Hepatomegaly

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

Hepatomegaly is seldom a patient’s chief complaint. It’s usually discovered 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.

Physical assessment

Inspect the patient’s skin and sclerae for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (often 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, inability to concentrate and poor mentation, and — in a severely ill patient — coma.

Medical causes

Cirrhosis

In late 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 can produce 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.

Heart failure

Heart failure produces hepatomegaly along with jugular vein distention, cyanosis, nocturia, dependent edema of the legs and sacrum, steady weight gain, confusion and, possibly, nausea, vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Massive right-sided heart failure may cause anasarca, oliguria, severe weakness, and anxiety. If left-sided heart failure precedes right-sided heart failure, the patient exhibits dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, tachycardia, and fatigue.

Hepatitis

In viral hepatitis, early signs and symptoms include nausea, anorexia, vomiting, fatigue, malaise, photophobia, sore throat, cough, and 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 commonly cause moderate to massive hepatomegaly and splenomegaly as well as abdominal discomfort. General signs and symptoms include malaise, 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 headache, malaise, and fatigue. After 3 to 5 days, the patient typically develops 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. Obesity may also produce findings related to respiratory difficulties, hypertension, cardiovascular disease, diabetes, renal disease, gallbladder disease, and psychological difficulties.

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, fever, fatigue, weakness, pruritus, and skin lesions (usually on the legs).

Special considerations

Prepare the patient for hepatic enzyme, alkaline phosphatase, bilirubin, albumin, and globulin studies to evaluate liver function, and for X-rays, liver scan, celiac arteriography, 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 by-product 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 disease, Gaucher’s disease, and Niemann-Pick disease; or poorly controlled type 1 diabetes mellitus.

Patient counseling

Instruct the patient to avoid alcohol. Explain the importance of following the treatment plan to correct or control the underlying disorder as needed. Tell the patient to avoid exposure to people with infections and to maintain good personal hygiene. Explain the importance of pacing activities and having frequent rest periods.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Liver pain

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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.

More About Causes of Liver pain

• Back to symptom: Liver pain: Introduction (review 28 causes)
• Next Book Extract About Liver pain: Jaundice (Signs & Symptoms: A 2-in-1 Reference for Nurses)
• All Book Extracts: All Online Book Extracts for Liver pain

More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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