Hepatomegaly

Hepatomegaly is enlargement of the liver. The liver edge is normally palpable in children and thin adults and some patients may have a palpable right lobe of the liver. It is smooth, uniform, non-tender and descends to meet the palpating fingers on inspiration. The best way to assess size is by percussion - a normal-sized liver can appear enlarged if displaced downwards by lung disorders. An enlarged liver expands down and across towards the left iliac fossa (LIF). To avoid missing a really big liver, always begin liver palpation in the LIF and work towards the right upper quadrant.

Presentation

Associated symptoms may be few or rather vague - eg, loss of appetite, weight loss and lethargy. There may be symptoms relating to liver dysfunction - eg, jaundice, bruising, gynaecomastia, spider naevi, ascites; or related to the underlying cause - eg, xanthelasma suggests autoimmune liver disease. Measure the hepatomegaly by percussing the upper and lower borders (will rule out causes such as emphysema which can push the liver down giving a false impression of hepatomegaly).

On palpation

Smooth hepatomegaly suggests: hepatitis, chronic heart failure, sarcoid, early alcoholic cirrhosis, tricuspid incompetence with a pulsatile liver. Craggy hepatomegaly suggests: primary hepatoma or secondary tumours.

NB: a small liver is typical in late cirrhosis and nodular cirrhosis typically produces a small shrunken liver not a large craggy one. Ask particularly about alcohol consumption, sexual activity, IV drug abuse, blood transfusions and recent travel.

Aetiology
Venous congestion failure

Viral hepatitis (acute and chronic). Infectious mononucleosis Epstein-Barr virus (EBV). Cytomegalovirus (CMV). Malaria. Helminthic infection. Pyogenic abscess.

Amoebic abscess. Biliary disease

Autoimmune

Autoimmune liver disease.

Extra-hepatic obstruction. Primary biliary cirrhosis. Primary sclerosing cholangitis.

Tumours and infiltrative diseases

Secondaries (metastatic carcinoma). Primary hepatic tumour - eg hepatocellular carcinoma. Granulomatous hepatitis. Amyloidosis. Sarcoidosis.

Haematological disorders

Sickle cell disease. Haemolytic anaemia. Myeloma. Leukaemia or lymphoma.

Metabolic

Toxic/drug-related

Haemochromatosis. Wilson's disease. Glycogen storage diseases. Porphyria. Non-alcoholic fatty liver disease. DM-associated fatty liver.

Alcoholic liver disease: acute alcoholic hepatitis and alcoholic fatty liver. Drug-induced hepatitis - eg, statins, macrolides, amiodarone, paracetamol (indicates significant damage).

Hepatomegaly in neonates and children

Infections: TORCH* infections, hepatitis viruses and EBV and malaria. Metabolic: galactosaemia, lipid storage disorders - eg, Gaucher's disease. Neoplastic: leukaemia, lymphoma and hepatoblastoma. Haematological: sickle cell anaemia and thalassaemia. Cardiovascular: congestive cardiac failure and tricuspid regurgitation. Miscellaneous: schistosomiasis, toxins, sepsis, polycystic kidneys and liver. Drugs: for example, antituberculous medications.

Hepatomegaly

With normal bilirubin: consider hepatoblastoma, metabolic diseases. With raised conjugated bilirubin: o With splenomegaly: TORCH infections, sepsis and disorders of carbohydrate metabolism - eg, galactosaemia.

Without splenomegaly: liver tumour, choledochal cyst, biliary atresia, neonatal hepatitis. With raised unconjugated bilirubin: CCF, toxins, haemolytic anaemias.

*TORCH is an acronym for TOxoplasmosis, Rubella, CMV and Herpes simplex. Some use the 'O' to stand for 'Other infections': ie hepatitis B, syphilis and varicella zoster.

What to do if a patient has hepatomegaly

If unwell, may need urgent admission. Full history - include recent travel, tattoos, IV drug abuse, medications including herbal remedies, alcohol intake and sexual history. Full examination - look for stigmata of chronic liver disease, delirium tremens, lymphadenopathy, and presence of splenomegaly; digital rectal examination may be necessary. If the patient does not need urgent admission then request some basic investigations - eg, LFTs, liver ultrasound scan, hepatitis screen. Further tests can be decided according to the results of these tests. Consider referral to a specialist (CT scan or liver biopsy may be needed).

Further reading & references

Hepatomegaly, Medline Plus

1. French's Index of Differential Diagnosis, 13th ed, (1997) Butterworth Heinemann; ISBN 0-7506-1434-X 2. Professional guide to Signs and Symptoms, 3rd ed. Springhouse Corp. 2001 3. Harrison's Principles of Internal Medicine, 15th Ed. Eds: Braunwald, E et al. McGrawHill, USA, 2001 4. Kumar P, Clarke M; Clinical Medicine, 6th Ed, (2005). WB Saunders: London 5. Lissauer T, Clayden G; Illustrated textbook of Paediatrics, 1997, Mosby Original Author: Dr Gurvinder Rull Last Checked: 10/12/2012 Current Version: Dr Gurvinder Peer Reviewer: Dr Helen Rull Huins Document ID: 785 Version: 23 EMIS

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