PE - Approach to Hepatomegaly Flashcards
Outline the parameters to report in the abdominal examination
1) Nutrition state (cachectic or well-nourished)
2) Stigmata of chronic liver disease
3) Presence of conjunctival pallor and scleral jaundice
4) Lymphadenopathy
5) Abdominal distension
6) Clinical evidence of ascites
7) Hepatomegaly (size) + tender/non-tender + edge/surface
8) Absence of splenomegaly
9) Presence of umbilical nodule (Sister Mary Joseph)
10) Brutis or venous hum
11) Signs of encephalopathy to suggest liver failure
List differentials for tender hepatomegaly
1) Infectious (HBV, HCV, EBV, CMV, HHV-6, HIV, toxoplasmosis)
2) Alcoholic hepatitis
3) Malignancy including hematological
4) Hepatic congestion secondary to heart failure
5) Vascular liver disease (e.g. Budd-Chiari, sickle cell)
Outline what temporalis wasting indicates
Temporalis wasting is an early sign of generalized muscle atrophy
Outline the clinical significance of anemia
1) Chronic liver disease
2) Hematological malignancy
3) Malignancy
4) Hematological disease e.g. sickle cell disease
Define the normal liver span based on sex
Men = less than 10.5cm Women = less than 7cm
Outline the clinical significance of Sister Mary Joseph nodule
Metastatic deposit found in the following malignancies
1) Hepatocellular carcinoma
2) Colorectal adenocarcinoma
3) Gastric adenocarcinoma
4) Lymphoma
Describe the hepatic venous hum
Outline its clinical significance
Continuous murmur best heard over the epigastrium indicative of portal HT
Outline the clinical significance of hepatic encephalopathy
Hepatic encephalopathy tends to occur more in acute liver decompensation rather than chronic liver disease so consider acute causes of liver failure
If malignancy is a top differential after completing the examination what should be the next step?
Consider both primary and secondary malignancies so assess other systems to look for primary tumours
When is the jugular venous pressure relevant in abdominal examination?
1) Presence of ascites
2) Presence of hepatomegaly
Explain why the jugular venous pressure is relevant in abdominal examination if the patient has ascites or hepatomegaly
1) Cirrhosis is a state of systemic vasodilation so cardiac filling pressure is either low or normal thus JVP should be normal
2) If JVP is elevated then there is likely right heart failure causing hepatic congestion which may induce hepatomegaly w/ascites
3) Palpate the liver for pulsatile hepatomegaly in cases w/tricuspid regurgitation
List the cause of isolated hepatomegaly
1) Cirrhosis
1. Alcoholic fatty liver disease
2. Non-alcoholic steatohepatitis (NASH)
3. Primary biliary cirrhosis (PBC)
2) Malignancy (primary and secondary)
3) Infectious disease
1. HBV/HCV/HAV/HEV
2. EBV/CMV/HHV-6
3. HSV
4. Toxoplasmosis
5. Pyogenic liver abscess
6. Amoebic liver abscess
7. Hydatid disease
4) Infiltrative disease
1. Amyloidosis
2. Sarcoidosis
3. Glycogen storage disorders
5) Vascular liver disease
1. Budd-Chiari syndrome
2. Sickle cell disease
6) Polycystic liver disease
7) Tertiary syphilis (syphilitic gumma)
List the tumours that commonly metastasize to the liver
Colorectal most common!!!
List bengin liver tumours
1) Cavernous hemangioma = most common benign tumour; typically in women of childbearing age
2) Hepatic adenoma = associated w/use of estrogen containing contraceptives
3) Focal nodular hyperplasia = affects women of childbearing age w/no association to estrogen use
4) Nodular regenerative hyperplasia = elderly patients w/systemic autoimmune disease
List the infective causes of acute hepatitis
1) HBV
2) HCV
3) HAV
4) HEV
5) EBV
6) CMV
7) HSV
8) Toxoplasmosis
Define Budd-Chiari syndrome
Hepatic venous outflow obstruction
- obstruction commonly by thrombosis
- obstruction may occur at hepatic venules, hepatic vein, or IVC
- results in venous stasis, congestion, and damage to hepatic parenchymal cells
Describe the clinical presentation of Budd-Chiari syndrome
1) Subacutely w/abdominal pain + hepatomegaly
2) Acutely w/jaundice + hepatic encephalopathy
Ascites can be absent if there is adequate hepatic venous collateral circulation
Outline the diagnosis of Budd-Chiari syndrome
1) Doppler USG of hepatic vein
List the causes of Budd-Chiari syndrome
75% of cases have an identifiable underlying cause
1) Myeloproliferative disorders
2) Thrombophilias
- protein C deficiency
- protein S deficiency
- antithrombin III deficiency
- Factor V Leiden mutation
- prothrombin gene mutation
3) Antiphospholipid syndrome
4) Paroxysmal nocturnal hemoglobinuria
Outline the treatment of Budd-Chiari syndrome
No encephalopathy or hepatic failure = anticoagulate + medical management of ascites
Encephalopathy or hepatic failure = thrombolysis + angioplasty ± liver transplant
List the hepatic manifestations of sickle cell disease
1) Gallstone disease
- pigment stones from chronic hemolysis
2) Sickle hepatic crisis
- sickle thrombosis causing sinusoidal obstruction
- triad of RUQ + jaundice + hepatomegaly
- do not confuse w/Charcot’s triad for cholangitis of RUQ + jaundice + fever ± Reynold’s pentad confusion + hypotension
3) Intrahepatic cholestasis
- sickle thrombosis causing sinusoidal obstruction
- induces hepatocyte swelling and intrahepatic biliary obstruction
4) Fe overload from repeated blood transfusion
5) Blood borne disease from blood transfusion
