Hepatomegaly
Hepatomegaly: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Darryl G. White and Bruce A. Leibert
Approach
Hepatomegaly is a physical sign noted on abdominal examination that is present in hepatobiliary disease but is not specific or sensitive to one cause. Defining hepatomegaly can be enigmatic because of the highly variable liver size, which makes establishment of what constitutes normal somewhat difficult. The normal adult liver spans 8 to 12 cm for men and 6 to 10 cm for women, in the midclavicular line. Calculation methods for estimating liver size have been developed but they do not correlate well with percussion or ultrasound (1,2). Physical examination estimation of liver size and the clinical ability to suspect hepatomegaly are necessary to proceed with an appropriate workup.
History
A. Does the patient have known risk factors for liver disease (Table 9.5)?
B. Does the patient have symptoms associated with liver disease (Table 9.6)?
Physical examination
A. How does a clinician diagnose hepatomegaly?
1. Palpation and percussion. Evaluation of the liver is difficult given its irregular shape and its location within the abdomen. Approach palpation of the right upper quadrant from one of two directions: palpate from below using the fingertips to palpate superiorly or from above with the fingertips hooked over the lower rib. Either method is facilitated by the patient’s deep inspiration. Palpation must include the midline to identify an enlarged left lobe of the liver. On palpation, note the liver position, the extent of its palpation below the costal margin, and its texture and consistency. Palpate for the lower edge and percuss for the upper margin. These two points give the highest accuracy in estimating liver size. If the margin is not palpated but hepatomegaly is suspected, then attempt direct percussion of both margins.
2. Auscultation. The “scratch method” (gently stroking or scratching the skin surface in a parallel plane while listening with the stethoscope for change in sound and intensity of frequency) has been used to identify margins; however, a recent study by Tucker comparing ultrasound to the results of the scratch test found that this test was unreliable and inaccurate (3). Auscultation of the right upper quadrant has been described and several findings can be noted: friction rubs, bruits, and abnormal pulsations.
3. Other associated signs. Associated physical examination findings include jaundice, vascular spiders, palmar erythema, gynecomastia, ascites, splenomegaly, testicular atrophy, peripheral edema, Dupuytren’s contracture, parotid enlargement, and encephalopathy. Although none of these physical examination signs are pathognomonic for hepatobiliary disease, their presence in the setting of hepatomegaly support further diagnostic testing.
B. How accurate is the physical assessment? Palpation of the liver 2 cm below the costal margin correlates with a 50% chance of having hepatomegaly on further diagnostic workup. A 63% chance exists that a palpable liver relates to liver disease (4). The converse is also true: A nonpalpable liver could also be enlarged, therefore, the need for further assessment should be based on clinical context and associated signs. The liver span has classically been measured in the midclavicular line, although some have suggested that the use of the midclavicular line is too inaccurate. Several studies have attempted to establish a new reference point but no consensus has developed. Direct percussion (lightly tapping with index finger) is more accurate in identifying the extent of the margins than indirect percussion. Indirect percussion (heavy tapping of one finger against another finger held against the body firmly) often will not illicit a change over the thin lower margin or detect a change at the upper margin, depending on the contour of the diaphragm and the volume of the lower lungs (2). Nuclear medicine scintigraphy or ultrasound study defines hepatomegaly as greater than 15.5 cm. Studies comparing physical examination to these modalities have not shown physical examination to be accurate or consistent, with high interexaminer differences. Skrainka et al. evaluated liver size estimation by direct percussion, indirect percussion, palpation, and ultrasound. His results demonstrated that experienced clinicians (medicine consultants) accurately assessed liver size compared with ultrasound and that direct percussion measurements correlated the best with liver size in all groups (5).
Testing
A. What are appropriate diagnostic tests in the setting of hepatomegaly? An ultrasound of the right upper quadrant should be obtained, as well as a chest x-ray, and kidney, urinary tract, and bladder studies. Initial laboratory evaluation should include a complete blood count, electrolytes, creatinine, glucose, liver enzyme testing (alanine aminotransferase, aspartame transferase, γ-glutamyl transpeptidase, alkaline phospatase), and true liver function tests (albumin, prothrombin time, partial thromboplastin time and bilirubin). If liver enzymes are elevated, a hepatitis serology panel is added. Nondiagnostic ultrasound or hepatic masses should prompt computed tomography scan. Further differential testing is shown in Table 9.7.
B. Liver biopsy is indicated for unexplained hepatomegaly or jaundice, persistent abnormal liver tests, chronic viral hepatitis, suspected cirrhosis or portal hypertension, primary or secondary malignancy, suspected hemochromatosis, suspected Wilson’s disease, and hepatic dysfunction following liver transplantation.
Diagnostic assessment
How are the physical examination findings used to form a differential diagnosis?
A. Smooth nontender liver: suspect fatty infiltration, congestive heart failure (CHF), portal cirrhosis, primary biliary cirrhosis, lymphoma, portal obstruction, hepatic venous thrombosis, hepatic vein thrombosis, lymphocytic leukemia, amyloidosis, schistosomiasis, or kala-azar.
B. Smooth tender liver: suspect early CHF, acute hepatitis, amoebic abscess, or hepatic abscess.
C. Nodular liver: suspect late portal cirrhosis, tertiary syphilis, hydatid cyst, or metastatic carcinoma.
D. Very hard nodular liver: nearly always indicates metastatic carcinoma.
Summary
The combination of history, physical examination, and appropriate laboratory studies should yield a quick and accurate diagnosis. New therapies for chronic liver disease, specifically chronic viral liver diseases, make the early diagnosis and accurate identification of hepatobiliary disease highly beneficial to patients. Any suspected liver disease should be pursued completely.
References
1. Castell DO, O’Brien KD, Muench H, Chalmers TC. Estimation of liver size by percussion in normal individuals. Ann Intern Med 1969;70:1183–1189.
2. Naylor CD. Physical examination of the liver. JAMA 1994;27:1859–1865.
3. Tucker WN, Saab S, Leland SR, Matthews WC. The scratch test is unreliable for determining the liver edge. J Clin Gastroenterol 1997;25:410–414.
4. Rosenfield AT, Laufer I, Schneider PB. The significance of a palpable liver: a correlation of clinical and radioisotope studies. Am J Roentgenol Radium Ther Nucl Med 1974;122:313–317.
5. Skrainka B, Stahlhut J, Knight F, Holmes RA, Butt JH. Measuring liver span: bedside examination versus ultrasound and scintiscan. J Clin Gastroenterol 1986;8:
267–270.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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