Hepatomegaly
Clinic: measure size of liver
Palpate lower edge of liver
Percuss upper edge of liver
Liver scratch test
- patient supine, auscult over epigastrum, scratch skin
on midclavic line below right nipple. Upper and lower
level of scratching sound = distance
- 10-12 cm = normal
> 14 cm = hepatomegaly
< 8 cm = cirrhosis
Diagnoses
Hepatomegaly
Cirrhosis
Reidel’s lobe (normal variant of prominent
right lobe)
Primary hepatocellular carcinoma
Tricuspid regurgitation
Splenomegaly
Palpate in right lateral decubital position
Percuss spleen during inspiration and
expiration
Diagnoses:
Splenomegaly
Splenectomy
Ascites
Percuss abdomen for shifting dullness
Percuss abdomen for fluid waves
Auscult abdomen while percussing flank
(puddle sign)
Visually inspect venous pattern of skin over
abdomen
CLASSIFICATION OF
JAUNDICE
Unconjugated Conjugated
Hyperbilirubinemia Hyperbilirubinemia
A. Overproduction
Sepsis
Unconjugated Hyperbilirubinemia
Gilbert's syndrome
Crigler-Najjar syndrome
Jaundice in newborns
Diffuse advanced hepatocellular disease
(e.g., hepatitis, cirrhosis)
Conjugated Hyperbilirubinemia
Dubin-Johnson syndrome
Rotor syndrome
Conjugated Hyperbilirubinemia
B. Cholestasis
Intrahepatic
Drug-induced (e.g., methyltestosterone, estrogens, oral contraceptives)
Recurrent jaundice of pregnancy
Recurrent familial jaundice
Early primary biliary cirrhosis
Viral hepatitis
Alcoholic hepatitis
Extrahepatic
Obstruction of major excretory bile ducts: gallstones
Carcinomas of common bile duct, ampulla of Vater, head of pancreas
Inflammatory strictures of bile ducts
Atresia of bile ducts
Acute liver disease
Liver abcess
Hepatic polichistosis
Systemic diseases with prominent liver
involvement
Gilbert`s syndrome
Rotor syndrome
Dubin-Jonson syndrome
Acute viral hepatitis
Etiology
Hepatitis A = RNA virus transmitted by fecal- oral route
•anicteric in 50% of cases.
Laboratory
• Leukocytosis
• Elevated GOT
• elevated serum bilirubin
• decreased serum albumin
• modest increase in serum alkaline phosphatase
Cholestatic phase
• marked elevations of alkaline phosphatase and
direct bilirubin
• GPT always < GOT
• Alcohol-induced thrombocytopenia (10% of patients)
Diagnosis
•liver biopsy: large droplet fatty liver,
polymorphonuclear infiltration, alcoholic hyaline
(Mallory bodies), hepatocyte necrosis, sclerosis
of central veins
Therapy
•supportive
•daily diet of 2500-3000 kcal
•supplements B vitamins (especially thiamine)
and folate
•absolute abstinence from alcohol is crucial
•Corticosteroids = controversial therapeutic role
(useful in very severe cases)
Gallstones
•extremely common, occur in 20% of the population
•in Western populations composed primarily of
cholesterol
•pigment gallstones, composed primarily of calcium
bilirubinate, are found in patients with chronic
hemolysis as well as in Oriental population
Symptoms
•intermittent colicky pain in right upper quadrant
•fever, chills, jaundice
•sepsis from ascending cholangitis, closed space infection
Lab
•elevated serum levels of alkaline phosphatase and transaminases
Dg
•Endoscopic retrograde cholangiopancreatography
•Percutaneous transhepatic cholangiography
•Ultrasound
•CT
Liver Test Patterns in Hepatobiliary Disorders
Bilirubinuria
Etiologic
Complete regression of infective or drug
induced granulomas
Do not give antibiotics blindly
Sarcoidosis: corticosteroids
Neoplasms of the liver
Hepatocellular carcinoma
Metastatic disease – most common
Symptoms
- weight loss
- abdominal pain
- right upper quadrant mass
- unexplained deteriorationof previously stable
patient with cirrhosis
Neoplasms of the liver
Dg: 3 key elements
Hepatic friction rub or bruit
Painful growing hepatomegaly in pts with
cirrhosis
Elevation of alfa-fetoprotein in serum >
400microg/l