Hepatomegaly (OSCE Guide)

2/03/2020

Hepatomegaly (OSCE Guide)

Hepatomegaly simply means enlargement of the liver. Mean Liver size is 10.5 cm for an adult male and 7 cm for an adult female. Liver size depends on sex, age, body size. Hepatomegaly is considered only when the liver is enlarged at least 3cm from its normal size.

Sometimes the liver is “pushed down” by the hyperexpanded lungs (Emphysema). This is where the “Liver span” (distance from the upper border of the liver to lower border of the liver at the right midclavicular line) is more important than the “liver extension” below the costal margin. So, always confirm whether the liver is actually enlarged or just pushed down before you come to a conclusion.

80% of the abdominal cases given at the exams have organomegaly. But Isolated Hepatomegaly is different from Hepatosplenomegaly. Latter is discussed as a separate case in the app. It has its own differential diagnosis. So, once you have detected hepatomegaly, always exclude a co-existing splenomegaly.

HEPATOMEGALY – EXAMINATION

GENERAL EXAMINATION

  • Generalized Oedema & Abdominal Distention – Background CLCD
  • Cachexia – Malignancy (Liver secondaries)
  • Stigmata of CLCD – Parotid swelling, Gynaecomastia, Body hair loss, Spider navei, Palmar erythema, Dupuytren’s contracture, White nails.
    Background CLCD & Hepatomegaly favors the diagnosis of Hepatocellular Carcinoma.
  • Jaundice (Sclera, Palms) – Malignancy (Liver secondaries), CLCD
  • Pallor (Conjunctiva, Tongue) – Hematological malignancy, CLCD
  • Finger Clubbing – GI Lymphoma, CLCD4
  • Asterixis – Hepatic encephalopathy
  • Ankle Oedema
  • Lymphadenopathy – Cervical, Axillary, Epitrochlear (Malignancy)

ABDOMINAL EXAMINATION

INSPECTION
  • Abdominal Distention (Ascites seen in malignancy & portal hypertension)
  • Right hypochondrial Fullness – (Large hepatomegaly)
  • Surgical Scars (Peritoneal aspiration marks, Liver biopsy marks)
  • Sister-Mary-Joseph Nodule – Metastatic deposits from bowel CA, hepatocellular CA, and lymphoma
PALPATION
  • Superficial Palpation – Routine
  • Organomegaly (Hepatomegaly)
    1. Palpate for the lower margin & estimate the size
    2. Feel the tenderness, nodularity, regularity and consistency
    3. Percuss for the lower margin from below upwards
    4. Percuss for upper margin from above downwards
    5. Exclude coexisting Splenomegaly
PERCUSSION
  • Percuss for the liver
  • Percuss for free fluid
AUSCULTATION
  • Look for Hepatic bruit (Hepatocellular CA, Hepatic metastasis, Alcoholic hepatitis)

EXTENDED EXAMINATION

Sometimes hepatomegaly may be due to venous congestion secondary to right heart failure. Look for,

  • Elevated JVP
  • Loud second heart sound
  • Third heart Sound

HEPATOMEGALY – CASE PRESENTATION 01

This cachectic patient is not pale, icteric and there are no peripheral stigmata of CLCD. There is finger clubbing. There is left supraclavicular lymphadenopathy which are hard, fixed and non-tender. There is a palpable umbilical nodule (Sister-Mary-Joseph). There are no surgical scars or distended superficial abdominal veins. Abdomen is non-tender to superficial palpation. There is a right hypochondrial mass which I cannot get above and moves with respiration. Its dull to percussion and its dullness continues with the Liver dullness. It is enlarged 5cm below the costal margin in the right midclavicular line. It is nontender, irregular and hard in consistency and has a nodular surface. The upper border of the liver is at 5th intercostal space in the midclavicular line. There is a hepatic bruit.

There is no splenomegaly or ballotable loin masses or shifting flank dullness. The JVP is not elevated, and there is no evidence of heart failure.

My diagnosis is Hepatomegaly probably due to secondary metastasis from underlying intra-abdominal malignancy. GI lymphoma is highly likely as evident by Sister-Mary-Joseph nodule and Finger clubbing.

HEPATOMEGALY – CASE PRESENTATION 02

This patient is not pale, not icteric and there are no peripheral stigmata of CLCD. There is finger clubbing. There is no ankle oedema or lymphadenopathy.

The abdomen is not distended. There are no surgical scars or distended superficial abdominal veins. Abdomen is non-tender to superficial palpation.

There is a right hypochondrial mass which I cannot get above and moves with respiration. Its dull to percussion and its dullness continues with the Liver dullness. It is enlarged 2cm below the costal margin in the right midclavicular line. It is tender, regular and firm in consistency and has a smooth surface. The upper border of the liver is at 5th intercostal space in the midclavicular line. There is no hepatic bruit.

There is no splenomegaly or ballotable loin masses or shifting flank dullness.

The JVP is elevated. There is loud second heart sound. There are coarse late-inspiratory crepitations in the lower zones of both lung fields.

My diagnosis is Tender Hepatomegaly probably secondary to hepatic congestion due to right heart failure. The cause for the right heart failure could well be due to pulmonary hypertension secondary to bronchiectasis.


FREQUENTLY ASKED QUESTIONS

1. Hepatocellular Carcinoma (Hepatoma) 2. Malignant Deposits in Liver 3. Alcoholic Liver Disease 4. Nonalcoholic Fatty Liver Disease (NAFLD) 5. Primary Biliary Cirrhosis 6. Alcoholic Hepatitis 7. Hepatic Congestion 8. Infectious Disease 9. Hepatic Infiltration 10. Vascular Diseases of Liver 11. Polycystic Liver Disease
1. Focal Nodal Hyperplasia 2. Nodular Regenerative Hyperplasia 3. Hepatic Adenoma 4. Cavernous Haemangioma
1. Colorectal carcinoma 2. Oesophageal carcinoma 3. Gastric carcinoma 4. Lung carcinoma 5. Breast carcinoma 6. Renal carcinoma 7. Bone tumours
1. Constrictive Pericarditis 2. Congestive Cardiac Failure 3. Right Heart Failure 4. Restrictive Cardiomyopathy 5. Budd-Chiari Syndrome
1. Viral - Hepatitis A, B, C, E, EBV, CMV, Herpes Simplex 2. Toxoplasmosis 3. Amoebiasis
1. Amyloidosis 2. Glycogen storage diseases
1. Bud-Chiari Syndrome 2. Sickle Cell Disease
It is caused by obstruction to hepatic venous outflow. It can occur at any level from Hepatic venules, Hepatic Vein or IVC and the most common cause is venous thrombosis. It is diagnosed by USS Abdomen and thrombolysis & angioplasty are the treatment options.
It indicates a recent enlargement of the liver.
It is due to the stretching of the liver capsule (Pain sensitive) due to the enlargement of the liver.
1. Infective Hepatitis 2. Alcoholic Hepatitis 3. Hepatic Congestion 4. Malignancy
It is associated with Alcoholic Hepatitis & Liver Malignancy (Primary or Metastatic).
It is almost diagnostic of Portal Hypertension.
Usually heard in hepatic neoplasm with inflammatory changes.
A patient who had cirrhosis with portal hypertension has developed hepatocellular carcinoma.

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