Synopsis
Assess enlarged lymph nodes and spleen by distribution, tempo and systemic context, identify malignancy or infection requiring urgent action and choose imaging, blood or tissue tests that preserve diagnostic value.
- Confirm that a lump is a lymph node and map every region. Size alone is insufficient; site, consistency, tenderness, fixation, matting, skin change, duration and progression all alter probability.
- Localised tender nodes usually follow drainage from infection or inflammation, while generalised lymphadenopathy broadens the differential to viral infection, HIV, tuberculosis, medicines, autoimmune disease and haematological malignancy.
- Supraclavicular, persistent hard or fixed nodes, progressive enlargement, unexplained splenomegaly, cytopenias and systemic symptoms justify urgent cancer-pathway or haematology assessment under current NICE criteria.
- Ask specifically about measured fever, drenching night sweats, unintentional weight loss, pruritus, recurrent infection, bruising, alcohol, travel, animal exposure, sexual health, tuberculosis risk and new medicines.
- Examine liver, spleen, skin, joints, throat, breasts, testes and likely drainage territories. A palpable spleen generally implies enlargement, but ultrasound distinguishes spleen from a renal or other abdominal mass.
- Use blood and imaging to choose tissue, not to avoid it. Excision preserves architecture and is often preferred for suspected lymphoma; core biopsy is an alternative when excision is impractical and adequate tissue can be obtained.
- Fine-needle aspiration may answer selected metastatic-carcinoma questions but often cannot classify lymphoma because architecture, flow and molecular material are needed.
- Give people with splenomegaly safety advice about contact trauma and urgent pain or collapse; after splenectomy, fever is an emergency requiring the established infection-prevention plan.
Key red flags
Stridor, dysphagia, facial swelling, venous distension or neurological deficit with cervical or mediastinal adenopathy indicates airway, vascular or neural compression.
Sudden left-upper-quadrant or shoulder-tip pain, guarding, syncope or shock in a patient with splenomegaly suggests rupture and concealed haemorrhage.
Investigation priorities
Identify cytopenia, lymphocytosis, blasts, myeloid proliferation, haemolysis and hypersplenic response.
Management branches
Nodes or spleen are associated with airway, vascular, neurological or haemodynamic compromise.
- Use ABCDE, senior surgical, haematology, oncology and critical-care help, cross-sectional or bedside imaging chosen for stability, and blood-bank preparation when internal bleeding is possible.
- Preferred management preserves diagnostic tissue while stabilising the threatened organ; corticosteroid, radiotherapy, surgery or endovascular alternatives require specialist choice because each can alter later pathology.
- Escalate suspected splenic rupture to emergency surgical and major-haemorrhage pathways and suspected airway or SVC compromise to monitored treatment without sending an unstable patient for routine outpatient biopsy.