Hepatomegaly is enlargement of the liver. The liver edge is normally palpable in children and thin adults and some patients may have a palpable right lobe of the liver. It is smooth, uniform, non-tender and descends to meet the palpating fingers on inspiration. The best way to assess size is by percussion - a normal-sized liver can appear enlarged if displaced downwards by lung disorders. An enlarged liver expands down and across towards the left iliac fossa (LIF). To avoid missing a really big liver, always begin liver palpation in the LIF and work towards the right upper quadrant.
- Associated symptoms may be few or rather vague - eg, loss of appetite, weight loss and lethargy.
- There may be symptoms relating to liver dysfunction - eg, jaundice, bruising, gynaecomastia, spider naevi, ascites; or related to the underlying cause - eg, xanthelasma suggests autoimmune liver disease.
- Measure the hepatomegaly by percussing the upper and lower borders (will rule out causes such as emphysema which can push the liver down giving a false impression of hepatomegaly).
- Smooth hepatomegaly suggests: hepatitis, chronic heart failure, sarcoid, early alcoholic cirrhosis, tricuspid incompetence with a pulsatile liver.
- Craggy hepatomegaly suggests: primary hepatoma or secondary tumours.
NB: a small liver is typical in late cirrhosis and nodular cirrhosis typically produces a small shrunken liver not a large craggy one. Ask particularly about alcohol consumption, sexual activity, IV drug abuse, blood transfusions and recent travel.
|Venous congestion failure|
|Tumours and infiltrative diseases
Hepatomegaly in neonates and children
- Infections: TORCH* infections, hepatitis viruses and EBV and malaria.
- Metabolic: galactosaemia, lipid storage disorders - eg, Gaucher's disease.
- Neoplastic: leukaemia, lymphoma and hepatoblastoma.
- Haematological: sickle cell anaemia and thalassaemia.
- Cardiovascular: congestive cardiac failure and tricuspid regurgitation.
- Miscellaneous: schistosomiasis, toxins, sepsis, polycystic kidneys and liver.
- Drugs: for example, antituberculous medications.
- With normal bilirubin: consider hepatoblastoma, metabolic diseases.
- With raised conjugated bilirubin:
- With raised unconjugated bilirubin: CCF, toxins, haemolytic anaemias.
What to do if a patient has hepatomegaly
- If unwell, may need urgent admission.
- Full history - include recent travel, tattoos, IV drug abuse, medications including herbal remedies, alcohol intake and sexual history.
- Full examination - look for stigmata of chronic liver disease, delirium tremens, lymphadenopathy, and presence of splenomegaly; digital rectal examination may be necessary.
- If the patient does not need urgent admission then request some basic investigations - eg, LFTs, liver ultrasound scan, hepatitis screen. Further tests can be decided according to the results of these tests.
- Consider referral to a specialist (CT scan or liver biopsy may be needed).
Further reading & references
- Hepatomegaly, Medline Plus
- French's Index of Differential Diagnosis, 13th ed, (1997) Butterworth Heinemann; ISBN 0-7506-1434-X
- Professional guide to Signs and Symptoms, 3rd ed. Springhouse Corp. 2001
- Harrison's Principles of Internal Medicine, 15th Ed. Eds: Braunwald, E et al. McGraw-Hill, USA, 2001
- Kumar P, Clarke M; Clinical Medicine, 6th Ed, (2005). WB Saunders: London
- Lissauer T, Clayden G; Illustrated textbook of Paediatrics, 1997, Mosby
|Original Author: Dr Gurvinder Rull||Current Version: Dr Gurvinder Rull||Peer Reviewer: Dr Helen Huins|
|Last Checked: 10/12/2012||Document ID: 785 Version: 23||© EMIS|
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