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
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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
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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
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Viral hepatitis (acute and chronic).
Infectious mononucleosis Epstein-Barr virus (EBV).
Cytomegalovirus (CMV).
Malaria.
Helminthic infection.
Pyogenic abscess.
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Amoebic abscess.
Biliary disease
Autoimmune
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Autoimmune liver disease.
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Extra-hepatic obstruction.
Primary biliary cirrhosis.
Primary sclerosing cholangitis.
Tumours and infiltrative diseases
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Secondaries (metastatic
carcinoma).
Primary hepatic tumour - eg
hepatocellular carcinoma.
Granulomatous hepatitis.
Amyloidosis.
Sarcoidosis.
Metabolic
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Haemochromatosis.
Wilson's disease.
Glycogen storage diseases.
Porphyria.
Non-alcoholic fatty liver disease.
DM-associated fatty liver.
Haematological disorders
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Sickle cell disease.
Haemolytic anaemia.
Myeloma.
Leukaemia or lymphoma.
Toxic/drug-related
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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
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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
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With normal bilirubin: consider hepatoblastoma, metabolic diseases.
With raised conjugated bilirubin:
o With splenomegaly: TORCH infections, sepsis and disorders of carbohydrate
metabolism - eg, galactosaemia.
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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
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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
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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
Disclaimer: This article is for information only and should not be used for the diagnosis or
treatment of medical conditions. EMIS has used all reasonable care in compiling the information
but make no warranty as to its accuracy. Consult a doctor or other health care professional for
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Hepatomegaly - Physiology for Medical Students