Hepatomegaly and splenomegaly

1. HEPATOMEGALY
Anatomy
Located in the right upper quadrant of the abdomen under the Rt
lower rib cage against the diaphragm and variable extent into the
Lt upper quadrant.
The normal liver extends from the 5th ICS in the Rt MCL down
to the costal margin.
Functions of liver
1. Metabolism of carbohydrates, fats, proteins.
2. Synthesis of bile and prothrombin.
3. Excretion of drugs, toxins, poisons, bile pigment & heavy
metals.
4. Protective by conjugation, destruction, phagocytosis,
antibody formation and excretion.
5. Storage of glycogen, iron, fat, vitamin A and D.
Mechanism
1) Increase in the number or size of the cells intrinsic to the liver
storage eg Fat, malnutrition, obesity, DM.
2) Inflammation hepatitis.
3) Infiltration of cells- cystic masses secondary or metastatic
processes.

2. 4) Increased size of vascular space intrahepatic obstruction to
hepatic vein
outflow, hepatic vein thrombosis. CCF 5) Increased size of
biliary space, congenital hepatic fibrosis
6) Idiopathic.
Hepatomegaly
Enlargement of liver.
Presence of a palpable liver does not always represent
hepatomegaly.
Causes
1. Infective
2. Congestive
3. Degenerative and Infiltrative
4. Storage disorders
5. Neoplasia 6. Toxins
Infective -
a. Along the biliary tree - Cholangitis
b. Along Portal vein - Amoebiasis, schistosomiasis, bacterial
infections.

3. c. Along hepatic artery - Bacterial-typhoid, brucellosis,
Tuberculosis, Syphilis, weil's disease. Viral Infective hepatitis,
infectious mononucleosis.
Protozoal-Malaria, kala-azar.
Fungal - Actinomycosis, histoplasmosis.
Parasitic-Echinococcosis[hydatid cyst]
Congestive
a. Congestive cardiac failure.
b. Cardiomyopathy.
c. Congestive pericarditis.
d. Budd-Chiari syndrome.
Degenerative and Infiltrative
a. Alcoholic fatty liver.
b. Lymphomas.
c. Leukemias.
d. Multiple myeloma.
Storage Disorders -
a. Neimann-pick disease.
b. Gaucher's disease.
c. Amyloidosis.
Neoplasia

4. a. Hepatocellular carcinoma
b. Cholangiocarcinoma
Toxins
Alcohol, arsenic, phosphorous, chlorpromazine.
Causes of painful hepatomegaly -
1) Congestive cardiac failure.
2) Viral hepatitis.
3) Hepatic Amoebiasis
4) Pyemic abscess
5) Hepatoma
6) Actinomycosis
7) Budd-Chiari syndrome.
Clinical Presentation –
-Pain in right hypochondrium Jaundice
-Anorexia
-Anaemia
-Nausea and vomiting, haematemesis, melena.
-Abdominal distension
-Abdominal discomfort
-Fever
-Malaise

5. -Breathlessness
-Petechiae, purpura, ecchymosis, lymphadenopathy etc.-
Leukaemia
- Koilonychia, platynychia - Iron deficiency
On examination -
Neck - engorged veins. Raised JVP in constrictive Pericarditis.
Chest spider naevi, gynecomastia (liver failure)
Skin scratch marks(cholestasis)
CNS tremors & dystonia(wilsons ds)
Abdomen E/0:
Inspection -Skin- engorged veins.
Position of umbilicus.
Movement with respiration.
Asymmetry or visible swellings.
Palpation -
Classical method
Orient your hand so that the fingers are roughly parallel to the
right costal margin.
Ask the patient to breathe in. If the liver is enlarged, the liver
edge will hit the side of your index finger as the liver moves
caudally. You will feel it through the abdominal wall.

6. The liver is palpated as the patient inspires. This is because the
diaphragm, moving inferiorly during inspiration, pushes the
liver down.
Dipping method
In patients with ascites, it may be difficult to feel the liver edge
by direct palpation.
Place your hand on the upper abdomen.
Rapidly flex your metacarpophalangeal joints, so that your
fingers suddenly dip into the patient's abdomen.
The fingers will displacing the underlying fluid and hit the liver,
confirming that a mass, be liver, is present.
Findings to be noted in palpation
Hepatomegaly
Local rise of temperature Tenderness
Extent of enlargement below costal margin
Margin - sharp or rounded/regular or irregular.
Surface-smooth, irregular or nodular Consistency-soft, firm or
stony hard
Pulsatility (pulsatile/ not pulsatile)-A pulsatile liver may be
present in tricuspid regurgitation, hepatocellular carcinoma and
hemangiomas.
Percussion -

7. Liver dullness.
Liver span -The liver span is the measurement (in centimeters)
of the liver from its upper border, determined by percussion, to
its lower border, determined by palpation. Normal liver size is
12-15cms in Ht extending from 5th rib or to the palpable border
of Rt costal margin.
Measurement is done to find out shrinkage or enlargement
The following are screenings and tests performed to
determine the cause of hepatomegaly
Abdominal CT scans
Abdominal X-rays Abdominal MRI
Abdominal Ultrasound
Liver function test
Blood test for Hepatitis
Biopsy to rule out cancer
Management
Management of hepatomegaly is depend upon its underlying
cause and should be treated accordingly.

8. SPLENOMEGALY
NORMAL SPLEEN
• Normal size 12 cm length, 7 cm width (radionuclide scan)
-13cm craniocaudal diamtr (USG)
weight-< 250gm
Located along- 9th, 10th, 11th ribs mid-axillary o Spleen should
be twice the size to be PALPABLE
o Palpable spleens are not always ABNORMAL 3% normal
population has palpable spleen
FUNCTIONS
• Quality control over RBC - culling & pitting
o Synthesis of antibodies.
o Removal of antibody coated bacteria & RBC

9. EXAMINATION OF SPLEEN
o Inspection
o Percussion - nixon method - rt.lateral ducubitus, > 8cm -
castells method supine, lower ICS,full exp & insp splenomegaly
dullness.
- traubes sign
supine,6th rib,costal margin, anterior axill. line splenomegaly
dullness
o Palpation bimanual method, hooking maneuver
DIFFERENCES
spleen
kidney
。 Round edge
。 No notch
Sharp edge
o Notch-med border
o Cross midline O Moves with respiration
o Not cross midline
o Not moves with resp.
o Cannot get above it
o Can get above it
SPLENOMEGALY

10. o Mild, moderate,massive
• Massive beyond umblicus, crosses mid line into pelvis (>8cm)
o Moderate- b/w costal margin & umblicus (4-8cm)
o Mild just palpable (1-3cm)
HYPERSLENISM
o Splenomegaly
• Pancytopenia.
o Presence of hypercellular marrow
Reversal with splenectomy
SYMPTOMS OF SPLENOMEGALY
o Pain
Early satiety
o Feeling of heaviness in LUQ
MECHANISM OF SPENOMEGALY
o Reactive Reticulo-endothelial hyperplasia
o Lymphoid hyperplasia
o Proliferation of lymphoma cells
o Infiltration by abnormal cells
• Extramedullary hemopoeisis
o Proliferation of macrophages d/t RBC destruction
o Vascular congestion

11. CAUSES OF SPLENOMEGALY
- Infective
- Hyperplastis
- Congestive
- Infiltration
INFECTIVE
o Acute & subacute- IMN, infective endocarditis, severe
pyogenic inf. Viral hepatitis, CMV,AIDS
o Chronic TB,syphilis, brucellosis
Tropical splenomegaly
o Malaria,kala azar, trypanosomiasis
CONGESTIVE
o Intra hepatic obst.portal hypertension
- cirrhosis,biliary cirrhosis, hemochromatosis - primary
sclerosing cholangitis
o Extra-hepatic portal hypertension
- venous malf,thrombosis, stenosis
- ext.occlusion of portal, splenic vein o Chronic passive
congestion of cardiac origin
HYPERPLASTIC
o Extramedullary hemopoeisis- myeloprolif.d/s

12. - marrow damage
- marrow infiltration
o Reticulo endothelial hyperplasia -(abn.RBC)
- sickle cell d/s,spherocytosis, Hbnopathies, thalassemia major,
PNH
INFILTRATIVE
o Malignant infiltration- CML, lymphoblastic - lymhomas,
MPD,
- angiosarcoma, tumors - metastasis (melanoma)
- storage d/s -Gaucher's, Neiman-pick
。 benign
- amyloidosis
- hurler's syndrome, MPS
- cysts,fibromas,hemangiomas,hamartomas
- Eosinophilic granulomas
DISORDERED IMMUNOREGULATION
• Felty's syndrome- RA+ splenomegaly+leucopenia
• Systemic lupus erythromatosis
• Collagen vascular diseases
• Sarcoidosis
• Immune thrombocytopenia

13. MASSIVE SPLENOMEGALY (>8CM >1000GM)
• Myeloproliferative disorder
• Chronic malaria,kala-azar (trop. Splenomegaly)
• Storage disorders Thalassemia major
• Sarcoidosis
• Hairy cell leukemia
• Gaucher disease
• Diffuse splenic hemangiomatosis
MODERATE SPLENOMEGALY(4-8CM)
• Cirrhosis.
• Lymphomas
• Amyloid
o Splenic abscess,infarct
o Hemolytic anemias
• IMN
MILD SPLENOMEGALY (1-3CM)
o Acute infective conditons
o Acute malaria,tyhoid,kala-azar,septicemias
STEP-WISE APPROACH TO SPLENOMEGALY

14. o History
o Physical examination.
o Laboratory testings
o Imaging
• Specialised testing
HISTORY
• Age, gender
o Race
o h/o recent infections like malaria o Fever, weight loss,
sweating (lymphomas, infections)
o Pruritis
o Abnormal bleeding/bruising © Joint pain
o h/o alcholism
o h/o trauma
o h/o neonatal umblical sepsis o Residence & travel abroad
HISTORY.....CONTENT
o Jaundice
o High risk sexual behavior (AIDS)
o Past medical history
o Drugs
PHYSICAL EXAMINATION

15. •Size of the spleen
• Hepatomegaly
•Lymphadenopathy
o Fever
o Icterus
• Bruising, petechiae Oral & supf.sepsis
o Stigmata of liver disease
o Stigmata of RA/SLE
o Splinter hemorrhage, retinal hemorrhage
o Cardiac murmurs
LAB INVESTIGATIONS
•CBC
o Blood smear
o Retic count o Blood C/S
o Serology (fungal, viral,parasitic)
• LFT
o Hb electropheresis/ coombs test
o Coag.profile o Amylase/lipase.
o AMA, Anti CCP,RA factor
• Bone marrow analysis
IMAGING

16. • USG- sensitive & specific non-invasive
o CT scan - etiology of splenomegaly
- liver size, heterogeneity - splenic mets, abscess,calcf.,cysts
- retro peritoneal LN
- craniocaudal In > 10 cm o Liver- spleen colloid scan- (RBC-
Cr51,Tc99)
-hepatic steatosis,SOL,splenic functions
- PHT, colloid shift +
• MRI/ Doppler usg- portal/splenic vein thrombosis
- cavernomas
o MRI scan- liver hemangiomas
hemochromatosis erlenmeyer flask sign(Gaucher)
• PET scan - Dx & staging of lymphomas
- determine metabolic cells in spleen
SPECIALISED TESTING
Abd.fat pad aspiration
o JAK-2 mutation
• Gene testing(bcr-abl,C282Y) o Enzyme testing
- Lymph node biopsy
- FNAB spleen
Splenectomy

17. o Lung or skin biopsy
。 Liver biopsy
SPECIAL SITUATIONS ASSOCIATED WITH
SPLENOMEGALY
• Fever typhoid, malaria,kalaazar, infect.endocarditis,
leukemia,lymphoma.
• Tender spleen- rupture,abscess,infarct
o a/c illness+ anemia- AIHA,leukemia
o Fever + LN- IMN,leukemia,lymhomas,SLE,sarcoid
• Anemia. hemolytic anemia,hemoglobinopathies
o Jaundice- cirrhosis,hemolytic anemia
o Pulsatile spleen- aneurysm o High ESR- connective tissue
disorder
• Leukopenia- felty's syndrome, septicemia
TROPICAL SPLENOMEGALY (HMS)
o Massive splenomegaly
o Endemic areas of malaria,kala-azar
o IgM antibodies + No parasite in blood.
o Lymhocytic infiltration of splenic sinusoids Long term anti-
malarials
SUMMARY
o Splenomegaly - major physical finding

18. o Step wise approach- history,physical exam
o Look for associated features
o Lab investigation & Imaging
o Search for etiology & treat.