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Hepatomegaly Microchapters


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Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Seyedmahdi Pahlavani, M.D. [2],Iqra Qamar M.D.[3]
Synonyms and Keywords: Enlarged liver; liver enlargement


The liver is an organ present in vertebrates and some other animals. The adult human liver normally weighs between 1.4 to 1.6 kilograms (3.1 to 3.5 pounds), and it is a soft, pinkish-brown "boomerang shaped" organ. It is located on the right side of the upper abdomen below the diaphragm. The size of the liver increases with age and ranges between 5 cm to 15 cm in adulthood. A normal liver is less than 16 cm on ultrasound evaluation. Hepatomegaly may be found during physical examination or on imaging studies. Imaging is more accurate in determining liver size.[1][2] In some conditions normal liver may be palpated as enlarged liver including thin people, during deep inspiration, right pleural effusion, and emphysema resulting in hyperinflation of the chest with diaphragmatic descent and downward displacement of the liver. Common pathological causes that may result in hepatomegaly are hepatitis, storage disorders, impaired venous outflow, infiltrative disorders, and biliary obstruction.


Various causes of hepatomegaly may be classified on the basis of etiology into hepatitis, storage disorders, impaired venous outflow, infiltrative, and obstructive causes.[3][4][5][6][7][8][9][10][11][12][13][14]

Etiology Disease
Hepatitis Infections Acute and chronic viral hepatitis
Bacterial liver abscess
Parasitic infections
Granulomatous hepatitis
Ischemia Ischemic hepatitis ("shock liver")
Toxins Alcoholic hepatitis
Steatosis Alcoholic fatty liver disease
Nonalcoholic steatohepatitis
Medications Drug induced liver injury (DILI)
Immune mediated hepatitis Autoimmune hepatitis
Copper deposition Wilson disease
Storage disorders Glycogen Glycogen storage disorders
Diabetes mellitus
Lipid Gaucher disease
Nonalcoholic steatohepatitis
Protein Alpha-1 antitrypsin deficiency
Iron Hemochromatosis
Impaired venous outflow Cardiac Right heart failure
Constrictive pericarditis
Hepatic vein Hepatic vein thrombosis
Inferior vena cava web
Intrahepatic Sinusoidal obstruction syndrome
Peliosis hepatis
Infiltrative diseases Benign primary liver tumors Hemangiomas
Focal nodular hyperplasia
Malignant primary liver tumors Hepatocellular carcinoma
Fibrolamellar carcinoma
Metastatic or disseminated tumors Myeloma
Metastatic solid tumors
Biliary obstruction Primary biliary cirrhosis
Primary sclerosing cholangitis
Biliary atresia
Other Anatomic variations Riedel's lobe
Cystic liver disease Polycystic liver disease
Caroli's disease

Differential Diagnosis

Patients with hepatomegaly need to be differentiated from other patients presenting with similar complaints such as abdominal pain.[3][4][5][6][7][8][9][10][11][12][13][14]

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound

Organ system Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Nausea or vomiting Jaundice Weight loss Hypo-


Rebound Tenderness Lab Findings Imaging
Pancreato-biliary disorders Pancreatic carcinoma Epigastric + + +

Skin manifestations may include:

Primary biliary cirrhosis RUQ/Epigastric +
  • ERCP
  • Pruritis
Primary sclerosing cholangitis RUQ + + ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
  • The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Systemic disease Whipple's disease Diffuse ± ± + ± Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Hemochromatosis RUQ
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
  • Hyperglycemia
  • Ultrasound shows evidence of cirrhosis
Extra intestinal findings:
  • Hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Hematologic causes Myeloma Diffuse ± + ±
  • Anemia
  • Elevated ESR and CRP
  • Proteinuria
  • Mainly in old age
  • Back pain
  • Kidney involvement
Lymphoma Diffuse + + ±
  • Anemia
  • Elevated ESR and CRP
Leukemia Diffuse + ± + ±
  • Anemia
  • Elevated ESR and CRP
Disease Abdominal Pain Fever Nausea or vomiting Jaundice Weight loss Hypo-


Rebound Tenderness Lab Findings Imaging Comments
Cardiac causes Heart failure Diffuse/ RLQ/LLQ + ±
  • CBC
  • Increased BNP and Pro BNP
  • Echocardiography
  • Exertional dyspnea
  • Chest pain
  • Edema
Constrictive pericarditis Diffuse/ RLQ/LLQ + ± -
  • Echocardiography
  • Exertional dyspnea
  • Chest pain
  • Edema
Hepatic causes Viral hepatitis RUQ + + + + Positive in fulminant hepatitis +
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + + ±
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + + +
  • US
  • CT
  • Liver biopsy

Other symptoms:

Budd-Chiari syndrome RUQ ± ± CT scan findings: Ascitic fluid examination shows:


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