HEPATOMEGALY
HEPATOMEGALY: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the Following Questions:
- Is there jaundice? Hepatomegaly with jaundice may make one think of hemolytic anemias; toxic or infectious hepatitis; bile duct obstruction due to stones, carcinoma of the pancreas, or ampulla of Vater; and biliary cirrhosis.
- Is there fever? Hepatomegaly with fever should make one think of viral hepatitis, infectious mononucleosis, ascending cholangitis, and other infectious diseases.
- Is there splenomegaly? Hepatomegaly and splenomegaly should make one think of alcoholic cirrhosis, amyloidosis, reticuloendotheliosis, various hemolytic anemias, biliary cirrhosis, and myeloid metaplasia. It should also make one think of various parasitic diseases.
- Is there an enlarged gallbladder? The presence of hepatomegaly with jaundice and enlarged gallbladder is characteristic of bile duct obstruction due to carcinoma of the pancreas, bile ducts, or ampulla of Vater. The clinician should remember that hydrops of the gallbladder with a common duct stone can mimic the same clinical presentation.
- Is the splenomegaly massive? Massive splenomegaly is characteristic of Gaucher's disease, kala azar, and myeloid metaplasia. Occasionally, other forms of reticuloendotheliosis may also be associated with massive splenomegaly.
- Is there another abdominal mass? The presence of another abdominal mass suggests metastatic carcinoma.
- Is the liver tender? Tenderness of the liver is seen with viral or toxic hepatitis, congestive heart failure, and ascending cholangitis.
DIAGNOSTIC WORKUP
Routine diagnostic studies include a CBC, sedimentation rate, ANA test, Monospot test, chemistry panel, chest x-ray, EKG, and flat plate of the abdomen.
If viral hepatitis is suspected, a hepatitis profile should be ordered. If congestive heart failure is suspected, a venous pressure and circulation time and pulmonary function tests should be done. A CT scan of the abdomen will assist in the diagnosis of metastatic carcinoma and often find a primary source for the metastasis. Metastatic neoplasms and the various forms of cirrhosis may be diagnosed by liver biopsy, but one should keep in mind that it is dangerous to do a liver biopsy if biliary cirrhosis is suspected. Gallbladder ultrasound or cholecystography should be done if cholecystitis and cholelithiasis are suspected. Transhepatic cholangiography or ERCP may need to be done. Exploratory surgery may be the only way to get a diagnosis, especially in obstructive jaundice.
The various infectious diseases will need antibody titers and skin tests to pin down the diagnosis. For example, a brucellin antibody titer or a Monospot test can be done. Skin tests for the various fungi and tuberculosis can be done.
The various hemolytic anemias may be diagnosed by blood smears, a sickle cell preparation, serum haptoglobin, and hemoglobin electrophoresis. The reticuloendothelioses require liver biopsy. Hemochromatosis is also diagnosed by liver biopsy, but a test for serum iron and iron-binding capacity should also be done. Wilson's disease is diagnosed by serum copper and ceruloplasmin tests. Venography will diagnose hepatic vein thrombosis.
Most physicians prefer to refer the patient with hepatomegaly to a gastroenterologist once the preliminary studies have been done. This would be the most cost-effective approach.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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