Hepatomegaly (with no CLD)

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Hepatomegaly (with no CLD) Powered By Docstoc
					Hepatomegaly
Presentation
Sir, this patient has an enlarged liver without any signs of liver cirrhosis. (The mass in
the RUQ is a liver mass as I am unable to get above the mass and am able to trace the
edge of the liver past the midline of the abdomen.) It is massively/moderately
enlarged with a
 Size – cm from the right costal margin with a span of cm
 Edge – regular or irregular
 Surface – smooth or nodular
 Consistency – soft, firm, hard
 Tender
 Pulsatile
 Bruit

The spleen is not palpable or percussible. The kidneys are not enlarged. There is no
associated ascites.

Examination of the peripheries:
 Jaundice, bruises, stigmata of CLD and edema of LL
 Hepatic flap
 Causes
   o Cachexia, Cx LNs, conjunctival pallor
   o Dupytren’s contracture, parotidomegaly
   o Toxic looking, rashes or injected throat or enlarged tonsils
   o CCF – presence of raised JVP

I would like to complete the examination by checking patient’s temperature chart for
fever (if infective cause is a differential) and a rectal examination for masses (if
secondaries are a differential).

In summary, this patient has an enlarged liver that is (state the important Cs). Hence
my differential diagnosis includes:

Massive
 HCC/Secondaries/myeloprolif
 RVF
 Alcoholic liver disease

Mild-moderate
 As above plus
 Infection
    Viruses – EBV, CMV, hepatitis A & B
    Bacteria – Weil’s disease (leptospirosis), meliodosis, abscesses, TB,
      brucellosis, syphilitic gumma
    Protozoal – hydatid cysts, amoebic abscess
 Malignancy – lymphoproliferative, myeloproliferative, primary, secondary,
   adenoma from OCP
 Infiltrative – sarcoid (erythema nodosum, lupus pernio), amyloid, fatty liver
 Endocrine – acromegaly, hyperthyroid
   Collagen Vascular disease
   Chronic hemolytic anaemia( AI, thalassemia, HS)
   Reidel’s lobe
   Possibility of minimal CLD signs with just hepatomegaly
     PBC
     Hemochromatosis

Tender
 Liver abscess/infective (viral/bacterial/parasitic)
 HCC/Secondaries
 Right Heart Failure/Budd chiari

Pulsatile
 TR
 HCC
 AVM

Hard/Irregular
 Mitotic (primary/Secondary)
 Macronodular cirrhosis ie >3mm (post hepatitis B, C, Wilson’s and AAT)
   (Micronodular cirrhosis implies alcoholic liver cirrhosis)
 Amyloidosis/Hydatid cyst/granulomatous disease/gummatous disease/APCKD

Questions
What are the causes?
See above

How would you investigate?
 According to the most likely etiologies
 Think of
         o Blood Ix – Dx and PX
         o Imaging
         o Liver Bx

How would you manage?
 According to the most likely etiologies

(Don’t forget that 40% of CLD has no peripheral stigmata of CLD – therefore think of
Alcoholic liver cirrhosis, PBC and Hemochromatosis in the right setting)

				
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posted:5/19/2012
language:English
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