Hepatomegaly

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).