types is assumed to occur at 4th -10th weeks of gestation.7
1.3.6 Retrorenal Spleen: This normal variant in splenic position occurs in ~20% of patients, when its inferior portion lies posterior to the upper pole of the left kidney.7
5
1.4 Pathological Conditions of the Spleen 1.4.1 Splenomegaly There are many causes of splenomegaly which can be divided into several categories (Table 1.1).5 In Western Europe and the USA viral infection, portal hypertension and haematological causes are most prevalent. In tropical areas protozoal infection and haemolytic anemias predominate. Correct identification of the cause of an enlarged spleen is frequently impossible by ultrasound alone. Correlation with clinical and laboratory findings is usually necessary to make the correct diagnosis.5 Table 1.1 Some Causes of Splenic Enlargement.5 Category
Type
Example
Infection
Acute viral and bacterial infections
Infectious mononucleosis, bacterial endocarditis
Chronic bacterial infections Chronic viral infections Protozoal infections*
Brucellosis, Tuberculosis AIDS Malaria, leishmaniasis, schistosomiasis
Tropical splenomegaly Congestive
Lymphohematological, non-neoplastic Lymphohematological, neoplastic
Posthepatic
Budd–Chiari syndrome, right heart failure
Hepatic
Cirrhosis
Prehepatic Portal
Splenic vein thrombosis or compression
Haemolytic anaemia
Sickle cell disease, thalassaemia, hereditary spherocytosis
Idiopathic thrombocytopenic purpura Myeloproliferative neoplasm Myelofibrosis*, polycythaemia vera Lymphoma Hodgkin Lymphoma, non-Hodgkin Lymphoma Leukaemia Chronic myeloid leukaemia*,chronic lymphocytic leukaemia
Immunological/
Rheumatoid arthritis, systemic lupus erythematosus
Inflammatory Storage diseases*
Gaucher’s disease, Niemann–Pick disease, mucopolysaccharidoses Amyloid, sarcoidosis, focal splenic masses
Miscellaneous
*Commonly causes massive splenomegaly. 6
1.4.2 Focal Abnormalities Splenic lesions can be solitary or multiple, diffuse, and infiltrative. Focal lesions of the spleen are relatively rare, being present in only 0.2–1% of all abdominal ultrasound examinations. Majority are hypoechoic relative to normal splenic parenchyma; Benign lesions are more common than malignant. Focal lesions can be cystic, complex cystic, or solid. Further, lesions can be categorized according to size as micronodular (<1 cm), nodular (1-3 cm), or focal mass (>3 cm). US is extremely helpful in finding and characterizing focal splenic lesions. However, because of the overlap in the appearance of splenic lesions, it is often not possible to make a specific diagnosis based on the sonographic findings alone.1
1.5 Sonographic Appearance of the Normal Spleen Normal splenic parenchyma is homogeneous. The liver is generally considered to be more echogenic than the spleen because liver contain large number of reflective vessels, but infact the echogenicity of the parenchyma is higher in the spleen than in the liver. Using a dual-image setting, the operator may compare the echogenicity of these two organs. The shape of the normal spleen is variable. The spleen consists of two components joined at the hilum: a superomedial component and an inferolateral component. Each of them can enlarge independently, without enlargement of the other component.1
7
1.6 Measurement of the Spleen As in measuring other body structures, it is helpful to have measurements that establish the upper limits of normal.1 In clinical practice, if spleen extended below the left costal margin by palpation is regarded to be enlarged. The reliability of clinical palpation is imprecise and has 56–82% sensitivity for identifying splenomegaly in comparison with imaging studies.8 The normal spleen is usually not palpable (except in slender young adults) whereas a non-palpable spleen is not always normal sized. The spleen has to increase in size three fold before it becomes palpable.9 In a study evaluating spleen size in patients with sarcoidosis, splenomegaly was present in 57% of the patients (using sonographic criteria to evaluate size) but only clinically palpable in 8%. Therefore, evaluation with radiologic imaging is required and is common for those case that the spleen is enlarged but not palpable.10 Prior to the development of sonography measurement of radiographic spleen length was obtained from plain x-ray to estimate the size which was not always reliable because plain radiographs give a composite shadow which may not be entirely the spleen.6 Several studies have sought to develop standards for splenic size, utilizing a variety of imaging techniques such as computed tomography(CT), scintigraphy, magnetic resonance imaging(MRI), and sonography.11-22 Volumetric measurements are most accurately obtained on CT or MRI.
6,11,12,16,17
Nevertheless routine CT for the
diagnosis and serial follow-up of patients for suspected splenic enlargement is difficult to justify in view of the radiation exposure (especially in a pediatric or adolescent population). The use of MRI is similarly hampered by expense and
8
limited availability in many areas of the world, particularly in developing countries.13 US is a well-established, widely used, non-invasive commonly available and relatively inexpensive means of assessing the spleen, without the risk of ionizing radiation.9 It can demonstrate the existence and composition of splenic masses, disruption of splenic texture or outline, progressive changes in masses and the size of the spleen.1
The range of the “normal sized” adult spleen, combined with its complex threedimensional shape, makes it difficult to establish a normal range of sonographic measurements. Multiple studies using different methods have tried to establish nomograms of spleen size by US. The length of the spleen measured on a coronal or coronal oblique view that includes the hilum is the most common, and reproducible measurement technique and found to be reliable (Fig 1.3). 15,16
Figure. 1.3-Coronal Sonogram of Spleen. Maximal Splenic Length, Determined Optically, is Measured in Longitudinal Coronal Plane, With Splenic Hilum Visualized 15 9
As we mention before spleen has two components (superomedial and inferolateral) each of them can enlarge independently without enlargement of the other component and the clinician ideally would assess splenic volume therefore US calculations of spleen volume had been proposed,1 and found to be the most sensitive method for identifying nonpalpable splenomegaly.23
Estimation of spleen volume by US using the formula for the volume of a prolate ellipsoid = 0.523 × L × W× Τ, (in which L =length, W= Width, T= thickness) become frequently used in many previous literatures.9,13,17,19,20,22,25,26 therefore we chose to use this formula in our study as well for calculating spleen volume. (Fig 1.4 & 1.5)
Figure 1.4 (a) Longitudinal Section Through the Spleen, at the Level of the Hilum Measure the Greatest Longitudinal Diameter in this View(Length) and the Perpendicular Diameter from the Surface of the Spleen to the Hilum(Thickness). (b) Transverse Sections Through the Spleen at the Same Level Measures the Anteroposterior Diameter(Width).27
10
Figure 1.5 Diagram Illustrating the Sonographic Measurement Technique. L = Length Measured as a Tendon Between the Two Organ Poles; B = Width; D = Thickness.14
There are conflicting data regarding the normal size of the adult spleen and also in its relation with gender, age, different body parameters {body -weight, height and body mass index (BMI)} and ethnicity. The size of adult spleen is larger in men than women of same age group.
9,12,15,24-26,28,29
, but no difference in spleen size
between the genders had also been reported.13,30 Decrease in the size of the spleen due to ageing reported in some literature.
28
In
most of literatures spleen volume correlate well with body-height, weight and BMI (more for height)9,13,24, however few studies reported no correlation between spleen volume and body parameters. 25,31 The spleen shows a linear increase in size in healthy women throughout pregnancy32,33 and changes in size of the spleen have also been documented following abdominal trauma34 and as an adaptation to high altitude.35 Small splenic 11
size (length ≤7 cm, width ≤3 cm) may indicate functional hyposplenia, particularly if accompanied by absent or reduced parenchymal blood flow on color Doppler.36 Many studies try to correlate the ethnicity of the subjects with spleen size using different imaging methods. Asian cohort studies showed smaller spleen sizes by US compared to publish literature.28,29 Spleen size was found to be smaller in AfricanAmerican collegiate athletes compared to the white American colleagues.24 spleen volume in African adults is smaller than data from Western sources, and cannot be explained by difference in body habitus.25 Since the US data from the previous studies demonstrated that the racial difference could affect the volume of spleen and the conflicting data about the relationship of the splenic volume with gender, age and body parameters. This necessitates the establishment of normative data of spleen volume for our population
1.7
Objectives
1. To establish reference value of splenic dimensions and volume in a healthy adult Kurdish population in sulaimani region
2. To determine the relationship of spleen parameters with age, gender, height, weight and BMI
12
CHAPTER TWO
SUBJECTS AND METHODS
SUBJECT AND METHODS 2.1 Subject selection This cross-sectional study was performed in Sulaimani Teaching Hospitals, Sulaimani Province, Kurdistan Regional Government, Iraq, between March to September 2016.Study was conducted on three hundred healthy adult Kurdish volunteers of both gender (145 males and 155 females)
2.1.1 Inclusion criteria Normal healthy Kurdish adult male and female population in sulaimani region who had normal complete blood count (CBC)
2.1.2 Exclusion criteria Subjects in this study will fill a short standardized interview questionnaire to exclude any previous or current conditions that might involve the size of the spleen. For our study group, the following exclusion criteria was used:
1. Subjects with age younger than 20 years. 2. Clinical or laboratory evidence of infection (subjects who had fever and or jaundice either at the time of the examination or within at least 6 weeks prior to the examination) 3. Subjects with skin infections at the area of the spleen. 4. Subjects with history of Rheumatoid disease 13
5. Anemia (Hemolytic anemia, chronic anemia, etc.) 6. Haemoglobinopathies (thalassemia and sickle cell anemia). 7. Subjects with lymphoproliferative disorders such as lymphomas (Hodgkin & Non-Hodgkin), leukemia, etc. 8. Myeloproliferative
neoplasm
(CML,
primary
myelofibrosis,
polycythemia Vera, essential thrombocythemia,chronic eosinophlic leukemia .etc). 9. Subjects in whom the entire length of the spleen could not be properly documented by US. 10. History of splenic trauma&/or those with partial splenectomy. 11. Subjects with focal spleen lesions. 12. Liver diseases (cirrhosis or portal hypertension). 13. Gravid women. 14. Non Kurdish races.
14
2.2 Study Design and Ultrasonographic Examinations The Baseline data including age, gender, height, and weight (the height and weight of the patient were measured using the standard anthropometric technique).37 Height was recorded in centimeters(cm), and weight was recorded in kilograms(kg). The BMI calculated by using formula of weight [kg]/height [m2]. Splenic length, thickness and width were recorded for each subjects. Each dimension was rescanned and recorded three different times to the nearest millimeter and the mean value obtained for accuracy of result. The spleen volume was calculated for each subject according to the standard prolate ellipsoid formula (length × thickness × width × 0.523); this formula is frequently used for estimating the volume of many irregularly shaped organs.13
The subjects were scanned using different US machines (according to the site where data collected) with curvilinear probes of (2-6 MHz). After explaining the purpose of examination and taking concept from the subject he or she placed in the right lateral decubitus(RLD)16 position with the left arm stretched up over the head. Examination done on deep inspiration so that the spleen descends downward. Occasionally, when the lung base obscured the spleen on deep inspiration, scans were obtained on shallow inspiration or at rest.
Longitudinal section (coronal oblique view) were obtained with the transducer aligned parallel to the intercostal spaces in the left upper quadrant, maximum diameter between superomedial and inferolateral points (length) and perpendicular diameter from hilum to lateral surface of the spleen (Thickness) are measured in this section (Fig 2.1.a). Then the transducer rotated 90 degrees counter clockwise 15
to image the spleen in transverse section, antero-posterior diameter (width) was measured in this section (Fig 2.1.b).
14,16,30,38
All measurements were made on
sections through the splenic hilum in order to create a constant reference point for repeating measurements according to the guidelines of the American Institute of Ultrasound in Medicine and as described by Lamb et al.16,38,39 (Fig 2.2 and 2.3)
Figure. 2.1 (a & b) a. Spleen Diameters at the Level of the Hilum in a Longitudinal Flank Scan.1= Length, 2=Thickness. b. Spleen Diameter at the Level of the Hilum in Transverse Flank Scan (a=Width)
16
Figure 2.2 Longitudinal Flank Scans of the Spleen.38
Figure 2.3 Transverse Flank Scans of the Spleen.38
17
In order to exclude blood diseases and thalassemic traits, we selectively study splenic parameters in Subjects that had normal complete blood count (CBC)
2.3 Ethical Approval This study was approved by the Scientific research and ethical committee of Medical school, Faculty of Medical Science, University of Sulaimani.
Institutional ethical approval was obtained from authorities of the Sulaimani teaching hospital. Informed consent was obtained from all the subject before they being used for the study. The reason for the study, possible effect and the stage of examination was explained to the subject as group or individually. All procedures followed in accordance with ethical standards of the responsible committee on human experimentation.
2.4 Statistical analysis Data were analyzed using the Statistical Package for Social Sciences (SPSS, version 19). Student’s t test of two independent samples was used to compare means of males and females. One-way analysis of variance (ANOVA) was used to compare means of different age groups. A post hoc test {Fisher’s Least Significant Difference (LSD)} was used to compare each two age groups. Pearson correlation coefficient (r) was used to measure the strength of correlation between two numerical variables. A p value of ≤ 0.05 was considered statistically significant.
18
CHAPTER THREE
RESULTS
RESULTS
The total number of the studied sample was 300. The proportion of females (51.7%) was nearly equal to that of males (48.3%), with a male: female ratio of 0.93: 1 (Table 3.1). The same table shows that around one third of the sample were of normal weight, and 23% were obese.
Table 3.1. Distribution of Sample by Age, Gender & BMI. Variables
Categories
Age
20‐29
30‐39
Sex
Total
88
%
29.3
99
33.0
40‐49
59
19.7
50‐59
19
6.3
≥ 60
35
11.7
Male
145
48.3
155
51.7
< 25
107
35.7
25‐29
124
41.3
≥ 30
69
23.0
300
100.0
Female BMI
No.
Figure 3.1 shows that higher number of male subjects (40.7%) were in the age group 30-39 years, while the age group 20- 29 years have higher female subjects (31%).
19
Percent
Male
45.0
Female
40.7
40.0 35.0 30.0
31.0 27.6
25.8
25.0
21.9
20.0
17.2
15.0 9.7
11.7 11.6
10.0 2.8
5.0 .0 < 30
30‐39
40‐49
50‐59
60+
Age (years)
Figure 3.1. Age Distribution by Gender.
Table 3.2 shows that the mean age (+ SD) of the studied sample was 38.7 + 14.1 years, ranging from 20 to 87 years, with a median of 35 years. The means of weight and height of males were significantly higher than those of females (p < 0.001), while no significant differences detected between the means of age and BMI of male and female.
20
Table 3.2. Anthropometric Data of the Whole Sample and for Males and Females. N
Age (y)
Height (cm)
Weight (kg)
BMI kg/m2
Mean
38.74
166.11
74.70
27.02
SD
14.166
9.9
15.806
5.07
Median
35.00
166.50
74.00
26.45
Minimum
20
146
40
16.44
Maximum
87
197
138
52.21
Mean
37.92
173.36
81.02
26.94
SD
13.104
6.831
14.136
4.30
Median
34.00
173
79.00
26.42
Minimum
20
155
51
16.98
Maximum
86
197
125
41.51
Mean
39.50
159.34
68.79
27.10
SD
15.094
7.143
15.013
5.71
Median
36.00
158
67.00
26.64
Minimum
20
146
40
16.44
Maximum
87
185
138
52.21
0.335
< 0.001
< 0.001
0.796
Total subject
Male
Female
P*
300
145
155
*Comparison between means of males and females.
Table 3.3 presents the means of spleen parameters of the whole sample. It shows also that the means of males of the studied parameters were significantly higher than the means of females (p < 0.001).
21
Table 3.3. Spleen Parameters of the Whole sample & Comparison Between Males & Females. Spleen length (cm)
Spleen thickness (cm)
Spleen width (cm)
Spleen volume (ml)
10.685 1.283 10.700 7.000 14.100 8.705 12.990
4.134 .587 4.100 2.900 6.100 3.200 5.200
7.388 .924 7.400 5.100 9.600 6.000 8.900
174.414 52.449 169.487 63.603 374.061 95.750 262.838
11.266 1.160 11.200 8.500 14.100
4.335 .558 4.300 3.200 6.100
7.779 .846 7.800 6.000 9.600
200.611 47.950 192.350 110.637 374.061
9.390 3.500 5th percentile th 13.200 5.370 95 percentile 155 Females 10.141 3.946 Mean 1.149 .552 SD 10.100 3.900 Median 7.000 2.900 Minimum 12.800 5.700 Maximum 8.180 3.000 5th percentile th 12.000 4.920 95 percentile < 0.001 < 0.001 p٭ *Comparison between means of males and females.
6.500 9.300
135.401 282.970
7.023 .843 7.000 5.100 9.300 5.700 8.640
149.907 44.051 141.648 63.603 283.312 87.471 243.423
< 0.001
< 0.001
Total subjects Mean SD Median Minimum Maximum 5th percentile 95th percentile Males Mean SD Median Minimum Maximum
N 300
145
Table 3.4 shows significant differences of the means of spleen parameters between the age categories. There was steady increase in spleen dimension from age 20-39 with higher value recorded in 4th decade, there after it start to decrease gradually as age increased no consistent pattern is observed, but the means of the older age groups were lower than the other ages. The post hoc test (LSD) shows, in general, significant differences between the means of the spleen parameters of those aged ≥ 60 years with the means of the younger age groups. 22
Table 3.4. Means of Spleen Parameters by Age Groups. Parameters
Age
N
Mean
SD
(years)
Significant
(ANOVA)
by LSD
.001
AXB
Spleen length
A) 20-29
88
10.633
1.182
(cm)
B) 30-39
99
11.017
1.267
AXE
C) 40-49
59
10.680
1.158
BXE
D) 50-59
19
10.600
1.113
CXE
E) ≥60
35
9.929
1.552
Total
300
10.685
1.283
Spleen
A) 20-29
88
4.194
.639
thickness (cm)
B) 30-39
99
4.215
.546
C) 40-49
59
4.090
.519
D) 50-59
19
3.947
.433
E) ≥60
35
3.931
.690
Total
300
4.134
.587
Spleen width
A) 20-29
88
7.326
.803
(cm)
B) 30-39
99
7.757
.937
AXE
C) 40-49
59
7.229
.779
BXC
D) 50-59
19
7.558
.970
BXE
E) ≥60
35
6.680
.903
CXE
Total
300
7.388
.924
DXE
Spleen volume
A) 20-29
88
174.161
52.003
(ml)
B) 30-39
99
191.963
53.511
AXE
C) 40-49
59
167.491
43.564
BXC
D) 50-59
19
169.216
48.285
BXE
E) ≥60
35
139.903
48.230
CXE
Total
300
174.414
52.449
DXE
23
p
.055
AXE BXE
< 0.001
< 0.001
AXB
AXB
Table 3.5 shows that the mean spleen volume, width, and thickness of male was higher than the means of female. All the differences were significant except in the age group 50-59 years. The mean spleen length followed the same pattern except that the mean of female in the age group 50-59 was higher than the mean of males (p = 0.734), small sample size at this age group, with higher female to male ratio 4:1 and nearly all the females were obese with BMI ranged from 27-41 kg/m2.
Table 3.5. Means of Spleen Parameters by Age and Gender. Spleen parameters Volume (ml) 20 - 29 30 - 39 40 - 49 50 - 59 ≥ 60 Length (cm) 20 - 29 30 - 39 40 - 49 50 - 59 ≥ 60 Thickness (cm) 20 - 29 30 - 39 40 - 49 50 - 59 ≥ 60 Width (cm) 20 - 29 30 - 39 40 - 49 50 - 59 ≥ 60
Males
Females
Mean
SD
Mean
SD
p
204.81 209.23 196.33 181.27 171.68
52.28 47.60 40.20 30.41 43.46
148.62 166.49 146.29 166.00 109.89
35.67 52.04 32.67 52.41 30.19
< 0.001 < 0.001 < 0.001 .589 < 0.001
11.33 11.41 11.37 10.43 10.65
1.04 1.17 1.15 .98 1.30
10.05 10.43 10.17 10.65 9.25
.97 1.19 .88 1.17 1.49
< 0.001 < 0.001 < 0.001 .734 .006
4.46 4.31 4.26 4.23 4.29
.62 .51 .50 .26 .70
3.98 4.08 3.96 3.87 3.59
.58 .57 .50 .44 .49
< 0.001 .043 .029 .154 .002
7.67 8.06 7.71 7.85 7.14
.79 .84 .65 .85 .89
7.04 7.31 6.87 7.48 6.24
.70 .89 .67 1.01 .69
< 0.001 < 0.001 < 0.001 .514 .002
24
Table 3.6 show that there is medium strength positive significant correlation of the height and weight with each of the spleen parameters more for volume followed by length, width and thickness, while weak correlations were detected between age and BMI with each of the studied spleen parameters.
Table 3.6. Correlation Between Age, Weight, Height & BMI with each of the Studied Spleen Parameters. Spleen parameters (N = 300) Age Weight Height BMI
Length
Thickness
Width
Volume
r
-0.187
-0.163
-0.253
-0.238
(p)
(< 0.001)
(< 0.005)
(< 0.001)
(< 0.001)
r
0.558
0.408
0.478
0.643
(p)
(< 0.001)
(< 0.001)
(< 0.001)
(< 0.001)
r
0.597
0.425
0.578
0.655
(p)
(< 0.001)
(< 0.001)
(< 0.001)
(< 0.001)
r
0.32
0.221
0.168
0.299
(p)
(< 0.001)
(< 0.001)
(< 0.004)
(< 0.001)
Figure 3.2, shows strong significant positive correlation between spleen length and spleen volume (r = 0.796, p < 0.001).
25
Spleen length 16 14 12 10 8 6 4 2 0 0.0
y = 0.019x + 7.288 R² = 0.633
100.0
200.0 Spleen volume
300.0
400.0
Figure 3.2. Correlation Between Spleen Length & Spleen Volume.
Figure 3.3, shows strong significant positive correlation between spleen thickness and spleen volume (r = 0.753, p < 0.001).
Spleen thickness 7
y = 0.0084x + 2.6648 R² = 0.5664
6 5 4 3 2 1 0 0.0
100.0
200.0 Spleen volume
300.0
400.0
Figure 3.3. Correlation Between Spleen Thickness & Spleen Volume. 26
Figure 3.4, shows strong significant positive correlation between spleen width and spleen volume (r = 0.757, p < 0.001).
y = 0.013x + 5.062 R² = 0.572
Spleen width 12 10 8 6 4 2 0 0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
Spleen volume Figure 3.4. Correlation Between Spleen Width & Spleen Volume.
In table 3.7, the spleen length was categorized into three groups (≤ 12, > 12 and > 13 cm). It is evident in the table that 22.8% of males had spleen length > 12 cm compared with 3.9% of females (p < 0.001). Only 3% of the individual had spleen length > 13 cm. Table 3.7. Spleen Length Categories Among Males & Females. Spleen
Male
Female
p
length (cm)
No.
%
No.
%
No.
%
≤ 12
112
77.2
149
96.1
261
87
> 12
33
22.8
6
3.9
39
13
> 13
9
6.2
-
-
9
3
Total
145
100
155
100
300
100
27
Total
< 0.001
CHAPTER FOUR
DISCUSSION
DISCUSSION The wide range of normal spleen size values reported in the literatures makes the establishment of normal ranges more difficult. Current knowledge of spleen size is based on different populations or derived from autopsy studies and the US data from the previous studies demonstrated that racial differences could affect the splenic volume. This necessitates the establishment of normative data of spleen dimensions for different areas.25,31 In our study we tried to determine spleen dimensions and volume in relation to body parameters in normal adult Kurdish population at sulaimani region.
A total of 300 subjects were studied comprising 145 males and 155 females with a mean age of 38 ±14 years and range of 20–87 years. Mustapha et al.25 studied 374 subjects (181 males and 193 females) ranging from 18–85 years (mean =34 y) and Badran et al.26 studied 205 subjects consisting of 115 males and 90 females with mean and modal age of 33 and 19 - 70 years respectively. were similar to the index study, Hosey et al.24 in their study of 631 adults consisting of 341 males and 290 females reported a mean age of 24 ± 9.5 years and Serter et al.31 study 2179 adult Turkish male subject with mean age of 22.4±3.6(range from 17-42) years. The mean age of Hosey and Serter et al.24,31 were lower than that of the current study.
The mean body height, weight and BMI of studied subjects were 166 cm, 75 kg and 27 kg/m2 respectively. Mustapha et al.25 reported a mean height of 168 cm, weight of 76.6 kg and BMI of 24 kg/m2. Badran et al.26 reported a mean body-height, weight and BMI of 169 cm, 75 kg and 26.5 kg/m2 respectively. Mean body height of 173 cm, weight of 69 kg and BMI of 22.6 kg/m2 were recorded by Serter et al.31 28
and Hosey et al.24 reported mean height of 176 cm and weight of 76 kg. The mean of the subject’s height in the index study are similar to those of Mustapha and Badran et al.25,26 but lower to that of Hosey and Serter et al.24,31 however BMI reported by Serter et al.31 is lower than our study.
The underlying concept of determining splenic volume by ultrasound is not new and has been presented in many previous studies. There is also variable data for mean and the upper limits of normal spleen volume in adults.20,25 The means and maximum spleen volume in our study were 174.4 ± 53 and 374.1 ml respectively (males = 201 ± 48 ml and female = 145± 44 ml). Badran et al.26 used conventional US in Jordanian population to assess spleen volume. He found mean spleen volume of 184 ±80 ml (206.4 ± 83 ml for male and 155.7±65 ml for female). Ehimwenma and Tagbo.13 determined spleen dimension in endemic tropical environment (Nigeria), they reported average spleen volume of 202 ± 49 ml in male and 153 ± 33 ml in female subjects and over all of 177.5 ml. Our recorded of mean spleen volume is in concordance with Badran and Ehimwenma et al.26,13
Kaneko et al.29 reported a mean spleen volume of 123 ± 45 ml in 238 Japanese subjects. In another study for same population, Harris et al.40 found the mean spleen volume to be 127 ± 63 ml in 230 subjects. The smaller spleen volume in Japanese is probably due to smaller body size compared to Kurdish population but despite of the similar body parameter to the index study, Mustapha et al.25 also records smaller mean spleen volume (120±56 ml) in normal adult African population and this can only be explained by regional and rational deference which has effect on spleen volume, this finding is also reported by Hosey et al.24 who found that African-
29
American athletes had smaller spleens despite being taller and heavier than WhiteAmerican athletes.
In one study of fifty-two healthy American volunteers by US, De Odorico et al.22 recorded a mean and maximum spleen volume of 192 ±72 and 411.8 ml respectively. Study based on CT in Saudi Arabian adult, Siddiqui et al.12 found mean spleen volume of 255 ± 72 ml (male = 285 ± 64 ml and female = 220 ± 65 ml). Geraghty et al.41 found the mean spleen volume of 209 ml in 149 individuals (maximum of 399.5 ml in male and 332.1 ml in female). Prassopoulos et al.42 reported a mean spleen volume of 214.6 ml in 140 patients. The mean and maximum spleen volume of our population are smaller than above mentioned literatures and these differences in spleen volume may be due to differences of the sample size, mean age, gender of individuals, body height, weight, technique and modality enrolled in the study and regional variations between populations studied
On the gender basis we found that the means of recorded spleen parameters in male subjects were significantly higher than of female subjects (p < 0.001). As there are moderate positive correlations between spleen parameters and both body height and weight, we would expect larger average spleen parameters in male on the basis of their larger body parameters recorded in this study for same age group (except age group 50-59 in which spleen length is higher in female). This is concordant with most of studies 9,12,22,24-26,28 but some studies had found no deference in spleen size between gender.13,30,41,42
30
There was steady increase in spleen dimension from age 20-39 in Kurdish population with higher value recorded in 4th decade, thereafter it starts to decrease gradually as age increased. In general, significant differences between the means of the spleen parameters of those aged ≥ 60 years with the means of the younger age groups (p <0.001). This finding may be due to the aging process in which older people have a smaller mass of organs compared to younger subjects, though the reasons of organ mass decrease were not known.30 Decrease in the size of the spleen due to ageing reported in previous literature but no consistent pattern is observed.15,28,29,43,44 However, our findings were in disagreement with the results described in Africans and American studies.13,20,24,25
This study showed positive correlation between spleen parameters (more for volume followed by length, width and thickness) with subject’s height and weight (p < 0.001). Spleen volume had significant positive correlation with body height (r= 0.655, p <0.001) more than weight (r=0.643, p< 0.001) and weakly with BMI (r=0.299, p<0.001). Many studies
9,13,24,26,30
reported good correlations between
spleen size and subject height and weight. Moreover, Spielmann et al.9 and Hosey et al.24 found strong correlation between subject height and spleen length. Studies demonstrating no relationship between spleen size and subject height and weight are also available.25,31
Spleen length measured on longitudinal coronal oblique scan with subject in supine and/or RLD position is reliable, widely used in clinical practice and highly correlate with spleen volume. 15,16,24,25,30,31,45,46 A study by Loftus et al.47 on 30 cadavers found a significant correlation between a sonographic measurement of splenic length and the actual length and volume as measured at autopsy. This in agreement with our 31
finding that shows strong significant positive correlation between spleen length and spleen volume (r = 0.796, p < 0.001). We also found strong correlation between spleen width and thickness with spleen volume (r = 0.757, p < 0.001 and r = 0.753, p < 0.001 respectively). Mustapha et al.25 also report strong correlation between spleen width and depth with spleen volume.
The means of recorded spleen length in our study was 10.7 ± 1.3cm; the length of spleen was ≤ 13 cm in 97% of the individuals and maximum spleen length of 14.1 cm also noted. There are variable data for the upper limits of normal spleen length with values ranging from 12 to 14 cm in adults. 9,15,24,28,39 In a German study of 703 normal adults, the length of the spleen was less than 11 cm in 95% of subjects.14 Rosenberg et al.15 established an upper limit of normal splenic length of 12 cm for girls and 13 cm for boys (≥15 years). Hosey et al.24 demonstrated, a mean splenic length of 10.65 cm. He also noted that 7% of athletes having a spleen length of more than 13 cm. Capaccioli et al.48 found a mean spleen length of 10.5 cm in a population of 180 Italian adults, without stratifying for age. The same result for mean spleen length were recorded by many other studies.26,30,31. Moreover, Badran et al.26 and Serter et al.31 report maximum spleen length of 15.6 and 17 cm respectably. Spielmann et al.9 suggest that maximum spleen length for individual taller than 183 cm is greater than 13 cm..14 Our average for spleen length is consistent with previous normal values reported for general adult population. These observations suggest that there is no significant racial bias of spleen length.
32
Study limitations. The main limitation in our study was the use of a single investigator to perform the measurements in all participants created the potential for suboptimal reproducibility and we were unable to assess interobserver variability. However, to mitigate concerns about reproducibility and intraobserver variability we used the mean of three measurements for each of the spleen parameters investigated. The other limitation factor is relatively small sample size as we measure the spleen parameters in healthy subjects who already have normal CBC.
33
CHAPTER FIVE
CONCLUSIONS & RECOMMENDATIONS
CONCLUSIONS AND RECOMMENDATIONS
5.1 Conclusions: 1. We have provided the normative data of splenic dimensions and volume in normal Kurdish adults which can be used in certain clinical situation in which objective measurement of splenic dimensions and comparisons with standard of normal splenic volume would be useful. 2. The recorded spleen parameters of subjects more than 60 years are significantly lower than younger age groups. 3. The spleen volume much higher in male than female, and significantly correlates with subject height and weight.
4. A 95th percentile of spleen length was 13cm can be used as upper limit of normal in our populations
34
5.2 Recommendations:
1. Calculating spleen volume for every patient suspected to have condition that effect spleen size reserving the single longitudinal measurement of spleen length for routine daily practice. 2. Further studies are needed for determining spleen size including larger sample size and/or using different modality in various region. 3. Determine normal value of spleen size using US for infant and children in Kurdish population.
4. Another study comparing splenic size as measured clinically, evaluated Sonographically and weighted after splenectomy in splenomegaly patient could be done as an extension of this study.
35
REFERENCES
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48. Capaccioli L, Stecco A, Vanzi E, Brizzi E. Ultrasonographic study on the growth and dimensions of healthy children and adult organs. Int J Anat Embryol 2000; 105:1–50.
41
APPENDIX
Data Collection Form Case sheet number: 1‐ 2‐ 3‐ 4‐ 5‐ 6‐ 7‐
8‐
Name: Age Gender: Male Female Height (M): Weight (Kg): Splenic dimensions: Length: Width: Depth: Laboratory investigations: PCV: WBC: MCV: MCHC: MCH: Exclusion criteria: ‐ Clinical or laboratory evidence of infection (subjects who had fever &/or jaundice either at the time of the examination or within at least 6 weeks prior to the examination): ‐
Yes No History of Rheumatoid disease (joint pain and/or swelling)
‐
Yes No Skin infections at the area of the spleen:
‐
Yes No Anemia (Hemolytic anemia, chronic anemia, etc.):
‐
Yes No Haemoglobinopathies (thalassemia and sickle cell anemia):
‐
Yes No Subjects with lymphoproliferative disorders such as lymphomas (Hodgkin & Non‐Hodgkin), leukemia, etc.:
‐
Yes No Myeloproliferative neoplasm (CML, primary myelofibrosis, polycythemia Vera, etc.):
‐
Yes No The entire length of the spleen could not be properly documented:
‐
Yes No History of splenic trauma&/or those with previous splenectomy:
‐
Yes No Non‐traumatic benign splenic lesions & non‐uniform parenchyma (infarctions, lobulations, cysts, accessory spleen, and hemangioma: Yes No Malignant lesions:
‐
Yes No Lymphadenopathy:
‐
Yes
No
ﺣﮑﻮﻣﻪﺗﯽ ﻫﻪﺭ ﻤﯽ ﮐﻮﺭﺩﺳﺘﺎﻥ/ﻋﻴﺮﺍﻕ ﻭەﺯﺍﺭەﺗﯽ ﺧﻮ ﻨﺪﻧﯽ ﺑﺎ ﻭ ﺗﻮ ـﮋﻳﻨﻪﻭەی ﺯﺍﻧﺴﺘﯽ ﺯﺍﻧﮑﯚی ﺳﻠ ﻤﺎﻧﯽ -ﻓﺎﮐﻪ ﺘﯽ ﺯﺍﻧﺴﺘﻪ ﭘﺰﻳﺸﮑﻴﻪﮐﺎﻥ ﺳﮑﻮ ﯽ ﭘﺰﻳﺸﮑﯽ – ﺑﻪﺷﯽ ﺗﻴﺸﻚ ﻭ ﺳﻮﻧﺎﺭ
ﭘﻴﯚﺍﻧﯽ ﻗﻪﺑﺎﺭەی ﺳﭙ ﺑﻪ@ﺋﺎﻣ ﺮﻯ ﺳـﻪﺭﻭی ﺩەﻧﮕﻰ ﻭەﭘﻪﻳﻮەﻧﺪی ﻟﻪﮔﻪڵ ﭘ ﻮەﺭەﮐﺎﻧﯽ ﺟﻪﺳﺘﻪ ﻟﻪ ﻧﺎﻭﭼﻪی ﺳﻠ ﻤﺎﻧﯽ
ﺋﻪﻡ ﻟ ﮑﯚ ﻴﻨﻪﻭەﻳﻪ ﭘ ﺸﮑﻪﺵ ﺑﻪ ﺳﮑﻮ ﯽ ﭘﺰﻳﺸﮑﯽ /ﻓﺎﮐﻪ ﺘﯽ ﺯﺍﻧﺴﺘﻪ ﭘﺰﻳﺸﮑﻴﻪﮐﺎﻧﯽ ﺯﺍﻧﮑﯚی ﺳﻠ ﻤﺎﻧﯽ ﮐﺮﺍﻭە ﻭەﻙ ﺑﻪﺷ ﻚ ﻟﻪ ﭘ ﺪﺍﻭﻳﺴﺘﻴﻪﮐﺎﻧﯽ ﺑﻪ ﺩەﺳﺘﻬ ﻨﺎﻧﯽ ﺑ ﻭﺍﻧﺎﻣﻪی ﺩﺑ ﻮﻣﯽ ﺑﺎ ی )ﺩﻭﻭ ﺳﺎڵ( ﻟﻪ ﺯﺍﻧﺴﺘﯽ ﺗﻴﺸﻚ ﻭﺳﻮﻧﺎﺭ ٢٠١٦-٢٠١٤
ﺋﺎﻣﺎﺩەﮐﺮﺩﻧﯽ
ﻋﻠﯽ ﺣﺴﻴﻦ ﺣﺴﻦ ﺑﻪ ﮐﺎﻟﻮﺭﻳﻮﺱ ﻟﻪ ﭘﺰﻳﺸﮑﯽ ﻭ ﻧﻪﺷﺘﻪﺭﮔﻪﺭی ﮔﺸﺘﯽ
ﺑﻪ ﺳﻪﺭﭘﻪﺭﺷﺘﯽ
ﺩﮐﺘﯚﺭ ﺻﻼﺡ ﻣﺤﻤﺪ ﻓﺎﺗﺢ ﺩﮐﺘﯚﺭﺍ ﻟﻪ ﺗﻴﺸﻚ ﻭ ﺳﻮﻧﺎﺭ ٢٠١٦ﺯ
٢٧١٦ﮐﻮﺭﺩی
١٤٣٩ﮐﺆﭼﯽ
@@ón‚íq @ôäò†@یìŠó@õ‹Žïàb÷@ôäbåŽïèŠbØói@ói@ŽÞr@ôäbØòŠòíŽïq@õòŠbiŠò†@óïïä@a‡nò†Šói@@óÜ@ìaìóm@ñŠbïäaŒ@Z@‡äìa‹Øbi o @ói@bèòìŠóè@ òì@çaìín’óîóŽïq@ôÝr@ôn’ì‹@õòŠbióÔ@õòŠbiŠò†@óîóè@Ûóîói@ˆ†@õbma†@òì@ Na†óáŽï÷@ôäýó @ìbä@óÜ @òì@HBMI@ónóu@ðîbnŠbi@õŠòíŽïq@~@õ‰ŽîŠ†@~@”ŽïØI@ónóu@@ôäbØòŒaìbïu@òŠòíŽïq@ì@~@çóàóm@~@Œó òŠ@ói@oòíîóq N@†aˆóä @ôäaín“ïäa†@ íŽ i@ ÞŽ r@ õòŠbióÔ@ ì@ çbØóïîŠì†@ íŽ i@ ðîòìbšŠó@ ôÙŽï‚‹ä@ ôån’Ša†@ íŽ i@ Z@ óØòìóåïÜŽíÙŽïÜ@ óÜ@ wäbàb÷ o @õŠòíŽïqòì@”ŽïØ@~@õ‰ŽîŠ†@~@Œó òŠ@~@çóàóm@ói@õ‡äòíîóq@òì@ôäbáïÝ@õóšìbä@óÜ@†ŠíØ@ôn슇äóm@@õìín“îóŽïq N@H@BMI @ónóu@ðîbnŠbi @óÜ@ôäbáïÝ@õóšìbä@~@aŠ†@ãb−ó÷@ôäbáŽïÝ@õŠbØ‹ŽïÐ@õóäbƒ’Ží‚óä@óÜ@óî@ðîó ‹i@óäbq@òìóåïÜŽíÙŽïÜ@ãó÷@Z@çbØóŽîŠ o @~@çóàóm N@HŽôà@ 155@ì@‹ćïä@ 145@I@Œó òŠ@ì솊óè@Žíi@o슇äóm@õìín“îóŽïq@ô“‚ói@Ží‚@õ†ŠíØ@ 300@@ Šó @õŠbïäaŒ@ôäbØóïäò†@ìŠó@òŠòíŽïq@òì@N@a‹Ø@ŠbàŽím@H@@BMI @ónóu@ðîbnŠbi@õŠòíŽïq@~@”ŽïØ@~@ónóu@õ‰ŽîŠ†@~@Œó òŠ @ðîóäaíŽïq@õòìóäaìóy@õó“ŽïØìbè@ôäbåŽïèŠbØ@ói@ói@ŽÞr@õòŠbióÔ@ì@~@ôäbq@~@õŠìínó÷@~@õ‰ŽîŠ†@Ûòì@ça‹ØŠbàˆó÷@ŽÞr NH@0N523@ x ôäbq@x@õŠìínó÷@x õ ‰ŽîŠ†@I@ôvïÝïÝéï÷ 9 ±166 , ﺳﺎ َﻝ38±14@~ @ HBMI@I@ónóu@ðîbnŠbi@õŠòíŽïq@~@”ŽïØ@~@õ‰ŽîŠ†@~@çóàóm@õa‹ÙŽïm@Z@çbØóàb−ó÷ o @ì@ôäbq@~@ õŠìínó÷@~@õ‰ŽîŠ†@õa‹ÙŽïm@òì@N@Ûóî@õaì†@óÜ@Ûóî@ìíi@@2ﻡ/ âØ 5 ± 27 , âØ@15.8±74.7, ﺳﻡ N@Ûóî@õaì†@óÜ@Ûóî ﻣﻝ52.4± 174.4 , ﺳﻡ0.9±7.3, ﺳﻡ0.6±4.1, ﺳﻡ1.3 ±10.6 @ŽÞr@õòŠbióÔ @ói@óîóè@õ‡äòíîóq@ìbšŠói@ôØóîòíŽï’@ói@ŽÞr@õòŠbióÔ. @çbäˆ@ôè@óÜ@çìíi@‹mòŠìó @çaìbïq@ôÝr@ôäbØòŠòíŽïq@òì @óØ@òìóîaŠŒŽì†@òìó÷@a‡ÙŽïmbØ@óÜ.(r =0.643 P ˂ 0.01) ”ŽïØ@òì ( r= 0.655 P˂ 0.001 )@õ‰ŽîŠ† @òìN@ òŒaìý@ ôØóïî‡äòíîóq@ ìa‹ØŠbàŽím@ ôÝr@ õòŠbióÔ@ ßó óÜ@ ónóu@ ðîbnŠbi@ õŠòíŽïq@ ì@ çóàóm@ çaíŽïä@ õ‡äòíîóq @õ‰ŽîŠ†@Žíi@‹mbîŒI@ŽÞr@õòŠbióÔ@Žßó óÜ@ŽÞr@ôäbq@ì@õŠìínó÷@~õ‰ŽîŠ†@çaíŽïä@óÜ@òìóîaŠŒŽì†@ÆïmòŒŽíq@ôØóïî‡äòíîóq N@H@ŽÞr @ò†ŠíØ@ íŽ i@ òŠbióÔ@ ì@ ÞŽ r@ ôäbØóî@ õŠìì†@ õòŠbiŠò†@ †‹Ø@ •óÙ“Žïq@ çbáïîóäaíŽïq@ õbma†@ óáŽï÷@ ZçbØóàb−ó÷Šò† o @oŽî‹Øò†@óØ@a†ìa‹ÙîŠbî†@ðîóäbƒ’Ží‚óä@ôÙŽïmóÜby@‡äóš@óÜ@oŽî‹åŽïéi@ŠbØói@oŽî‹Øò†@óØ@çbØóî@ôn’ì‹@òìín“îóŽïq @@N@ŽÞr@ôn’ì‹@ðîóäaíŽïq@õòŠbióÔ@ßó óÜ@õ†ŠìaŠói@ì@ŽÞr@ôäbØóïîŠìì†@Žíi@ômóibi@õŠòíŽïq@Žíi@oïi@”‚ói@†í
@Z@çbØó’ì@ôÝïÝØ o çbØóïäò†@ìŠó@óÜŽíqó’ @ŽÞr@õòŠbióÔ@–@ @ŽÞr@õ‰ŽîŠ†@–
ﺣﮑﻮﻣﺔ ﺍﻗﻠﻴﻢ ﻛﺮﺩﺳﺘﺎﻥ /ﺍﻟﻌﺮﺍﻕ ﻭﺯﺍﺭﺓ ﺍﻟﺘﻌﻠﻴﻢ ﺍﻟﻌﺎﻟﻲ ﻭﺍﻟﺒﺤﺚ ﺍﻟﻌﻠﻤﻲ ﺟﺎﻣﻌﺔ ﺍﻟﺴﻠﻴﻤﺎﻧﻴﺔ -ﻛﻠﻴﺔ ﺍﻟﻌﻠﻮﻡ ﺍﻟﻄﺒﻴﺔ ﻛﻠﻴﺔ ﺍﻟﻄﺐ -ﻗﺴﻢ ﺍﻷﺷﻌﺔ
ﻗﻴﺎﺱ ﺍﻷﺑﻌﺎﺩ ﺍﻟﺨﻄﻴﺔ ﻟﻠﻄﺤﺎﻝ ﺑﺎﺳﺘﺨﺪﺍﻡ ﺍﻟﻤﻮﺟﺎﺕ ﻓﻮﻕ ﺍﻟﺼﻮﺗﻴﺔ ﻭﺍﺭﺗﺒﺎﻁﻬﺎ ﺑﻤﻌﺎﻳﺮ ﺍﻟﺠﺴﻢ ﻓﻲ ﻣﻨﻄﻘﺔ ﺍﻟﺴﻠﻴﻤﺎﻧﻴﺔ
ﺍﻁﺮﻭﺣﺔ ﻣﻘﺪﻣﺔ ﺇﻟﻰ ﻛﻠﻴﺔ ﺍﻟﻌﻠﻮﻡ ﺍﻟﻄﺒﻴﺔ /ﻛﻠﻴﺔ ﺍﻟﻄﺐ ﻓﻲ ﺟﺎﻣﻌﺔ ﺍﻟﺴﻠﻴﻤﺎﻧﻴﺔ ﮐﺠﺰء ﻣﻦ ﻣﺘﻄﻠﺒﺎﺕ ﺍﻟﺤﺼﻮﻝ ﻋﻠﻰ ﺩﺭﺟﺔ ﺍﻟﺪﺑﻠﻮﻡ ﺍﻟﻌﺎﻟﻲ )ﺳﻨﺘﺎﻥ( ﻓﻲ ﺍﻷﺷﻌﺔ ﺍﻟﺘﺸﺨﻴﺼﻴﺔ ٢٠١٦ -٢٠١٤
ﺃﻋﺪﺕ ﻣﻦ ﻗﺒﻞ
ﻋﻠﻲ ﺣﺴﻴﻦ ﺣﺴﻦ ﺑﮑﻠﻮﺭﻳﻮﺱ ﻓﯽ ﺍﻟﻄﺐ ﻭ ﺍﻟﺠﺮﺍﺣﺔ ﺍﻟﻌﺎﻣﺔ
ﺑﺎﺷﺮﺍﻑ
ﺍﻟﺪﮐﺘﻮﺭ ﺻﻼﺡ ﻣﺤﻤﺪ ﻓﺎﺗﺢ ﺩﮐﺘﻮﺭﺍە ﻓﯽ ﺍﻷﺷﻌﺔ ﺍﻟﺘﺸﺨﻴﺼﻴﺔ
٢٠١٦ﻡ
٢٧١٦ﮐﻮﺭﺩﻱ
١٤٣٩ﻫﺠﺮﻱ
ﻣﻠﺧﺹ oﺍﻟﺨﻠﻔﻴﺔ :ﻟﻴﺴﺖ ﻫﻨﺎﻙ ﻣﻌﻠﻮﻣﺎﺕ ﻣﺘﺎﺣﺔ ﻋﻦ ﻣﻌﺎﻳﺮ ﺍﻟﻄﺤﺎﻝ ﺑﺄﺳﺘﺨﺪﺍﻡ ﺍﻟﻤﻮﺟﺎﺕ ﻓﻮﻕ ﺍﻟﺼﻮﺗﻴﺔ ﻟﺪی ﺍﻟﺴﮑﺎﻥ ﺍﻻﮐﺮﺍﺩ ﻭ ﻫﻨﺎﻙ ﺑﻴﺎﻧﺎﺕ ﻣﺘﻀﺎﺭﺑﺔ ﺑﺨﺼﻮﺹ ﺍﻟﺤﺠﻢ ﺍﻟﻄﺒﻴﻌﻲ ﻟﻄﺤﺎﻝ ﺍﻟﺒﺎﻟﻐﻴﻦ ﻭ ﺍﻳﻀﺎ ﻓﻴﻤﺎ ﻳﺘﻌﻠﻖ ﺑﺎﻟﺠﻨﺲ ,ﺍﻟﻌﻤﺮ ﻭ ﻣﻌﻠﻤﺎﺕ ﺍﻟﺠﺴﻢ ﺍﻟﻤﺨﺘﻠﻔﺔ )ﺍﻟﻮﺯﻥ ,ﺍﻟﻄﻮﻝ ﻭ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ( ﻭ ﺍﻟﻌﺮﻕ. oﺍﻟﻬﺪﻑ ﻣﻦ ﺍﻟﺪﺭﺍﺳﺔ :ﻷﻧﺸﺎء ﻗﻴﻤﺔ ﻣﺮﺟﻌﻴﺔ ﻷﺑﻌﺎﺩ ﻭ ﺣﺠﻢ ﺍﻟﻄﺤﺎﻝ ﻟﻠﺴﻜﺎﻥ ﺍﻷﻛﺮﺍﺩ ﺍﻟﺒﺎﻟﻐﻴﻦ ﺍﻷﺻﺤﺎء ﻓﻲ ﻣﻨﻄﻘﺔ ﺍﻟﺴﻠﻴﻤﺎﻧﻴﺔ ﻭ ﻋﻼﻗﺘﻪ ﻣﻊ ﺍﻟﻌﻤﺮ ,ﺍﻟﺠﻨﺲ ,ﺍﻟﻄﻮﻝ ,ﺍﻟﻮﺯﻥ ,ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ. oﺍﻟﻄﺮﻕ :ﺍﺟﺮﻳﺖ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﺍﻟﻤﺴﺘﻌﺮﺿﺔ ﻓﻲ ﻣﺴﺘﺸﻔﻰ ﺍﻟﺴﻠﻴﻤﺎﻧﻴﺔ ﺍﻟﺘﻌﻠﻴﻤﻲ ,ﻣﺤﺎﻓﻈﺔ ﺍﻟﺴﻠﻴﻤﺎﻧﻴﺔ ﻋﻠﻰ ٣٠٠ﻣﻦ ﺍﻻﻛﺮﺍﺩ ﺍﻟﻤﺘﻄﻮﻋﻴﻦ ﺍﻟﺒﺎﻟﻐﻴﻦ ﺍﻷﺻﺤﺎء ﻟﻜﻼ ﺍﻟﺠﻨﺴﻴﻦ ) ١٤٥ﺫﻛﺮ ﻭ ١٥٥ﺍﻧﺜﻰ( ,ﺗﻢ ﺗﺴﺠﻴﻞ ﺍﻟﻌﻤﺮ ,ﺍﻟﺠﻨﺲ ,ﻁﻮﻝ ﺍﻟﺠﺴﻢ ,ﺍﻟﻮﺯﻥ ﻭ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ .ﻭ ﺗﻢ ﺣﺴﺎﺏ ﺍﻟﻘﻴﺎﺳﺎﺕ ﻓﻮﻕ ﺍﻟﺼﻮﺗﻴﺔ ﻟﻤﻌﻠﻤﺎﺕ ﺍﻟﻄﺤﺎﻝ ﺍﻟﻤﺸﺘﻤﻠﺔ ﻋﻠﻰ ﺍﻟﻄﻮﻝ ,ﺍﻟﺴﻤﻚ ,ﺍﻟﻌﺮﺽ ﻭ ﺣﺠﻢ ﺍﻟﻄﺤﺎﻝ ﺑﺄﺳﺘﻌﻤﺎﻝ ﻣﻌﺎﺩﻟﺔ ﺍﻷﺳﺘﺮﺧﺎء ﺍﻷﻫﻠﻴﻠﺠﻴﺔ ﺍﻟﻘﻴﺎﺳﻴﺔ )ﺍﻟﻄﻮﻝ Xﺍﻟﻌﺮﺽ Xﺍﻟﻌﻤﻖ.( ٠٫٥٢٣ X oﺍﻟﻨﺘﺎﺋﺞ :ﻛﺎﻥ ﻣﺘﻮﺳﻂ ﺍﻟﻌﻤﺮ .ﺍﻟﻄﻮﻝ .ﺍﻟﻮﺯﻥ ﻭ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ ﻫﻮ ١٤ ±٣٨ﻋﺎﻣﺎ ٩ ±١٦٦ ,ﺳﻢ ١٥٫٨ ±٧٤٫٧,ﻛﻐﻢ ٥±٢٧ ,ﻛﻐﻢ/ﻡ 2ﻋﻠﻰ ﺍﻟﺘﻮﺍﻟﻰ. ﻭﻛﺎﻧﺖ ﻣﺘﻮﺳﻄﺎﺕ ﻁﻮﻝ ﺍﻟﻄﺤﺎﻝ ,ﺍﻟﺴﻤﻚ ,ﺍﻟﻌﺮﺽ ﻭ ﺍﻟﺤﺠﻢ ﻫﻰ ١٫٣±١٠٫٦ﺳﻢ ٠٫٦± ٤٫١,ﺳﻢ ٧٫٣, ٠٫٩±ﺳﻢ ٥٢٫٤±١٧٤٫٤ ,ﻣﻞ ,ﻋﻠﻰ ﺍﻟﺘﻮﺍﻟﻰ .ﻭ ﻛﺎﻧﺖ ﻣﻌﻠﻤﺎﺕ ﻁﺤﺎﻝ ﺍﻛﺒﺮﻓﯽ ﺍﻟﺬﮐﻮﺭ ﻣﻨﻬﺎ ﻓﯽ ﺍﻻﻧﺎﺙ .ﺍﻥ ﺣﺠﻢ ﺍﻟﻄﺤﺎﻝ ﻫﻮ ﻣﺮﺗﺒﻂ ﺑﺸﻜﻞ ﻛﺒﻴﺮ ﻣﻊ ﺍﻻﺭﺗﻔﺎﻉ )ﺭ= ،٦٥٥ﺏ > (٠٫٠٠١ﻭ ﺍﻟﻮﺯﻥ )ﺭ= ،٦٤٣ﺏ > (٠٫٠٠١ﻓﻲ ﺣﻴﻦ ﺗﻢ ﺍﻟﻜﺸﻒ ﻋﻦ ﺿﻌﻒ ﺍﻷﺭﺗﺒﺎﻁ ﺑﻴﻦ ﺍﻟﻌﻤﺮ ﻭ ﻣﺆﺷﺮ ﻛﺘﻠﺔ ﺍﻟﺠﺴﻢ ﻣﻊ ﺣﺠﻢ ﺍﻟﻄﺤﺎﻝ ﺍﻟﻤﺴﺠﻞ ﻭ ﺗﻢ ﺍﻟﻌﺜﻮﺭ ﻋﻠﻰ ﻋﻼﻗﺔ ﺍﻳﺠﺎﺑﻴﺔ ﺑﻴﻦ ﻁﻮﻝ ﺍﻟﻄﺤﺎﻝ ,ﺍﻟﺴﻤﻚ ﻭ ﺍﻟﻌﺮﺽ ﻣﻊ ﺣﺠﻢ ﺍﻟﻄﺤﺎﻝ ) ﺍﻷﻓﻈﻠﻴﺔ ﻟﻄﻮﻝ ﺍﻟﻄﺤﺎﻝ (. oﺍﻷﺳﺘﻨﺘﺎﺝ :ﻟﻘﺪ ﻗﺪﻣﻨﺎ ﺑﻴﺎﻧﺎﺕ ﻣﻌﻴﺎﺭﻳﺔ ﻋﻦ ﺍﺑﻌﺎﺩ ﺍﻟﻄﺤﺎﻝ ﻭ ﺍﻟﺤﺠﻢ ﻟﻸﻛﺮﺍﺩ ﺍﻟﺒﺎﻟﻐﻴﻦ ﺍﻟﻄﺒﻴﻌﻴﻴﻦ ﻭ ﺍﻟﺘﻲ ﻳﻤﻜﻦ ﺍﺳﺘﺨﺪﺍﻣﻬﺎ ﻓﻲ ﺣﺎﻻﺕ ﺳﺮﻳﺮﻳﺔ ﻣﻌﻴﻨﺔ ﻭ ﺍﻟﺘﻲ ﻳﻤﻜﻦ ﺍﻥ ﻳﻜﻮﻥ ﺍﻟﻘﻴﺎﺱ ﺍﻟﻤﻮﺿﻮﻋﻲ ﻷﺑﻌﺎﺩ ﺍﻟﻄﺤﺎﻝ ﻭ ﺍﻟﻤﻘﺎﺭﻧﺎﺕ ﻣﻊ ﺍﻟﺤﺠﻢ ﺍﻟﻄﺒﻴﻌﻲ ﺍﻟﻘﻴﺎﺳﻲ ﻟﻠﻄﺤﺎﻝ ﻣﻔﻴﺪﺍ .
oﻣﻔﺘﺎﺡ ﺍﻟﻜﻠﻤﺎﺕ : ﺍﻟﻤﻮﺟﺎﺕ ﻓﻮﻕ ﺍﻟﺼﻮﺗﻴﺔ ﺣﺠﻢ ﺍﻟﻄﺤﺎﻝ -ﻁﻮﻝ ﺍﻟﻄﺤﺎﻝ
