Hepatomegaly

• Inflammatory disorders, resulting in tender hepatomegaly
  –Hepatitis (viral or drug-induced): Associated with jaundice, fever, nausea, vomiting, fatigue, diarrhea, weight loss
  –Alcoholic liver disease: Associated with liver failure and portal hypertension (e.g., caput medusae, spider angiomata, hemorrhoids, testicular atrophy, ALT is more than two times higher than AST)
• Infiltrative disorders
  –Fatty liver (NASH): Predisposing factors include middle age, obesity, female gender, diabetes, and hyperlipidemia
  –Sarcoidosis: Associated with cough, hilar lymphadenopathy; more common in blacks, women, ages 30–40
  –Hemochromatosis: Iron overload resulting in bronzed skin color, diabetes, abnormal iron panel
  –Wilson's disease: Copper excess resulting in liver failure, lenticular degeneration, and Kayser-Fleischer rings in cornea
• Neoplasms present with focal enlargement, arterial bruit and/or hepatic rub, and constitutional symptoms (e.g., fever, night sweats, weight loss)
  –Metastatic cancer is more common than primary liver cancers (colon, lung, breast)
  –Hepatocellular carcinoma is most common primary liver cancer (often due to chronic hepatitis or cirrhosis)
  –Hepatic adenoma or hepatic cysts
  –Leukemia/lymphoma

• Liver abscess
• Less common causes (“zebras”) include tricuspid regurgitation, Budd-Chiari syndrome, schistosomiasis, amyloidosis, kala-azar (visceral leishmaniasis), and HIV/AIDS

Workup and Diagnosis

• History should include past medical history, alcohol and drug use, medications (including herbal remedies), family history of liver disease, and presence of constitutional symptoms
• Physical exam should include palpation of liver surface for tenderness, consistency, nodularity, pulsations, bruits, rubs; skin examination (e.g., for jaundice, spider angiomata); cardiac exam; lymphadenopathy
• Liver function tests (ALT, AST, GGTP, albumin) and coagulation tests (PT/PTT/INR) to assess liver function
• Hepatitis serologies may be indicated, including hepatitis A, B, and C; CMV; and EBV
• Ultrasound will discriminate solid masses from cysts
• Abdominal CT to evaluate masses and fatty liver
• Doppler ultrasound to determine blood flow
• MRI of abdomen is useful to diagnose excess deposition of iron (hemochromatosis) or copper (Wilson's disease)
• Radionuclide scanning to characterize inflammatory and neoplastic lesions
• Angiography is the gold standard to differentiate hemangioma from solid tumor
• Iron panel (hemochromatosis) and ceruloplasmin (Wilson's disease)
• Consider gastroenterology consultation

Treatment

• Heart failure: Diuretics, inotropes, and afterload reduction
• Viral hepatitis: Supportive care and antivirals in some chronic cases
• Alcoholic liver disease: Abstinence from alcohol, steroids in severe cases, and possible transplant
• Fatty liver: Treat underlying obesity, diabetes, hyperlipidemia
• Sarcoidosis: Steroids
• Hemochromatosis: Iron removal by weekly phlebotomy for 2–3 years and/or deferoxamine chelation
• Wilson's disease: Copper chelation with D-penicillamine or trientine; may require liver transplantation
• Neoplasms: Resection and chemotherapy
• Abscess or cyst: Antimicrobials, percutaneous drainage, and/or surgical resection
• Amyloidosis: Prednisone and alkylating agents

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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