Hepatomegaly

Question 1

What are the causes of isolated hepatomegaly?

Answer 1

Cirrhosis
Carcinoma
CCF
Infection (HBV, HCV)
Auto-immune (PBC, PSC, AIH)
Infiltration (amyloid, myeloproliferative disorders)

Question 2

Which tumours commonly spread to the liver?

Answer 2

Colorectal (most common)
Upper GI
Lung
Breast
Renal
Endometrial
Bone
Sarcomas

Question 3

What are the infective causes of acute hepatitis?

Answer 3

Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis E
Epstein-barr virus
Cytomegalovirus
Toxoplasmosis
Herpes simplex virus

Question 4

Size of hepatomegaly and its causes

Answer 4

Question 5

Approach to hepatomegaly

Answer 5

1. Nutritional status
   - Cachetic - cirrhosis, malignancy
   - Normal - infectious, alcohol without cirrhosis, early malignancy, congestion, vascular

1A. Anaemia - chronic liver disease, sickle cell anaemia, malignancy

2. Examination of hepatomegaly
   - Normal liver span: 10.5cm in men, 7cm in women
   (upper border via percussion in right midclavicular line, lower border via palpation)
   - Tenderness: acute hepatic enlargement
   - Surface and edge: smooth, regular or irregular/nodular
   - Consistency: soft, firm or hard
   - Pulsatility and bruit - alcoholic, HCC, portal hypertension venous hum

2A. Sister Mary Joseph (SMJ) nodule over the umbilicus
- Gastric or colon adenocarcinoma, HCC, lymphoma deposit

3. Signs of liver cirrhosis, portal hypertension, ascites
4. Abdominal scars - paracentesis, liver biopsy
5. Lymphadenopathy - infection, malignancy
6. Examine JVP if cirrhosis, ascites present
7. Ask to examine other systems - thyroid, breast, pelvis, lungs

Question 6

What are the benign liver tumours?

Answer 6

1. Cavernous haemangioma - women of childbearing age
2. Hepatic adenoma
3. Focal nodular hyperplasia - women of childbearing age

Question 7

What are the hepatic manifestation of sickle cell anaemia?

Answer 7

1. Gallstone disease - chronic haemolysis causing pigment stones
2. Sickle hepatic crisis - sickle thrombosis causing sinusoidal obstruction
   > RUQ pain, jaundice, tender hepatomegaly
3. Intrahepatic cholestasis - sickle thrombosis in sinusoids causing swelling, intrahepatic obstruction
4. Iron overload - blood transfusion
5. Risk of viral hepatitis from blood transfusion

Question 8

What is Budd Chiari Syndrome?
What are the causes?
What are the clinical manifestations?
How to confirm diagnosis and treatment?

Answer 8

Obstruction to hepatic venous outflow
Can occur at any level: hepatic venules, veins or inferior vena cava
Commonly due to thrombosis - causing stasis, congestion and damage to hepatic parenchymal cells

Causes:
1. Myeloproliferative disease
2. Thrombophilias - protein C/S deficiency, ATIII, FV leiden mutation, prothrombin gene mutation
3. APLS
4. Paroxysmal nocturnal haemoglobinuria

Clinical manifestations:
1. Jaundice
2. Abdominal pain and hepatomegaly
3. Hepatic encephalopathy
4. May not have ascites - development of hepatic venous collateral circulation

Diagnosis:
1. US Doppler hepatic vein

Treatment:
1. Anticoagulation
2. Medical management of ascites, encephalopathy, liver failure
3. Emergency - thrombolysis, angioplasty
4. Fulminant liver failure -> liver transplant