HEPATOMEGALY

CLINICAL APPROACH
 INTRODUCTION
• ANATOMY
 The liver is the largest organ of the body,
weighing 1–1.5 kg and representing 1.5–2.5% of the
lean body mass.
 The liver is located in the right upper quadrant of
the abdomen under the right lower rib cage against
the diaphragm and projects for a variable extent into
the left upper quadrant.
 The majority of cells in the liver are hepatocytes,
which constitute two-thirds of the mass of the liver.
 The remaining cell types are Kupffer cells (members
of the reticuloendothelial system), stellate (Ito or fat-
storing) cells, endothelial cells and blood vessels, bile
ductular cells, and supporting structures.
 Viewed by light microscopy, the liver appears to be
organized in lobules, with portal areas at the
periphery and central veins in the center of each
lobule.
 From a functional point of view, the liver is organized
into acini, with both hepatic arterial and portal
venous blood entering the acinus from the portal
areas (zone 1) and then flowing through the
sinusoids to the terminal hepatic veins (zone 3); the
intervening hepatocytes constituting zone 2.
 FUNCTIONS OF LIVER
• Hepatocytes perform numerous and vital roles in maintaining
homeostasis and health.The functions of liver include:
 Synthesis of most essential serum proteins (albumin, carrier
proteins, coagulation factors, many hormonal and growth
factors),
 Production of bile and its carriers (bile acids, cholesterol,
lecithin, phospholipids),
 Regulation of nutrients (glucose, glycogen, lipids, cholesterol,
amino acids), and
 Metabolism and conjugation of lipophilic compounds
(bilirubin, anions, cations, drugs) for excretion in the bile or
urine.
 Enlargement of the liver is called Hepatomegaly
 Anterior liver span is 10-14 cms in the right MCLin
an adult and is related to age,sex,body mass and
height of the patient
 Liver span is increased in true enlargement of the
liver.
 APPROACH
• HISTORY
 Fever, jaundice, abdominal pain, anorexia,
nausea, vomiting, malaise, weight loss.
 Skin rashes, arthralgia
 Alcoholism.
 Tuberculosis
 Blood transfusion, IV drug abuse,Surgeries
 Drug history
• EXAMINATION
 INSPECTION
Localized distention of the upper
abdomen, fullness in the right hypochondrium.

 PALPATION
Conventional method
• If liver is palpable,the following points have to be
noted
 Degree of enlargement: Expressed in cms below the
RCM in the MCL
 Consistency:Soft,firm or hard
Causes of:
Soft liver:
CCF
Acute viral hepatitis
Aute malaria
Fatty liver
 Firm liver
Cirrhosis, Chronic malaria,Chronic Kala azar,Hepatic
amebiasis,Lymphoma.
Hard Liver:
Hepatocellular carcinoma,metastasis in the liver,CML
 Tenderness:Tender ,non tender
Causes of tender Hepatomegaly
• Congestive cardiac failure
• Viral hepatitis
• Hepatic amoebiasis
• Pyemic abscess
• Hepatoma
• Actinomycosis
• Secondaries
• Budd-Chiari syndrome.
 Surface of the liver:Smooth or irregular
Causes of irregular surface
Cirrhosis
Metastasis in the liver
HCC
Hepatic cysts
Multiple liver abcess
Gumma of the liver
 Margin or border of liver
Sharp or rounded.
Usually a soft liver has rounded margins, firm
or hard liver has sharp borders.
Margins may be irregular in cirrhosis.
 Movement with respiration: Moves downward with
inspiration.
 Left lobe enlarged or not: Examine in the mid line in
the epigastrium between the xiphoid process and
umbilicus
• Causes of enlargement of left lobe of liver:
Amoebic liver abcess
Hepatoma
Metastasis in liver

 Pulsations: Pulsatile or non pulsatile

Causes of pulsatile liver:
CCF(functional TR)
Organic TR
TS
Hemangioma of liver
 AV fistula in liver
Transmitted epigastric pulsations from RVH

 Palpable Hepatic rub:

Causes:
After recent biopsy of liver
Perihepatitis(liver abcess)
Carcimoma of liver(primary or
secondary)
• PERCUSSION
 Liver span
Detected by percussing the upper and
lower borders of liver at the right MCL.
Normal 10 – 14 cms in the adult in the right
MCL.
Increased in true enlargement of liver and
not in pushed down liver
 Upper border of liver dullness(normal or shifted)
Normally found in the right 5th ICS at right
MCL
• AUSCULTATION:
 Hepatic Bruit
HCC
Acute alcoholic hepatitis
Hemangioma of liver
AV fistula of liver
 Hepatic rub
• INVESTIGATIONS
CBC
LFT
ANA
HbsAg, Anti-HAV,Anti HCV
Serology for CMV,EBV,HIV,VDRL.
Imaging: CXR,USG abdomen , CT scan abdomen.

Liver Biopsy : Cirrhosis, lymphoma,

hemochromatosis , amyloidosis.