PE - Approach to Hepatomegaly

Question 1

Outline the parameters to report in the abdominal examination

Answer 1

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

Question 2

List differentials for tender hepatomegaly

Answer 2

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)

Question 3

Outline what temporalis wasting indicates

Answer 3

Temporalis wasting is an early sign of generalized muscle atrophy

Question 4

Outline the clinical significance of anemia

Answer 4

1) Chronic liver disease
2) Hematological malignancy
3) Malignancy
4) Hematological disease e.g. sickle cell disease

Question 5

Define the normal liver span based on sex

Answer 5

Men = less than 10.5cm
Women = less than 7cm

Question 6

Outline the clinical significance of Sister Mary Joseph nodule

Answer 6

Metastatic deposit found in the following malignancies

1) Hepatocellular carcinoma
2) Colorectal adenocarcinoma
3) Gastric adenocarcinoma
4) Lymphoma

Question 7

Describe the hepatic venous hum

Outline its clinical significance

Answer 7

Continuous murmur best heard over the epigastrium indicative of portal HT

Question 8

Outline the clinical significance of hepatic encephalopathy

Answer 8

Hepatic encephalopathy tends to occur more in acute liver decompensation rather than chronic liver disease so consider acute causes of liver failure

Question 9

If malignancy is a top differential after completing the examination what should be the next step?

Answer 9

Consider both primary and secondary malignancies so assess other systems to look for primary tumours

Question 10

When is the jugular venous pressure relevant in abdominal examination?

Answer 10

1) Presence of ascites

2) Presence of hepatomegaly

Question 11

Explain why the jugular venous pressure is relevant in abdominal examination if the patient has ascites or hepatomegaly

Answer 11

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

Question 12

List the cause of isolated hepatomegaly

Answer 12

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)

Question 13

List the tumours that commonly metastasize to the liver

Answer 13

Colorectal most common!!!

Question 14

List bengin liver tumours

Answer 14

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

Question 15

List the infective causes of acute hepatitis

Answer 15

1) HBV
2) HCV
3) HAV
4) HEV
5) EBV
6) CMV
7) HSV
8) Toxoplasmosis

Question 16

Define Budd-Chiari syndrome

Answer 16

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

Question 17

Describe the clinical presentation of Budd-Chiari syndrome

Answer 17

1) Subacutely w/abdominal pain + hepatomegaly
2) Acutely w/jaundice + hepatic encephalopathy

Ascites can be absent if there is adequate hepatic venous collateral circulation

Question 18

Outline the diagnosis of Budd-Chiari syndrome

Answer 18

1) Doppler USG of hepatic vein

Question 19

List the causes of Budd-Chiari syndrome

Answer 19

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

Question 20

Outline the treatment of Budd-Chiari syndrome

Answer 20

No encephalopathy or hepatic failure = anticoagulate + medical management of ascites

Encephalopathy or hepatic failure = thrombolysis + angioplasty ± liver transplant

Question 21

List the hepatic manifestations of sickle cell disease

Answer 21

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