Module 3 Chapter 11: Approach to Big Livers and Big Spleens

Question 1

Define hepatomegaly

Answer 1

• Hepatomegaly (big liver) is a liver >12 cm in the mid-clavicular line [see Chapter 2.4]

o It may be noted on physical examination or on imaging (US, CT, MRI)

Question 2

Outline the scheme for reasons behind hepatomegaly

Answer 2

congestive, infiltrative, infectious, and inflammatory

Question 3

4 examples of conestive reasons for hepatomegaly

Answer 3

1. congestive heart failure (would see edema and ascites, and increased JVP)
2. Constricute pericardiitis (would see pulsatile liver, edema, increased JVP, Kussmaul sign)
3. Budd Chiari syndrome (obstruction of large hepatic veins by clot.  Hx clues = hypercoagulable states such as antithrombin III deficiency, activated protein C
   resistance, protein C or S deficiencies, lupus anticoagulant, paroxysmal nocturnal hemoglobinuria (PNH), malignancy, connective tissue disease
    PE clues = RUQ pain, weight gain, ascites ± jaundice and can cause ALF
4. Sinusoidal obstruction syndrome (SOS) or Venoocclusive disease

•  Obstruction or damage to the small central veins within the liver
   Hx clues = can be seen with chemotherapy given for bone marrow transplantation (BMT)
   PE clues = RUQ pain, weight gain, ascites ± jaundice and can cause ALF

Question 4

examples of benign and malignant infiltrative causes of hepatomegaly

Answer 4

benign: fatty liver, amyloidosis, polycystic liver disease, myelofibrosis
malignant: primary cancer (HCC, iCCA), metastasis from somewhere else (ex/ pancreas or gastric cancer), hematologic cancer like lymphoma, leukemia, MM (also would present with splenomegaly)

might be able to tell because of age, life style factors (ex/ smoking), weightloss from liver, or palapable mass.

Question 5

infectious examples of causes of hepatomegaly

Answer 5

viruses (EBV, hepatitis)

liver abcess

TB

Schistosomiasis

Question 6

inflammatory causes of hepatomegaly

Answer 6

alcoholic hepatitis

chronic liver disease

sarcoidosis

histocytosis

Question 7

Outline the scheme for reasons behind splenomegaly

Answer 7

basically the same as hepatomegaly but with hemolytic issues too.

Question 8

why does splenomegaly occur because of congestive reasons

Answer 8

portal hypertension. Liver disease causes portal bein swelling, blood pools in the splenic arteries and esophageal and gastric vessels, causing varices and spleen swelling. causes more platelet sequestration.

Question 9

congestions from portal hypertension is a common cause of splenomegaly, usually due to cirrhosis. But rarely, it is due to non-cirrhotic portal hypertension, which can be:

Answer 9

 Pre-hepatic = portal vein thrombosis, splenic vein thrombosis, splenomegaly

 Intra-hepatic
- Pre-sinusoidal = schistosomiasis, primary biliary cirrhosis (PBC), sarcoidosis,
congenital hepatic fibrosis, idiopathic
- Sinusoidal = Nodular Regenerative Hyperplasia (NRH), vitamin A or vinyl chloride
toxicity

• Post-sinusoidal = Budd Chiari Syndrome (BCS), sinusoidal obstruction syndrome (SOS)

 Post-hepatic = cardiac disease, IVC obstruction

Nodular regenerative hyperplasia (NRH)
can lead to non-cirrhotic portal
hypertension
 Diagnosis is by liver biopsy (best seen
on reticulin stain) which shows nodules, like in cirrhosis, but without fibrosis

Question 10

Patient presents with splenomegaly but does not have cirrhosis. liver biopsy comes back that shows nodeuls without fibrosis. What should you suspect?

Answer 10

Nodular regenerative hyperplasia (NRH)
can lead to non-cirrhotic portal
hypertension
 Diagnosis is by liver biopsy (best seen
on reticulin stain) which shows nodules, like in cirrhosis, but without fibrosis

Question 11

low platelets in a patient with chronic liver disease is a clue that the patient has developed:

Answer 11

cirrhosis