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Hepato- and/or Splenomegaly

Hepatomegaly
Causes
Apparent
• Low-lying diaphragm

2. Cirrhosis
• Infection
• Alcohol and other drugs e.g. INH, methyldopa
• Metabolic
− Haemochromatosis
− Wilson’s disease
− α1 antitrypsin deficiency
− Cystic fybrosis
• Congestion
− Heart failure
− Budd Chiari syndrome
• Autoimmune
− Primary biliary cirrhosis
− Chronic autoimmune hepatitis
• Sclerosing cholangitis

3. Inflammation
• Hepatitis
• Schistosomiasis
• Abscesses (pyogenic or amoebic)

4. Cysts
• Hydatid
• Polycystic

5. Metabolic
• Fatty liver
• Amyloid
• Haemochromatosis
• Glycogen storage disease

6. Haematological
• Leukemias
• Lymphoma
• Myeloproliferative disorders

7. Tumours
• Primary carcinoma
• Secondary

8. Venous congestion
• Heart failure
• Hepatic vein occlusion

9. Biliary obstruction

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Internal Medicine – Paarl
Hospital

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Specific types of hepatomegaly
Firm and irregular liver
• Hepatocellular carcinoma
• Metastatic disease
• Cirrhosis

Tender liver
• Hepatitis
• Rapid liver enlargement e.g. right heart failure, Budd-Chiari syndrome (hepatic vein
thrombosis)

Pulsatile liver
• Tricuspid regurgitation
• Hepatocellular carcinoma
• Vascular abnormalities

Differential diagnosis of Hepatomegaly

Fatty liver Hepatitis

Non-tender liver Tender liver

No ascites

Isolated hepatomegaly

Ascites

Peripheral oedema Peripheral oedema No peripheral oedema


Pulsatile liver Non-pulsatile liver Liver bruit
Absent hepatojugular
reflex

Cardiac failure Budd-Chiari Hepatoma


Tricuspid valve Liver metastases
disease
Internal Medicine – Paarl
Hospital

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Splenomegaly
Causes
1. Infection
• Acute
− Septic shock
− Infective endocarditis
− Typhoid
− Infectious mononucleosis
• Chronic
− Tuberculosis
− Brucellosis
• Paracytic
− Malaria
− Kala-azar
− Schistosomiasis

2. Inflammation
• SLE
• Rheumatoid arthritis
• Sarcoidosis

3. Haematological
• Haemolytic anaemias
• Haemoglobinopathies
• Leukemias
• Lymphomas
• Myeloprolipherative disorders

4. Portal hypertension

5. Infiltration
• Amyloid

6. Tumours
• Primary
• Secondary

7. Storage diseases
• Gaucher’s disease

8. Tropical splenomegaly

Massive splenomegaly
• Chronic myeloid leukemia
• Myelofibrosis
• Chronic malaria
• Kala azar
• Gaucher’s disease

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Internal Medicine – Paarl
Hospital

Differential diagnosis of Splenomegaly

Hereditary Mononucleosis Tuberculosis


spherocytosis Felty’s syndrome Brucellosis
Lymphoma Endocarditis
Leukemia Malaria

± Mild jaundice Lymphadenopathy Fever


Cholesystectomy scar ± Fever ± Lymphadenopathy

Isolated splenomegaly

Massive splenomegaly Ascites


Jaundice
Spider nevi

Myelofibrosis End-stage cirrhosis


Chronic myeloid leukemia
Lymphoma

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Internal Medicine – Paarl
Hospital

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Portal hypertension
Definition
Portal vein pressure > 12 mmHg

Signs
1. Portasystemic shunt
• Caput medusae
• Oesophageal / gastric varices
• Anorectal varices
• Venous hum
2. Splenomegaly
3. Ascites

Causes
Prehepatic
1. Portal vein compression
• Lymphnodes e.g. Lymphoma, TB
• Carcinoma
2. Portal vein thrombosis

Intrahepatic
1. Liver cirrhosis
2. Alcoholic hepatitis
3. Schistosomiasis
4. Infiltration
• Lymphoma
• Sarcoidosis
• Rare: Myelosclerosis
5. Congenital hepatic fibrosis
6. Nodular hyperplasia

Posthepatic
1. Veno-occlusive disease
2. Budd-Chiari syndrome
3. Inferior vena cava obstruction
4. Constrictive pericarditis
5. Heart disease with right heart failure

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Internal Medicine – Paarl
Hospital

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Treatment of Portal Hypertension
Ascites
1. Aldosterone ± loop diuretic (Lasix)
2. Paracentesis
3. Shunt: Peritoneum → jugular

Varices
1. Non-selective β-blocker (Propranolol)
• Reduce resting pulse by 25%
• Mechanism: β1 block = ↓ cardiac output; β2 block = ↓ vasodilatation of splanchnic artery

2. Sclerotherapy or Banding
3. Sengstaken tube in acute setting
4. TIPS (Transjugular intrahepatic portacaval shunt)

Hepatosplenomegaly
Causes
1. Chronic liver disease with portal hypertension

2. Haematological disease
• Myeloprolipherative disease
• Lymphoma
• Leukemia
• Sickle cell anaemia
• Pernicious anaemia

3. Infection
• Infectious mononucleosis
• Cytomegalovirus
• Acute viral hepatitis

4. Infiltration
• Amyloid
• Sarcoid

5. Connective tissue disease


• SLE

6. Acromegaly

7. Thyrotoxicosis

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Internal Medicine - Paarl
Hospital

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