Hepatomegaly

Physical Examination

General Examination:

• Palmar erythema, Dupuytren's contracture, or leukonychia indicative of chronic liver disease.

• Spider nevi found on the arms, chest, or face, typically associated with liver disease.

• Flapping tremor or asterixis, signifying hepatic encephalopathy.

• Presence of fetor hepaticus, a distinctive breath odour associated with severe liver disease.

• Lymphadenopathy or thyroid enlargement, possibly suggesting metastatic disease or a primary cause, respectively.

Inspection:

• Visible hepatomegaly may be present in severe cases.

• Ascites can be indicated by a distended abdomen, shifting dullness or fluid thrill.

• Caput medusae, the appearance of distended and engorged superficial epigastric veins.

• Jaundice or pallor could indicate underlying liver disease or anaemia.

• Hepatic stigmata such as spider nevi, gynecomastia or loss of axillary hair might be found.

Palpation:

• Hepatomegaly: The liver may be palpable below the costal margin

• Liver surface and consistency: A nodular liver might suggest cirrhosis or metastasis. A hard consistency might be indicative of malignancy.

• Tenderness over the liver, suggesting inflammation (hepatitis) or congestion (congestive cardiac failure).

• Murphy's sign: Pain on deep inspiration during palpation of the right upper quadrant can indicate cholecystitis.

Percussion:

• An enlarged liver span can be confirmed through percussion.

• Percussion can also be used to assess the presence of ascites. Shifting dullness or a positive fluid thrill would suggest the presence of free fluid within the peritoneal cavity.

Auscultation:

• Listen for bowel sounds, which may be reduced in paralytic ileus, a complication of severe liver disease or ascites.

• Bruits or venous hums may be audible in case of vascular abnormalities or liver malignancies.

Additional Examination if Required:

• Assess lower limbs for evidence of deep vein thrombosis (DVT) or pedal oedema.

• Examine the anus and rectum if there's suspicion of gastrointestinal bleeding.

• Testicular examination if there is suspicion of a primary testicular tumour metastasising to the liver.

Causes of Hepatomegaly

Alcohol-Related Liver Disease:

• Alcoholic fatty liver disease

• Alcoholic hepatitis

• Cirrhosis due to chronic alcohol abuse

Metabolic and Endocrine Causes:

• Non-alcoholic fatty liver disease (NAFLD)

• Non-alcoholic steatohepatitis (NASH)

• Diabetes Mellitus

Viral Infections:

• Viral hepatitis (Hepatitis A, B, C, D, E)

• Infectious mononucleosis

Circulatory Disorders:

• Congestive heart failure

• Right-sided heart failure or tricuspid regurgitation

• Budd-Chiari syndrome (blockage of the hepatic veins)

Malignancies:

• Primary liver cancer, like hepatocellular carcinoma

• Metastatic cancer to the liver

Autoimmune Diseases:

• Autoimmune hepatitis

• Primary biliary cirrhosis

• Primary sclerosing cholangitis

Other Infectious Causes:

• Bacterial infections like Leptospirosis, Tuberculosis

• Parasitic infections like Malaria, Amoebiasis, Schistosomiasis

Metabolic Disorders:

• Hemochromatosis (iron overload)

• Wilson's disease (copper accumulation)

• Glycogen storage diseases

Drug-Induced Liver Injury:

• Certain medications can cause liver injury leading to hepatomegaly.

Rare Conditions:

• Alpha-1-antitrypsin deficiency

• Amyloidosis

• Polycystic liver disease

Causes of tender hepatomegaly

• Infection: viral hepatitis

• Malignancy

• Alcoholic hepatitis

• Liver congestion in cardiac failure

• Budd-Chiari syndrome