Hepatomegaly
Hepatomegaly: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Hepatomegaly, an enlarged liver, indicates potentially reversible primary or secondary liver disease. This sign may stem from diverse pathophysiologic mechanisms, including dilated hepatic sinusoids (in heart failure), persistently high venous pressure leading to liver congestion (in chronic constrictive pericarditis), dysfunction and engorgement of hepatocytes (in hepatitis), fatty infiltration of parenchymal cells causing fibrous tissue (in cirrhosis), distention of liver cells with glycogen (in diabetes), and infiltration of amyloid (in amyloidosis).
Hepatomegaly may be confirmed by palpation, percussion, or radiologic tests. It may be mistaken for displacement of the liver by the diaphragm (in a respiratory disorder), by an abdominal tumor, by a spinal deformity such as kyphosis, by the gallbladder, or by fecal material or a tumor in the colon.
History and physical examination
Hepatomegaly is seldom a patient’s reason for seeking care. It usually comes to light during palpation and percussion of the abdomen.
If you suspect hepatomegaly, ask the patient about his use of alcohol and exposure to hepatitis. Also ask if he’s currently ill or taking any prescribed drugs. If he complains of abdominal pain, ask him to locate and describe it.
Inspect the patient’s skin and sclerae for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (common in cirrhosis). Next, inspect the contour of his abdomen. Is it protuberant over the liver or distended (possibly from ascites)? Measure his abdominal girth.
Percuss the liver, being careful to identify structures and conditions that can obscure dull percussion notes, such as the sternum, ribs, breast tissue, pleural effusions, and gas in the colon. (See Percussing for liver size and position.) Next, palpate the liver’s edge during deep inspiration; it’s tender and rounded in hepatitis and cardiac decompensation, rocklike in carcinoma, and firm in cirrhosis.
Take the patient’s baseline vital signs, and assess his nutritional status. An enlarged liver that’s functioning poorly causes muscle wasting, exaggerated skeletal prominences, weight loss, thin hair, and edema.
Evaluate the patient’s level of consciousness. When an enlarged liver loses its ability to detoxify waste products, metabolic substances toxic to brain cells accumulate. As a result, watch for personality changes, irritability, agitation, memory loss, inability to concentrate, poor mentation, and—in a severely ill patient—a coma.
Medical causes
Amyloidosis
This rare disorder can cause hepatomegaly and mild jaundice as well as renal, cardiac, and other GI effects.
Cirrhosis
Late in this disorder, the liver becomes enlarged, nodular, and hard. Other late signs and symptoms affect all body systems. Respiratory findings include limited thoracic expansion due to abdominal ascites, leading to hypoxia. Central nervous system findings include signs and symptoms of hepatic encephalopathy, such as lethargy, slurred speech, asterixis, peripheral neuritis, paranoia, hallucinations, extreme obtundation, and coma. Hematologic signs include epistaxis, easy bruising, and bleeding gums. Endocrine findings include testicular atrophy, gynecomastia, loss of chest and axillary hair, and menstrual irregularities. Integumentary effects include abnormal pigmentation, jaundice, severe pruritus and dryness, poor tissue turgor, spider angiomas, and palmar erythema.
The patient may also develop fetor hepaticus, enlarged superficial abdominal veins, muscle atrophy, right-upper-quadrant pain that worsens when he sits up or leans forward, and a palpable spleen. Portal hypertension—elevated pressure in the portal vein—causes bleeding from esophageal varices.
Diabetes mellitus
Poorly controlled diabetes in overweight patients commonly produces fatty infiltration of the liver, hepatomegaly, and right-upper-quadrant tenderness along with polydipsia, polyphagia, and polyuria. These features are more common in type 2 than in type 1 diabetes. A chronically enlarged fatty liver typically produces no symptoms except for slight tenderness.
Granulomatous disorders
Sarcoidosis, histoplasmosis, and other granulomatous disorders commonly produce a slightly enlarged, firm liver.
Heart failure
This disorder produces hepatomegaly along with jugular vein distention, cyanosis, nocturia, dependent edema of the legs and sacrum, steady weight gain, confusion and, possibly, nausea, vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Massive right-sided heart failure may cause anasarca, oliguria, severe weakness, and anxiety. If left-sided heart failure precedes right-sided heart failure, the patient exhibits dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachypnea, arrhythmias, tachycardia, and fatigue.
Hemochromatosis
This rare disease of iron metabolism causes hepatomegaly, altered skin pigmentation and, possibly, cardiac failure.
Hepatic abscess
Hepatomegaly may accompany fever (a primary sign), nausea, vomiting, chills, weakness, diarrhea, anorexia, elevated right hemidiaphragm, and right-upper-quadrant pain and tenderness.
Hepatitis
In viral hepatitis, early signs and symptoms include nausea, anorexia, vomiting, fatigue, malaise, photophobia, sore throat, cough, and headache. Hepatomegaly occurs in the icteric phase and continues during the recovery phase. Also, during the icteric phase, the early signs and symptoms diminish and others appear: liver tenderness, slight weight loss, dark urine, clay-colored stools, jaundice, pruritus, right-upper-quadrant pain, and splenomegaly.
Leukemia and lymphomas
These proliferative blood cell disorders commonly cause moderate to massive hepatomegaly and splenomegaly as well as abdominal discomfort. General signs and symptoms include malaise, low-grade fever, fatigue, weakness, tachycardia, anorexia, weight loss, and bleeding disorders.
Liver cancer
Primary tumors commonly cause an enlarged, irregular, nodular, firm liver with pain or tenderness in the right upper quadrant and a friction rub or bruit over the liver. Common related findings are anorexia, weight loss, cachexia, nausea, and vomiting. Peripheral edema, ascites, jaundice, and a palpable right-upper-quadrant mass may also develop. When metastatic liver tumors cause hepatomegaly, the patient’s signs and symptoms reflect his primary cancer.
Mononucleosis (infectious)
Occasionally, this disorder causes hepatomegaly. Prodromal symptoms include headache, malaise, and fatigue. After 3 to 5 days, the patient typically develops a sore throat, cervical lymphadenopathy, and temperature fluctuations. He may also develop stomatitis, palatal petechiae, periorbital edema, splenomegaly, exudative tonsillitis, pharyngitis and, possibly, a maculopapular rash.
Obesity
Hepatomegaly can result from fatty infiltration of the liver. Weight loss reduces the liver’s size.
Pancreatic cancer
In this disease, hepatomegaly accompanies such classic signs and symptoms as anorexia, weight loss, abdominal or back pain, and jaundice. Other findings include nausea, vomiting, fever, fatigue, weakness, pruritus, and skin lesions (usually on the legs).
Pericarditis
In chronic constrictive pericarditis, an increase in systemic venous pressure produces marked congestive hepatomegaly. Distended jugular veins (more prominent on inspiration) are a common finding. The usual signs of heart disease typically are absent; other features include peripheral edema, ascites, fatigue, and decreased muscle mass.
Other causes
Drugs
Hepatomegaly is a rare but serious side effect of drugs used to treat HIV-positive hepatitis, such as tenofovir and lamivudine.
Special considerations
Prepare the patient for hepatic enzyme, alkaline phosphatase, bilirubin, albumin, and globulin studies to evaluate liver function, and for X-rays, liver scan, celiac arteriography, computed tomography scan, and ultrasonography to confirm hepatomegaly.
Bed rest, relief from stress, and adequate nutrition are important for the patient with hepatomegaly to help protect liver cells from further damage and to allow the liver to regenerate functioning cells. Dietary protein intake may need to be monitored and possibly restricted. Ammonia, a major cause of hepatic encephalopathy, is a byproduct of protein metabolism. Hepatotoxic drugs or drugs metabolized by the liver should be given in very small doses, if at all. Expalin these treatment measures to the patient.
Pediatric pointers
Assess hepatomegaly in children the same way you do in adults. Childhood hepatomegaly may stem from Reye’s syndrome; biliary atresia; rare disorders, such as Wilson’s disease, Gaucher’s disease, and Niemann-Pick disease; or poorly controlled type 1 diabetes mellitus.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
More About Chronic liver disease
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- JAUNDICE
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- "Differential Diagnosis in Primary Care" (2007)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Jaundice
- "A Pocket Manual of Differential Diagnosis" (1999)
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- Fatty liver
- "Professional Guide to Diseases (Eighth Edition)" (2005)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Hepatomegaly
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Jaundice
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Jaundice
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Hepatomegaly
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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- Jaundice
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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- JAUNDICE
- "Differential Diagnosis in Primary Care" (2007)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Asterixis [Liver flap, flapping tremor] (Professional Guide to Signs & Symptoms (Fifth Edition))
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