Hepatomegaly | Doctor

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

Presentation

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.

Aetiology ¹^,²^,³^,⁴^,⁵

Venous Congestion Failure Right ventricular failure Constrictive pericarditis Budd-Chiari syndrome	Infections Viral hepatitis (acute and chronic) Infectious mononucleosis - Epstein-Barr virus (EBV) CMV Malaria Helminthic infection Pyogenic abscess Amoebic abscess
Autoimmune Autoimmune liver disease	Biliary Disease Extra-hepatic obstruction Primary biliary cirrhosis Primary sclerosing cholangitis
Tumours and Infiltrative Diseases Secondaries (metastatic carcinoma) Primary hepatic tumour, e.g. hepatocellular carcinoma Granulomatous hepatitis Amyloidosis Sarcoid	Haematological Disorders Sickle cell disease Haemolytic anaemia Myeloma Leukaemia or lymphoma
Metabolic Haemochromatosis Wilson's disease Glycogen storage diseases Porphyria Non-alcoholic fatty liver disease DM-associated fatty liver	Toxic/Drug-related Alcoholic liver disease: acute alcoholic hepatitis and alcoholic fatty liver Drug induced hepatitis, e.g. statins, macrolides, amiodarone, paracetamol (indicates significant damage).

Hepatomegaly in neonates and children⁵

Infections: TORCH* infections, hepatitis viruses and EBV and malaria.
Metabolic: galactosaemia, lipid storage disorders, e.g. 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: antituberculous medications for example.

Hepatomegaly

With normal bilirubin: consider hepatoblastoma, metabolic diseases.
With raised conjugated bilirubin:
- With splenomegaly: TORCH infections, sepsis and disorders of carbohydrate metabolism, e.g. galactosaemia.
- Without splenomegaly: liver tumour, choledochal cyst, biliary atresia, neonatal hepatitis.
With raised unconjugated bilirubin: CCF. toxins, haemolytic anaemias.

*TORCH is an acronym for TOxoplasmosis, Rubella, CMV and Herpes Simplex.
Some use the “O” to stand for Other Infections: ie Hepatitis B, Syphilis and Varicella Zoster

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, 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).

Document references

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. and Clayden, G. Illustrated textbook of Paediatrics, 1997, Mosby.

Internet and further reading

Medline Plus - Hepatomegaly

Acknowledgements

EMIS is grateful to Dr Gurvinder Rull for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
Document ID: 785
Document Version: 22
Document Reference: bgp92
Last Updated: 5 Jul 2009

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