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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Chronic Liver Cell Disease (OSCE Guide)

1/03/2020

Chronic Liver Cell Disease (OSCE Guide)

You do not have to be an expert in order to diagnose a patient with Chronic Liver Cell Disease (CLCD), as it is too obvious even with inspection alone. But you might be under-prepared for this case, just because you would not expect such easy cases at the exam settings.

So, try to memorize all the key features suggestive of CLCD and organize your presentation mentioning the important positives as well as the negatives. Always try your best to assess the aetiology and the complications of CLCD during your examination.

CHRONIC LIVER CELL DISEASE – EXAMINATION

GENERAL EXAMINATION

The general examination of CLCD is vital and you can get many important positive and negative findings for the diagnosis, aetiology & complications. There are two ways you can look into this step of examination. Easier way for a beginner would be, examining region by region remembering the clinical features you have to look for in each region.


But the smarter (and more advanced) way is mind mapping the clinical findings into diagnosis, aetiology & complications (Refer the Flashcard).

BIRD’S EYE EXAMINATION
  • Generalized Oedema & Ascites – Due to Hypoalbunaemia
  • Cachexia – Chronic Disease & Poor Nutrition
  • Running Fever – Spontaneous Bacterial Peritonitis (SBP) – (Complication)
  • Skin Pigmentation – Suspect Haemochromatosis – (Aetiology)
  • Petechiae & Ecchymosis – Due to coagulopathy & Thrombocytopenia (Complications)
  • Tattoos – Hepatitis B & C (Aetiology)
FACE
  • Jaundice (Sclera, Palms) – Suggestive of Decompensation of CLCD – (Complication)
  • Pallor (Conjunctiva, Tongue) – Anemia (Multifactorial: Blood loss, BM suppression, Poor Nutrition) – (Complication)
  • KF rings – Suspect Wilson’s Disease – (Aetiology)
  • Xanthelasma – Suspect Primary Biliary Cirrhosis (PBC) – (Aetiology)
  • Parotid Swelling – Alcoholic CLCD – (Aetiology)
CHEST & BACK
  • Gynaecomastia – Altered sex hormone metabolism (Palpate & Confirm)
  • Spider Navi – Number & size correlates with the severity. (Palpate & Confirm)
  • Body Hair Loss – Altered sex hormone metabolism
HAND & FOOT
  • Asterixis – Hepatic Encephalopathy
  • Finger Clubbing – Hypoalbunaemia
  • White nails – Hypoalbunaemia
  • Palmar Erythema – Vasodilatation in CLCD
  • Dupuytren’s Contracture – Alcoholic CLCD (Aetiology)
  • Ankle Oedema – Hypoalbunaemia

ABDOMINAL EXAMINATION

INSPECTION
  • Abdominal Distention (Ascites)
  • Smiling Umbilicus (Ascites)
  • Surgical Scars (Previous Hepatobiliary Surgery, Peritoneal Aspiration Marks, Liver Biopsy Marks)
  • Distended Superficial Abdominal Veins – Caput Medusa (Portal Hypertension – Complications)
PALPATION
  1. Superficial Palpation – Tender? Suspect SBP.
  2. Hepatomegaly
    • How many centimetres?
    • Is it tender? – Suspect Hepatoma (Complication of CLCD), Hepatitis (Alcoholic / Infective)
    • Is it hard in consistency with irregular margins? – Suspect Hepatoma (Complication)
    • Hepatic Bruit? – favours Hepatoma
  3. Splenomegaly – Indicates evidence of portal hypertension.

In patients with Cirrhosis liver is usually shrunken. So, you won’t be expecting the liver to be enlarged. But what if the liver is palpable? Then suspect Hepatoma, Alcoholic CLCD & NAFLD.

IMPORTANT FACT TO BE REMEMBERED
PERCUSSION
  • Assess the volume status of the patient. Grade the ascites. Elicit “Shifting flank dullness” in a patient with moderate ascites OR “Fluid thrill” in case of a large ascites.
AUSCULTATION
  • Liver and Splenic bruits (over the enlarged liver & spleen)
  • Hepatic Venous Hum (over the epigastrium)

CLCD – CASE PRESENTATION

This patient has generalized body swelling with gross abdominal distention and does not appear to be drowsy. He is icteric and anaemic. He has got no Xanthelasma or KF rings. The patient is having parotid swelling, gynaecomastia and there are multiple spider navei located on upper chest and the back. He has got palmar erythema, finger clubbing, leukonychia and there is Dupuytren’s contracture in the right hand. He has bilateral pitting ankle oedema and there is no asterixis.

The abdomen is distended and the umbilicus is slightly inverted & retracted (smiling umbilicus). There are no surgical scars or distended superficial veins of the abdomen. There is no tenderness on superficial palpation. Liver is not palpable. There is a left hypochondrial mass 3cm from the costal margin, which moves diagonally with respiration. Its superior border is not palpable and its not ballotable. There is a notch in its anterior border. It is dull to percussion and its dullness continues with the splenic dullness with no evidence of band of resonance in between. There is moderate ascites as evidenced by shifting flank dullness; no fluid thrill. There is no splenic or liver bruits.

My diagnosis is Decompensated Chronic Liver Cell Disease (CLCD) complicated with portal hypertension probably due to heavy alcoholic abuse. He has got no evidence of SBP or Hepatic Encephalopathy


FREQUENTLY ASKED QUESTIONS

1. Generalized Oedema & Ascites 2. Finger Clubbing 3. Dupuytren’s Contracture 4. White Nails 5. Palmar Erythema 6. Gynaecomastia 7. Body Hair Loss 8. Parotid Swelling 9. Ankle Oedema 10. Spider Navei
1. Portal Hypertensive Gastropathy - Blood loss 2. Poor Nutrition 3. Bone Marrow Suppression - Due to Alcohol
1. Palmar erythema 2. Gynaecomastia 3. Loss of body hair 4. Spider navei
Its due to recanalization of the umbilical vein secondary to portal hypertension. In portal hypertension, the direction of the flow is away from the umbilicus whereas in Inferior Vena cava obstruction, it is towards the umbilicus.
1. Hypoalbunaemia (Decreased production & intake) 2. Activation of Renin-Angiotensin Axis
1. Intraabdominal Malignancy 2. Congestive Heart Failure 3. TB peritonitis 4. Pancreatitis
1. Alcohol 2. Viral - Hepatitis B & C 3. Autoimmune - Autoimmune hepatitis, Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis 4. Metabolic - NASH, Wilson’s Disease, Haemochromatosis 5. Drugs - Methotrexate, Amiodarone
1. Infection 2. Spontaneous Bacterial Peritonitis (SBP) 3. GI Bleeding 4. Hypokalaemia 5. Sedatives 6. Hepatocellular Carcinoma
1. Ascites & Spontaneous Bacterial Peritonitis 2. Oesophageal varices & Hematemesis 3. Hypersplenism & Thrombocytopenia 4. Coagulopathy 5. Hepatic Encephalopathy 6. Hepatocellular Carcinoma
1. Running fever 2. Abdomen is tender to superficial palpation 3. Percussion tenderness
It is the reversible neurological dysfunction or coma due to liver failure.
Grade 1 - Insomnia / Day-night sleep pattern reversal Grade 2 - Disorientation Grade 3 - Confusion Grade 4 - Coma
1. Omit offending drugs - Omit Frusemide & Spironolactone 2. Find & Treat the cause - Treat constipation (Enema, Lactulose) 3. Antibiotics - IV Ceftriaxone & Oral Metronidazole 4. Supportive Care - NG feeding, IV fluids
• Resuscitate the patient - A B C approach • Correct Hypovolemia - IV fluid until blood is available • Prevent bleeding - IV infusion of Tranexamic acid & Octreotide • GI Tamponades - Temporary measure until definitive treatment carried out • UGIE & Banding - Definitive treatment option
1. FBC 2. Liver Function Test (Albumin, Total Protein, AST, ALT, GGT, ALP) 3. PT/INR 4. Serum Electrolytes 5. USS abdomen
1. To confirm the diagnosis (Assess the size & echotexture) 2. To detect Portal Hypertension & Splenomegaly 3. To detect any focal lesions
1. Hepatitis B Surface Antigen 2. Hepatitis C Antibodies 3. Serum Fe and Ferritin 4. Serum Ceruloplasmin 5. Liver biopsy
1. Slowing / Reversing the cause - Stopping Alcohol, Immunosuppressive therapy 2. Relieving Symptoms - Diuretics, Ursodeoxycholic acid (for itching) 3. Minimizing Acute decompensation - Treating infection & Constipation, Prophylactic Antibiotics 4. Treating Complications - Hepatic Encephalopathy, SBP 5. Liver transplant - Final resort
It is also known as Primary Biliary Cholangitis which is a autoimmune disorder of the liver. It results from a slow and progressive destruction of biliary canaliculi causing accumulation of bile and other toxins in the liver (Cholestasis). Eventually this results in scarring, fibrosis and cirrhosis.
1. Bilirubin 2. Ascites 3. Encephalopathy 4. Prothrombin Time 5. Albumin
1. Liver resection 2. TACE (Transarterial Chemo-embolization) 3. Liver transplant

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