Hepatomegaly 2018-01-30T16:38:25+08:00

Relevant physical signs

  • General appearance: cachectic / well-nourished, skin colour, volume status
  • Hands: palmar erythema, Dupytren’s contracture, clubbing
  • Nail changes: koilonychia, leukonychia
  • Asterixis (hepatic encephalopathy)
  • Arms: tattoos, needle track marks
  • Eyes: jaundice, anaemia
  • Mouth: angular stomatitis
  • Tongue: macroglossia
  • Neck: JVP, lymph nodes (especially left supraclavicular)
  • Chest: spider naevi / gynaecomastia
  • Abdomen:
    • Inspection: scars: surgical scars, liver biopsy, paracentesis, bone marrow biopsy scar
    • Check for gross abdominal distension / eversion of umbilicus
    • General palpation: 9 areas
    • Palpation for liver from RIF > RHC
      • Tender / non-tender
      • Smooth / irregular edge
      • Measure degree of enlargement below costal margin
      • Hepatic bruit: alcoholic hepatitis, hepatic carcinoma
      • Hepatic venous hum: continuous murmur – portal hypertension
      • Percuss liver edge
    • Palpation and percussion for spleen: RIF > LIF
    • Umbilical nodule (Sister Mary Joseph nodule) – metastatic deposit suggesting underlying gastric / colonic malignancy
    • Palpate kidneys
    • Shifting dullness to detect ascites
    • Listen for bowel sounds, aortic / renal artery bruits
  • Fluid status: sacral oedema / pedal oedema
  • Complete examination by:
    • Looking at temperature chart
    • Digital rectal examination – masses / PR bleeding
    • Urine dipstick examination (haematuria as RCC can go to liver)

Differential diagnosis

  • Malignancy
    • Primary hepatocellular carcinoma
    • Secondary, e.g. breast, GI tract, bone, lung
    • Benign: cavernous haemangioma, hepatic adenoma
  • Chronic liver disease / cirrhosis
    • Alcoholic liver disease
    • Non-alcoholic steatohepatitis
    • Primary biliary cirrhosis
    • Haemochromatosis
  • Infiltrative
    • Amyloidosis
    • Sarcoidosis
    • Glycogen storage disorders
  • Infective
    • Acute hepatitis A/B/C, EBV/CMV
    • Chronic hepatitis B/C
    • Liver abscess
    • Hydatid disease
    • Toxoplasmosis
  • Vascular liver disease
    • Budd-Chairi syndrome
    • Sickle cell disease
  • Congestive liver disease
    • Right heart failure (e.g. secondary to tricuspid regurgitation)
    • Constrictive pericarditis
    • Restrictive pericarditis
  • Extra-medullary haematopoiesis
  • Polycystic liver disease

Investigation:

  • Blood tests:
    • FBC: thrombocytopaenia secondary to hypersplenism, signs of infection
    • LFT: low albumin from decreased synthesis, transaminitis
    • PT: prolonged if reduced clotting factor synthesis
    • Renal panel: increasing creatinine with hepatorenal syndrome
    • AFP: tumour marker for HCC
    • Viral markers / viral load if applicable
    • Ferritin if haemachromatosis suspected
  • Ultrasound of hepatobiliary system: can screen for discrete mass lesions, abscesses
  • OGD if cirrhosis confirmed for varices surveillance
  • Transthoracic echocardiogram if cardiac cirrhosis suspected

Summary

Sir, this patient presents with non-tender / tender hepatomegaly. The liver edge is palpable ___ cm below the costal margin. There are no stigmata of chronic liver disease or asterixis to suggest hepatic encephalopathy, and the patient is well-nourished and not anaemic. There are no palpable lymph nodes. The spleen is not enlarged, and there are no scars to suggest previous paracentesis / liver biopsy or bone marrow biopsy. In this setting, my differentials would include ___ (as relevant above).

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