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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 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.
The most common causes of hepatomegaly in the UK are alcoholic liver disease, malignancy (particularly metastases) and congestive cardiac failure.
- Associated symptoms may be few or rather vague - eg, loss of appetite, weight loss and lethargy.
- There may be 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).
Suggests: hepatitis, chronic heart failure, sarcoid, early alcoholic cirrhosis, tricuspid incompetence with a pulsatile liver.
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.
Tumours and infiltrative diseases
Hepatomegaly in neonates and children
- 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.
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.