Hepatomegaly

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. To avoid missing a really big liver, always begin liver palpation in the LIF and work back towards the right upper quadrant.^1,2

• Associated symptoms may be few or rather vague, e.g. loss of appetite, weight loss and lethargy.
• There may be symptoms relating to liver dysfunction, e.g. jaundice, bruising, gynaecomastia, spider naevi, ascites; or related to the underlying cause, e.g. 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).

On palpation

• 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.

• 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, presence of splenomegaly and digital rectal examination may be necessary.
• If patient does not need urgent admission then request some basic investigations e.g. liver function tests, liver ultrasound scan, hepatitis screen.
  Further tests can be decided according to the results of these tests.
• Consider referral to specialist (may need CT or liver biopsy).