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Abdominal Ultrasound: Severe Malaria

Abdominal ultrasound is a rapid, radiation-free bedside tool in severe malaria used to quantify hepatosplenomegaly, assess for splenic complications and evaluate causes of jaundice or abdominal pain. It is particularly valuable in resource-limited endemic settings where portable machines allow assessment of critically ill or unstable patients. Ultrasound findings are non-specific but help gauge disease burden and detect potentially catastrophic splenic rupture or infarction.

Indications

  • Assessment of hepatosplenomegaly in severe or chronic malaria
  • Left upper quadrant pain or shoulder-tip pain suggesting splenic infarct or rupture
  • Jaundice and abnormal liver function (malarial hepatopathy versus other causes)
  • Suspected splenic rupture with haemodynamic instability (FAST assessment)
  • Evaluation of hyperreactive malarial splenomegaly and its complications
  • Baseline and follow-up of organ size during treatment and recovery

Contraindications & Cautions

  • No absolute contraindications; ultrasound is safe, non-ionising and repeatable
  • Safe in pregnancy and children
  • Operator dependence and bowel gas may limit assessment; overlying dressings or subcutaneous emphysema degrade images
  • Do not delay resuscitation of a haemodynamically unstable patient for a formal study; use bedside FAST first

Patient Preparation

  • Ideally fasting 4-6 hours to reduce bowel gas and distend the gallbladder, but not required in emergencies
  • Supine positioning; right and left lateral decubitus and coronal flank views optimise spleen and kidney assessment
  • Deep suspended inspiration to bring liver and spleen below the costal margin
  • Explain the examination and obtain verbal consent
  • Have the patient point to the site of maximal tenderness to guide focused scanning

Technique & Parameters

  • Curvilinear low-frequency transducer (2-5 MHz) for adults; higher frequency in small children
  • Measure spleen craniocaudal length in the coronal plane (normal adult <13 cm) and record maximal dimension
  • Measure liver span in the right mid-clavicular line (normal <15-16 cm) and assess parenchymal echogenicity
  • Systematically scan the gallbladder, biliary tree and both kidneys
  • Interrogate for free intraperitoneal fluid in Morrison's pouch, splenorenal recess and pelvis (FAST windows)
  • Colour and spectral Doppler of the splenic parenchyma and portal/splenic veins when infarct or portal hypertension is suspected

Systematic Review

  • Spleen: size, echotexture, focal lesions, subcapsular or perisplenic collection
  • Liver: size, echogenicity, surface contour, focal lesions and biliary dilatation
  • Gallbladder wall thickness and lumen (oedema, sludge)
  • Portal and splenic veins: patency, diameter and flow direction on Doppler
  • Kidneys: size, corticomedullary differentiation and hydronephrosis (blackwater fever, AKI)
  • Free fluid in all peritoneal recesses and pleural spaces
  • Retroperitoneum and pancreas as far as gas permits

Key Findings & Significance

  • Splenomegaly (>13 cm): reflects disease activity and hyperreactive malarial splenomegaly
  • Hepatomegaly with increased periportal/parenchymal echogenicity: malarial hepatopathy
  • Wedge-shaped peripheral hypoechoic non-enhancing region: splenic infarct
  • Perisplenic or free intraperitoneal fluid with a heterogeneous spleen: splenic rupture (surgical emergency)
  • Gallbladder wall oedema and periportal cuffing as non-specific inflammatory changes
  • Renal enlargement or altered echogenicity in malarial acute kidney injury

Differential Considerations

  • Massive splenomegaly: chronic/hyperreactive malaria, schistosomiasis, visceral leishmaniasis, lymphoma, haemoglobinopathy
  • Hepatomegaly with bright liver: malarial hepatopathy, viral hepatitis, steatosis, congestion
  • Splenic hypoechoic lesion: infarct, abscess, lymphoma, cyst
  • Free fluid with instability: splenic rupture versus other haemoperitoneum
  • Jaundice with dilated ducts: obstructive cause rather than haemolytic/hepatocellular malaria
  • Splenomegaly with portal vein dilatation: portal hypertension from schistosomiasis or chronic liver disease

Pearls & Pitfalls

  • An enlarged spleen is fragile - correlate with platelet count and coagulopathy before any intervention
  • Splenic rupture may be spontaneous and can present with minimal trauma; low threshold for FAST in a deteriorating patient
  • Left pleural fluid and lower rib artefact can mimic perisplenic collection
  • Measure the true maximal splenic length in a single coronal plane to avoid underestimation
  • Serial scans document response to therapy and resolution of organomegaly
  • Consider co-endemic causes (schistosomiasis, kala-azar) when splenomegaly is disproportionate

Structured Report

  • Record spleen and liver measurements and echotexture with comparison to prior studies if available
  • Describe focal splenic or hepatic lesions with size, location and Doppler characteristics
  • State presence, volume and location of free intraperitoneal fluid
  • Comment on biliary tree, gallbladder and kidneys
  • Flag any finding requiring urgent surgical review (rupture, large infarct with collection)
  • Impression: correlate with parasitaemia, platelets and clinical severity; recommend follow-up imaging as appropriate

References

  • WHO Guidelines for the Treatment of Malaria (severe malaria)
  • WHO Manual of Diagnostic Ultrasound (spleen and liver)
  • ACR Appropriateness Criteria: Right Upper Quadrant Pain / Jaundice
  • Rumack CM, Diagnostic Ultrasound (spleen and liver chapters)

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.