Hepatomegaly-clinical aspects

                                             Hepatomegaly-clinical aspects

Hepato megaly is enlargement of liver.

A diseased liver may be of normal size or shrunken also.

A palpable liver

may not be due to hepatomegaly.

Non enlarged palpable liver occurs in

,

· Emphysema,

· Sub phrenic abscess

· Visceroptosis

· Normal in children

· Aberrant lobe of liver-Riedels lobe

Causes

.

I.Generalized Enlargement

II.  Localised enlargement

      

  HEPATOMEGALY :LOCALISED ENLARGEMENT

     1.Amoebic abscess
      2.Hydatid cyst
      3.Polycystic liver
      4.Actinomycosis
      5.Primary/secondary malignancy liver
     6. hepatic adenoma
     7. Riedels Lobe liver

Common causes of Hepatomegaly

• CCF
• Secondary deposits in liver
• Infective causes
• Alcoholic liver
• Lymphoma
• Leukemia

Points of importance in clinical examination in Hepatomegaly

Summary information elicitable from history:

•   .Are there risk factors for liver disease?

•   Symptoms associated with liver disease

Note: liver does not contain nerves.

If massive, causes abdominal discomfort and feeling of fullness

Pain of enlarged liver is due to stretching of the capsule

History

Present history:

Fever

Viral hepatitis,typhoid,malaria,kala azar,TB Dysentery,

Gall stones CCF Alcoholism DM Malignancy

Abdominal symptoms-

Loss of appetite, nausea, vomiting, hemetemesis, melena, jaundice, pruritis 
Past history: Jaundice,tattoing,transfusion,diet,drugs,alcoholism,hemetemesis,melena 
Contact history:

TB,dog(hydatid)

Occupational

Personal History:Alcoholism

Family history:

Wilsons disease, hemochromotosis, 1 antitrypsin deficiency

Jaundice+fever: Infective hepatitis Leptospirosis Cholecystitis

:

Physical examination

Inspection

•   Localised swelling-Abscess,tumor

•   Pulsatile Liver – in

Tricuspid incompetence(systolic) Tricuspid stenosis(diastolic)

Palpation

•   Tenderness-Infective,congestive/malignant liver,hepatic amoebiasis,hepatic abscess

•   Consistency

Soft-CCF,acute viral hepatitis,acute malaria,typhoid,fatty liver

Firm liver-Cirrhosis,chronic malaria,K.azar,lymphoma

Rock hard- malignant

Nodular-finely granular-cirrhosis;coarsely nodular-malignancy, Hydatid cyst

•   Edge- Rounded in hepatitis,CCF,

Sharp- malignancy

•   Palpable gall bladder-pancreatic Cancer

Percussion

•   Upward enlargement-Amoebic abscess

•   Down ward enlargement- other hepatomegalies

Liver span

It is vertical distance between uppermost and lower most points of liver dullness-in Rt mid

clavicular line-Normal-12-15 cm

---

Diminished liver dullness Terminal stage of portal cirrhosis Acute fulminant hepatitis 
Percussion of upper border

In Rt.pneumothorax and emphysema upper border cannot be percussed.

Apparent diminution of liver dullness:

In perforation and in excessive gaseous distension

` Auscultation

Bruit over the liver- malignancy,hemangioma of liver

Venous hum-between xiphoid and umbilicus- in portal hypertension with collaterals

Hepatic rub- In tumor, After biopsy, perihepatitis

Other associated physical exam findings to look for: Jaundice,vascular spiders,palmar erythema,gynecomatia,testicular atrophy,Ascites,splenomegaly,peripheral edema

Their presence supports further diagnostic testing

Other masses which can simulate liver enlargement

Ca.Stomach,malignancy of right kidney,Ca.gall bladder,Ca.colon, omental mass

Degree of enlargement of liver

Mild:  1-2 fingers breadth below the costal margin

Moderate: 2-5 fingers breadth below the costal margin

Massive: more than 5 fingers breadth below the costal margin.

Causes of massive hepatomegaly; Malignancy;primary/secondary Congestive cardiac failure

Fatty infiltration Amyloid Hodgkins

Poly cystic liver

Rapid decrease in liver Size Improvement in CCF Mobilisation of fat from liver Massive hepatic necrosis

Atrophy of liver

Occurs in

Severe acute liver damage Cause-fulminant viral hepatitis Hepatic toxins

cirrhosis

(Atrophy of liver is detected by percussion of lower border. Area of percussion extends above costal margin)

Rapid enlargement of liver

Malignancy of liver

Amoebic abscess

Enlargement of left lobe of liver

Amoebic abscess

Hepatoma Secondaries Gumma of the liver

Causes of Hepatomegaly with splenomegaly

Same causes of splenomegaly

Hepatomegaly with generalized lymph adenopathy

Miliary tuberculosis

Leukemia

Lymphoma

Inectious mononucleosis

Hepatomegaly with pigmentation

Haemochromotosis(bronze liver)

Hepatomegaly with jaundice:

Acute viral hepatitis

Hemolytic jaundice Carcinoma of liver Cirrhosis of liver Cholangio hepatitis Leptospirosis

Lymphoma with lymphnodes at porta hepatis

Jaundice is rare in hepatoma

Drugs and liver

Cholestatic:

Erythromycin,oral contraceptives,anabolic steroids,anti thyroid, largactil,chemotherapeutics.

Hepato cellular damage:

Methyl dopa,eptoin,INH,Rifa,Halothane

Fatty liver: Tetracycline,valproic acid Granuloma

Phenyl butazone,Sulpha,allopurinol

Toxic agents

Metal- yellow phosphorous

Mush room

Hydrocarbon-carbon tetrachloride

Arsenic

 INVESTIGATIONS

               

Initial lab tests: Complete blood count Urea,creatinine,electrolytes,glucose

Liver function tests and liver enzyme tests

If liver enzymes elevated,hepatitis serology panel included

Diagnostic testing :

1.Ultrasoud abdomen especially Rt. upper quadrant

2.xray chest

3.Kidney ,urinary tract  bladder functions

4. CT SCAN: If USG non diagnostic,or if malignancy suspected

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