HEPATOSPLENOMEGALY

PBL 22SUPERVISED BY: DR. WALAA SHABANA

Surface anatomy of liver and spleen2

Causes of hepatosplenomegaly3 How to approach patient

with hepatosplenomegaly?4

Definition1OBJECTIVE

S

DEFINITION

Hepatosplenomegaly is an enlargement of liver and spleen beyond their normal size.

Surface anatomy of liver and spleen2

Causes of hepatosplenomegaly3 How to approach patient

with hepatosplenomegaly?4

Definition1OBJECTIVE

S

SURFACE ANATOMY OF LIVER• The limits of the normal liver are:

a) Left 5th intercostal space – below left nippleb) Right 5th costal cartilage midclavicular linec) Right 7th intercostal space midaxillary line – below right nippled) Right 9th intercostal space midaxillary line

• Upper border in 5th right intercostal space on full expiration• Lower border at the costal margin in the midclavicular line on full inspiration

NORMAL SPAN OF LIVER

• Normal liver span in the midclavicular line ranges from 9 cm to 14 cm and in the midline from 4 to 8 cm• The size of the normal liver

also varies with age, sex and body size• False positives for enlarged

liver span: right pleural effusion, consolidated lung.

SURFACE ANATOMY OF SPLEEN

• Lies in left hypochondrium• Long axis corresponds to the

posterior part of the 10th rib.• Upper border (A) corresponds to the

upper border of the 9th rib• Lower border (B) corresponds to

lower border of 11th rib.• Medial end (C) is 1.5 inches lateral to

the 10th thoracic spine.• Lateral end (D) reaches to the

midaxillary line.

Surface anatomy of liver and spleen2

Causes of hepatosplenomegaly3 How to approach patient

with hepatosplenomegaly?4

Definition1OBJECTIVE

S

1) Chronic liver disease with Portal

HTN

Liver Cirrhosis caused by:• Viral infection• Autoimmune liver disease• Alcoholic & Non-alcoholic steatohepatitis• Metabolic liver diseases

CAUSES OF HEPATOSPLENOMEGALY

• Viral:- Hepatotrophic (A,B,C,D,E)- Other viruses (herpes, CMV, EBV, varicella, HIV, rubella, adenovirus, enterovirus)

• Parasitic: shistosoma, malaria, leshmania, amoeba, toxoplasma• Bacterial: tuberculosis, typhoid, brucellosis, syphilis• Fungal: histoplasmosis

2) Infective

• Haemolytic anemia: sickle cell anemia, thalassaemia• Myeloproliferative disease

3) Hematological

4) Infiltration

6) Connective

tissue disease

5) Congestive

7) Neoplastic

8) Miscellaneou

s

• Amyloidosis, sarcoidosis, glycogen storage disease

• Right sided heart failure, Budd Chiari syndrome, constrictive pericarditis

• SLE, Rheumatoid arthritis

• Hepatocellular carcinoma, Leukemia, lymphomas, metastasis

• Thyrotoxicosis, Acromegaly

Surface anatomy of liver and spleen2

Causes of hepatosplenomegaly3 How to approach patient

with hepatosplenomegaly?4

Definition1OBJECTIVE

S

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY?

History taking

General examination

Abdominal examinations

Investigations

i. History Taking

We should ask about:• Risk factors for hepatitis e.g.,

medical stuff, history of blood transfusion• History of jaundice or chronic

liver disease• History of alcohol abuse, drugs,

contraceptive pills• Symptoms of Heart failure

• History of joint pain or rash (collagen disease)• History of travel abroad

(malaria)& contact to canal water (bilharziasis)• History of T.B

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY?

History taking

General examination

Abdominal examinations

Investigations

ii. General examination

Examine the patient for:• Signs of chronic liver disease e.g.,

jaundice, ms wasting, oedema L.L, palmar erythema, clubbing, spider naevi, ascites

• Signs of the heart failure• Enlarged lymph nodes

(lymphoma)• Arthritis, rash, hair falling, hand

deformities( collagen diseases)• Marked loss of weight

(malignancy)

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY?

History taking

General examination

Abdominal examinations

Investigations

iii. Abdominal examinationPalpation of Liver• Border:• Rounded border in congestion and infection• Sharp border in cirrhosis and malignancy

• Consistency:• Soft in congestion& infection• Firm in cirrhosis• Hard in malignancy• Tender liver in infection, congestion and malignancy

Palpation of spleen• The spleen has to be enlarged 2 or 3 times its usual size to be palpable under the costal margin• Mild splenomegaly : just below costal margin• Moderate splenomegaly : midway between costal margin and umbilicus• Huge splenomegaly: below umbilicus

Percussion• Splenomegaly causes dull Traub’s area

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY?

History taking

General examination

Abdominal examinations

Investigations

iv. Investigations

Laboratory Investigations• Serum electrolytes and BUN• CBC with differential and peripheral blood smear• Hepatitis serology e.g., HBsAg &HCV Abs• Liver functions: AST, ALT, GGT, alkaline phosphatase, bilirubin, total protein, albumin

Imaging• Abdominal ultrasound with Doppler• Chest x-ray (T.B)• Abdominal CT or MRI (hepatic masses, biliary tree,

anatomical obstructions)• Echocardiogram ( heart failure)

Liver biopsy• Liver biopsy is a procedure in which a small needle is inserted into

the liver to collect a tissue sample. • Performed to help identify the cause of:• Persistent abnormal liver blood tests (liver enzymes)• A liver abnormality found on ultrasound, CT scan• Unexplained enlargement of the liver

• Can also be used to estimate the degree of liver damage and determine the best treatment for the damage or disease.

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