Hepatomegaly

Background

Inferior view of the liver with surface showing lobes and impressions.

• Hepatomegaly is an enlarged liver, palpable below the right costal margin or >12cm in the midclavicular line on imaging
• In the ED, hepatomegaly is typically discovered incidentally on exam or imaging, or presents with RUQ pain/fullness
• Key EM considerations: differentiate benign causes (fatty liver, hepatic congestion) from emergent conditions (Budd-Chiari syndrome, acute liver failure, hepatic abscess)
• May indicate underlying serious disease: heart failure, malignancy, cirrhosis with decompensation

Clinical Features

Hepatomegaly palpable on exam in a pediatric patient.

Hepatomegaly on exam in an adult patient.

History

• RUQ fullness, pain, or discomfort
• Jaundice, dark urine, pale stools
• Abdominal distension (ascites)
• Weight loss, fatigue, malaise (malignancy, chronic liver disease)
• Alcohol use, medication/supplement history (hepatotoxins)
• Risk factors for hepatitis (travel, IV drug use, sexual history, blood transfusions)
• Dyspnea, orthopnea, edema (right heart failure)
• Prior cancer history (metastases)

Physical Exam

• Palpable liver edge below right costal margin
• Percussion span >12cm in midclavicular line (normal: 6-12cm)
• Liver character: smooth (congestion, fatty liver) vs. nodular (cirrhosis, metastases) vs. tender (hepatitis, congestion, abscess)
• Stigmata of chronic liver disease: spider angiomata, palmar erythema, gynecomastia, caput medusae, ascites
• Splenomegaly (portal hypertension, hematologic malignancy)
• JVD, peripheral edema (right heart failure, hepatic congestion)
• Hepatojugular reflux (congestive hepatopathy)

Red Flags

• Rapidly enlarging liver with pain (hepatic hemorrhage, Budd-Chiari, acute liver failure)
• Hepatomegaly + jaundice + coagulopathy + encephalopathy (acute liver failure)
• Hepatomegaly + fever + sepsis (hepatic abscess)
• New-onset ascites
• Hemodynamic instability

Differential Diagnosis

Hepatic Dysfunction

Infectious

• Hepatitis
  • Viral hepatitis
• Malaria
• HIV (present in 50% of AIDS patients)
• EBV
• Babesiosis, leptospirosis
• Typhoid
• Hepatic abscess, amebiasis

Neoplastic

• Metastases
• Hepatocellular carcinoma
• Multiple myeloma
• Leukemia
• Lymphoma
• Myeloproliferative disorders

Metabolic

• Hemochromatosis
• Wilson's disease
• Non-alcoholic steatohepatitis
• Inborn errors of metabolism

Biliary

• Biliary cirrhosis

Drugs

• Alcoholic cirrhosis
• Alcoholic hepatitis
• Hepatotoxic drugs

Miscellaneous

• Other causes of cirrhosis
• Autoimmune hepatitis
• Veno-occlusive disease
• CHF (right heart failure)

By Mechanism

• Congestion: right heart failure, Budd-Chiari syndrome, constrictive pericarditis, IVC obstruction
• Inflammation: viral hepatitis (A, B, C, EBV, CMV), alcoholic hepatitis, autoimmune hepatitis, drug-induced hepatotoxicity, hepatic abscess (pyogenic, amebic)
• Infiltration: fatty liver (NAFLD/NASH), amyloidosis, sarcoidosis, glycogen storage diseases
• Malignancy: hepatocellular carcinoma, metastatic disease (colon, breast, lung most common), lymphoma, leukemia
• Biliary: biliary obstruction, primary biliary cholangitis, primary sclerosing cholangitis

Evaluation

Evaluating liver size on ultrasound.

Hepatomegaly on CT.

Laboratory

• LFTs: AST, ALT (hepatocellular injury), alkaline phosphatase, GGT (cholestatic), bilirubin
• Coagulation studies (PT/INR): marker of synthetic function — elevated in acute liver failure
• Albumin: marker of synthetic function
• CBC: thrombocytopenia (portal hypertension/hypersplenism), elevated WBC (infection, leukemia)
• BMP: renal function (hepatorenal syndrome), glucose
• Acetaminophen level and toxicology screen if acute liver injury suspected
• Acute hepatitis serologies (HAV IgM, HBsAg, HBc IgM, HCV Ab) for acute hepatocellular pattern
• Lactate if concern for sepsis or shock liver
• Consider: ammonia (encephalopathy), autoimmune markers (ANA, ASMA), ceruloplasmin (Wilson's)

Imaging

• RUQ US: first-line imaging — evaluates liver size, echotexture, masses, biliary dilation, ascites, hepatic vein patency
• POCUS: rapid assessment for ascites, hepatic congestion, IVC dilation (right heart failure)
• CT abdomen with contrast: mass characterization, abscess identification, vascular evaluation
• Doppler ultrasound if Budd-Chiari suspected (hepatic vein thrombosis)

CHF Workup

• If congestive hepatopathy suspected: BNP, ECG, echocardiography

Management

• Treat underlying condition
• Acute liver failure: ICU admission, hepatology/transplant consultation, N-acetylcysteine if acetaminophen toxicity suspected, correct coagulopathy only if actively bleeding or procedural need
• Hepatic abscess: IV antibiotics, IR-guided drainage, ID consultation
• Budd-Chiari: anticoagulation, IR consultation for TIPS, hepatology
• Congestive hepatopathy: treat underlying heart failure
• Hepatic decompensation: manage ascites, encephalopathy (lactulose), GI bleeding as indicated
• Treat hepatic dysfunction if present

Disposition

Admit

• Acute liver failure
• Hepatic abscess
• New decompensated cirrhosis (ascites, encephalopathy, variceal bleed)
• Budd-Chiari syndrome
• Hemodynamic instability
• Suspected hepatic malignancy requiring urgent workup

Discharge

• Incidental finding with stable labs and no acute symptoms — outpatient GI/hepatology follow-up
• Known chronic liver disease without acute decompensation
• Return precautions: jaundice, confusion, abdominal swelling, bleeding, fever

See Also

• Hepatitis
• Acute liver failure
• Cirrhosis
• Hepatic dysfunction
• Right upper quadrant abdominal pain