Hepatomegaly

Hepatomegaly: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Acute hepatitis

❑ Chronic hepatitis

❑ Cirrhosis

❑ Right heart failure

❑ Fatty liver

❑ Hepatocellular carcinoma

❑ Metastatic cancer

❑ Lymphoma/leukemia

❑ Liver cysts

❑ Hepatic vein obstruction (Budd-Chiari)

❑ Primary biliary cirrhosis

❑ Hemochromatosis

❑ Amyloidosis

❑ Gaucher

Diagnostic Approach

The mean liver span is 10.5 cm in men and 7 cm in women. Larger span
correlates with greater height. A span 2 to 3 cm larger or smaller than these values is considered abnormal. The liver may be palpable but not enlarged (normal span) with emphysema, right-sided pleural effusion, Riedel lobe, and thin body habitus.

An hepatic arterial bruit is heard with alcoholic hepatitis or cancer, either primary or metastatic. A friction rub may be heard with perihepatitis, metastatic cancer, or after liver biopsy.

Clinical Findings

Acute hepatitis  The liver edge is smooth and usually quite tender. Fever, malaise, anorexia, nausea, and jaundice are usually present.

Chronic hepatitis  The liver edge is firm and tender.

Cirrhosis  The liver edge is firm and may have small nodules, especially as it begins to shrink in size in the later stages. The nodules are small in alcoholic or nutritional cirrhosis, and large with posthepatic causes. The spleen is usually enlarged, with ascites present. Other stigmata, such as vascular spiders, venous dilation on the abdominal surface, and palmar erythema, are helpful clues. An abdominal venous hum is virtually diagnostic of portal hypertension due to cirrhosis.

Right heart failure  The liver may be mildly to massively enlarged, with a firm, smooth, and tender surface. Hepatojugular reflux can often be demonstrated. A pulsating liver suggests tricuspid regurgitation.

Fatty liver  The liver surface is smooth and pliant and may be tender because of capsular distension. Suspect in alcohol binging, obesity, total parenteral nutrition, pregnancy, protein-calorie malnutrition, and jejunoileal bypass.

Hepatocellular carcinoma  The liver edge is hard, irregular, and nontender. The liver may be massively enlarged. The patient often has a history of chronic hepatitis B.

Metastatic cancer  The liver has an irregular, nodular, nontender surface. It is unusual for hepatomegaly to be the initial manifestation except in adenocarcinoma of unknown origin. Left supraclavicular adenopathy is a key clue if present.

Lymphoma/leukemia  Lymphadenopathy and splenomegaly are usually prominent, and night sweats are common. Hepatomegaly can also be found in 50% of patients with acute leukemia.

Liver cysts  Cysts feel spherical and fluid-filled even through the abdominal wall. They occur in 30% of patients with adult polycystic kidney disease.

Hepatic vein obstruction (Budd-Chiari)  Painful liver enlargement, ascites, signs of cirrhosis, and other thromboses are often seen.

Primary biliary cirrhosis  Marked pruritis, jaundice, splenomegaly, and an enlarged, firm, smooth liver are seen.

Hemochromatosis  Suspect hemochromatosis in a patient with diabetes, congestive heart failure, and bronze skin coloration. Other signs of cirrhosis are present, including ascites and spider angiomata.

Amyloidosis  Clues are enlargement of other viscera, such as the tongue, spleen, and heart, and peripheral neuropathy. There is usually an underlying disease producing chronic inflammation, or myeloma.

Gaucher  It may present with hepatosplenomegaly as late as the third decade in Ashkenazi Jews.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 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: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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