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
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?
- Commonest cause in the UK is alcohol abuse
- Other causes include:
- infection - hepatitis B/C
- infiltration - amyloidosis, haemochromatosis, sarcoidosis, Wilson's disease,
- autoimmune/other - primary biliary cirrhosis, autoimmune hepatitis, alpha-1 antitrypsin deficiency
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
