Hepatosplenomegaly

Relevant physical signs

• Stigmata of chronic liver disease
  • Clubbing
  • Leukonychia
  • Palmar erythema
  • Spider naevi (central arterioles which blanch and fill from inside out)
  • Gynaecomastia
  • Loss of body hair
  • Caput medusae
  • Excoriations (intense itching in primary biliary cirrhosis)
• Stigmata of decompensated liver disease
  • Asterixis
  • Encephalopathy
  • Ascites
  • Icterus
• Signs of underlying haematological disease
  • Hepatomegaly
  • Jaundice
  • Lymphadenopathy
  • Anaemia
  • Bone marrow biopsy scars
• Signs of chronic alcohol ingestion
  • Enlarged parotid glands
  • Dupuytren’s contracture
• Parkinsonism (Wilson’s disease)
  • Rigidity
  • Bradykinesia
  • Tremor
  • Kayser-Fleischer rings

Differential diagnosis

• Chronic liver disease with portal hypertension and hypersplenism
  • Alcoholic liver disease
  • Non-alcoholic steatohepatitis
  • Chronic hepatitis B / C
  • Congestive liver disease secondary to right heart failure
  • Primary biliary cirrhosis
  • Haemochromatosis
• Haematological disease
  • Extra-medullary haematopoiesis: myelofibrosis
  • Thalassaemia major / intermedia
  • Autoimmune haemolytic anaemia
  • Hereditary spherocytosis
  • Myeloproliferative disease
  • Lymphoproliferative disease
• Infection
  • Parasitic: malaria, visceral leishmaniasis, schistosomiasis, leptospirosis
  • Viral: viral hepatitis, Epstein-Barr virus, cytomegalovirus
• Neoplastic
  • Hepatocellular carcinoma with cirrhosis and portal hypertension
  • Secondary malignancy from breast, lung, GI tract
  • Benign haemangiomas
• Endocrine
  • Acromegaly
  • Hyperthyroidism
• Infiltrative
  • Sarcoidosis
  • Amyloidosis
  • Gaucher’s disease

Investigations

• Confirm diagnosis: ultrasound of the abdomen
  • Can proceed to triphasic computed tomography scan of the liver if necessary, with or without computed tomography of the rest of the abdomen and pelvis
• Haematological investigations
  • Full blood count (myeloproliferative / lymphoproliferative disorders)
  • Peripheral blood film (haemolysis, hereditary spherocytosis)
  • Haemoglobin electrophoresis (confirmatory diagnosis for thalassaemias)
  • Direct Coombs’ test (autoimmune haemolytic anaemia)
  • Bone marrow aspiration and trephine
  • Chest radiograph (mediastinal enlargement with lymphoma)
• Hepatology investigations
  • Synthetic function of the liver: albumin, prothrombin time
  • Full blood count to look for thrombocytopaenia
  • Alphafetoprotein to screen for hepatocellular carcinoma
  • Surveillance oesophagogastroduodenoscopy to look for oesophageal varices
  • Renal function to look for hepatorenal syndrome
• Age-appropriate malignancy screening
• Serum caeruplasmin (low) and 24-hour urinary copper excretion (high) in Wilson’s disease

Summary

Sir, this patient has hepatosplenomegaly. The liver span is ___ cm and the liver edge is smooth and non-tender. The spleen is palpable four finger breadths below the costal margin. There are no stigmata of chronic liver disease, and no parotid enlargement or Dupuytren’s contracture to suggest chronic alcohol ingestion. The patient appears to be mildly icteric, and is anaemic. There is no palpable lymphadenopathy. The most likely explanation for these findings are a chronic haemolytic anaemia; the differentials for this include thalassaemia intermedia or major, hereditary spherocytosis or autoimmune haemolytic anaemia. Other differentials for hepatosplenomegaly include chronic liver disease with portal hypertension, mitotic infiltration, which may either be primary with consequent portal hypertension, or secondary, myeloproliferative or lymphoproliferative disease, or infections such as chronic malaria.