Hepatomegaly for PACES

The most obvious abnormality is that the liver is enlarged to x cm below the costal margin<.
The liver edge is smooth/knobbly and tender/non-tender.
There is/isn't evidence of decompensation.
   - evidence of decompensation: asterixis, ascites, altered consciousness (encephalopathy)

Signs which suggest the possible aetiology of the hepatomegaly include....
  - signs of chronic liver disease suggesting cirrhosis
  - signs of right heart failure suggesting congestion
   - signs of cachexia ?? malignancy
   - xathalasmata - primary biliary cirrhosis
   - slate grey skin - haemochromatosis
   - Kayser-Fleischer ring - Wilsons

What are your differentials for hepatomegaly?
  • Cirrhosis, for which I would look for signs of chronic liver disease such as jaundice, scratch marks, spider naevi, gynaecomastia, palmar erythema
  • Cancer, which often results in a craggy liver edge.  I would look for cachexia.
  • Congestion secondary to right sided heart failure.  This may cause a smooth, tender liver edge which may be pulsitile.  Signs likely to accompany this include raised JVP and peripheral oedema.
  •  Rarer causes, such as: abscess, hydatid disease, Budd Chiari syndrome

What causes of liver cirrhosis do you know?

How would you investigate hepatomegaly?
  • bloods - FBC, LFTs, clotting, UEs, glucose
  • U/S abdomen
  • ascitic tap (if ascites present)
  • specific investigations looking for cause:
    • hep B and C serology
    • immunoglobulins and autoantibodies considering primary biliary cirrhosis and autoimmune heptatits
    • ferritin - haemochromatosis
    • caeruloplasmin - Wilson's disease
    • alpha-1 antitrypsin
    • liver biopsy
    • AFP

What complications of cirrhosis do you know of?
  • ascites - risk of infection, discomfort
  • coagulopathy - due to impaired synthetic function
  • portal hypertension - risk of variceal bleeding
  • hepatic encephalopathy - due to failure of liver to clear toxins

What do you understand by hepatic encephalopathy?
This is a condition in which due to the liver's failure to metabolise toxins they affect the brain, impairing neurotransmission.  It can manifest as confusion, mood/behavioural change and altered level of consciousness.  Signs include asterixis, apraxia, hyper or hyporeflexia.

What might precipitate hepatic encephalopathy?
  • GI bleeds
  • infection
  • constipation
  • increased protein intake
  • renal failure 
  • electrolyte inbalance
  • sedative drugs, such as benzodiazepines, antipsychotics, opiates

How would you manage a patient with hepatic encephalopathy?
  • treat any precipitating cause
  • give lactulose to decrease ammonia levels
  • correct any hypokalaemia (as this encourages ammonia production)
  • involve liver team

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