Hepatomegaly Causes, Symptoms, and Treatment

Last updated by Peer reviewed by Dr Hayley Willacy
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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 quadrant[1] .

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

  • 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.


  • Viral hepatitis (acute and chronic).
  • Infectious mononucleosis - Epstein-Barr virus (EBV).
  • Cytomegalovirus (CMV).
  • Malaria.
  • Helminthic infection.
  • Pyogenic abscess.
  • Amoebic abscess.


  • Right ventricular failure.
  • Congestive cardiac failure (CCF).
  • Constrictive pericarditis.
  • Budd-Chiari syndrome.


  • Autoimmune liver disease.

Biliary disease

  • Extrahepatic obstruction - eg, pancreatic cancer, cholangiocarcinoma.
  • Primary biliary cirrhosis.
  • Primary sclerosing cholangitis.

Tumours and infiltrative diseases

  • Secondaries (metastatic carcinoma).
  • Primary hepatic tumour - eg, hepatocellular.
  • Lymphoma.
  • Granulomatous hepatitis.
  • Amyloidosis.
  • Sarcoidosis.

Haematological disorders

  • Thalassaemia.
  • Sickle cell disease.
  • Haemolytic anaemia.
  • Myeloma.
  • Leukaemia.


  • Haemochromatosis.
  • Wilson's disease.
  • Glycogen storage diseases.
  • Porphyria.
  • Non-alcoholic fatty liver disease.
  • Diabetes mellitus-associated fatty liver.


  • Alcoholic liver disease: acute alcoholic hepatitis and alcoholic fatty liver.
  • Drug-induced hepatitis - eg, statins, macrolides, amiodarone, paracetamol (indicates significant damage).

Hepatomegaly in neonates and children[4, 5]

  • Infections: TORCH infections, hepatitis viruses and EBV and malaria.
  • Metabolic: galactosaemia, lipid storage disorders - eg, Gaucher's disease.
  • Neoplastic: leukaemia, lymphoma and hepatoblastoma.
  • Haematological: sickle cell anaemia and thalassaemia.
  • Cardiovascular: congestive cardiac failure and tricuspid regurgitation.
  • Miscellaneous: schistosomiasis, toxins, sepsis, polycystic kidneys and liver.
  • Drugs: for example, antituberculous medications.
  • With normal bilirubin: consider hepatoblastoma, metabolic diseases.
  • With raised conjugated bilirubin:
    • With splenomegaly: TORCH (TOxoplasmosis, Rubella, CMV and Herpes simplex) infections, sepsis and disorders of carbohydrate metabolism - eg, galactosaemia.
    • Without splenomegaly: liver tumour, choledochal cyst, biliary atresia, neonatal hepatitis.
  • With raised unconjugated bilirubin: CCF, toxins, haemolytic anaemias.
  • 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.

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