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
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