Hepatomegaly

What is 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 liver 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 quadrant¹ .

The most common causes of hepatomegaly in the UK are alcoholic liver disease, malignancy (particularly metastases) and congestive cardiac failure.

Hepatomegaly symptoms

• Associated hepatomegaly symptoms may be few or rather vague - eg, loss of appetite, weight loss and lethargy.

• There may be hepatomegaly 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

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, intravenous (IV) drug abuse, blood transfusions and recent travel.

Hepatomegaly causes (aetiology)^{1 2 3}

Hepatomegaly in neonates and children^{4 5}

What to do if a patient has hepatomegaly

• If unwell, may need urgent admission.

• Full history: include recent travel, tattoos, IV drug abuse, medications as well as 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.

• Investigations: if the patient does not need urgent admission then request some basic investigations - eg, LFTs, FBC and film, U&Es, clotting, inflammatory markers, hepatitis screen and liver ultrasound scan. Further tests can be decided according to the results of these tests.

• Referral to a specialist: for further assessment, diagnosis and management.