Hepatomegaly
Hepatomegaly: Excerpt from Handbook of Signs & Symptoms (Third 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 chief complaint. 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 sclera for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (commonly occurring 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, but be 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, during deep inspiration, palpate the liver’s edge; 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, the result is accumulation of metabolic substances toxic to brain cells. As a result, watch for personality changes, irritability, agitation, memory loss, an inability to concentrate and poor mentation, and — in a severely ill patient — coma.
Medical causes
Amyloidosis
Amyloidosis is a rare disorder that may cause hepatomegaly and mild jaundice as well as renal, cardiac, and other GI effects.
Cirrhosis
Late in cirrhosis, 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, or menstrual irregularities. Integumentary effects include abnormal pigmentation, jaundice, severe pruritus, extreme 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 such disorders commonly produce a slightly enlarged, firm liver.
Hepatic abscess
Hepatomegaly may accompany a fever (a primary sign), nausea, vomiting, chills, weakness, diarrhea, anorexia, an 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, a sore throat, a cough, and a 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
Leukemia and lymphomas are proliferative blood cell disorders that typically cause moderate to massive hepatomegaly and splenomegaly as well as abdominal discomfort
General signs and symptoms include malaise, a low-grade fever, fatigue, weakness, tachycardia, weight loss, bleeding disorders, and anorexia.
Liver cancer
Primary tumors commonly cause irregular, nodular, firm hepatomegaly, with pain or tenderness in the right upper quadrant and a friction rub or bruit over the liver Common related findings are weight loss, anorexia, 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 accompanying signs and symptoms reflect his primary cancer.
Mononucleosis (infectious)
Occasionally, infectious mononucleosis causes hepatomegaly
Prodromal symptoms include a 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 pancreatic cancer, hepatomegaly accompanies such classic signs and symptoms as anorexia, weight loss, abdominal or back pain, and jaundice Other findings include nausea, vomiting, a 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 cardiac disease typically are absent; other features include peripheral edema, ascites, fatigue, and decreased muscle mass.
Special considerations
Prepare the patient for liver enzyme, alkaline phosphatase, bilirubin, albumin, and globulin studies to evaluate liver function and for X-rays, a liver scan, celiac arteriography, a 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 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. These treatment measures should be explained 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, Gaucher’s, and Niemann-Pick diseases; or poorly controlled type 1 diabetes mellitus.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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