Objectives By the end lecture we will be able  1.To know what is normal liver and Spleen.  2. To know about various causes of hepatosplenomegaly.  3.How to do the clinical examination of the patients.  4. How will we do the workup of the patients.

Case-1  A previously well 25 year-old Man presented to the emergency department with 2 weeks history of jaundice which was associated with right upper quadrant pain, nausea and lethargy.

 What is your diagnosis?

Case-2  A 35 year-old female presented with one week history of fever. On examination she was looking pale, had ting of jaundice with tip of palpable spleen.

 What is your diagnosis?

Case-3  A 39-year-old female presented with a 3- months history of itching with recent change in color of her skin.  On examination she had scratch marks on her body with hepato-splenomegaly?

 What is your diagnosis?

4  A 51-year-old man presents to your outpatient clinic with H/O pain right Hypochondrium.  Physical exam reveals liver palpable 5 cm below the right costal margin which was tender and smooth. There is ankle edema.

 What is your diagnosis?

Case-5  A man of 45 consults his general practitioner (GP) with a 6-month history of reduced appetite with dragging pain in right hypochondrium.  On Examination  He has nine spider naive on his upper trunk with gynacomasia. There is pitting edema of his ankles. There is hepato-splenomegaly.

 What is your diagnosis?

Case-6  A 34-year-lady is sent to your clinic with a chief complaint of fever with rigors and right upper quadrant pain for 2 weeks. Her liver is palpable by 7 cms and is tender.

 What is your diagnosis?

 Definition  Hepatomegaly is swelling of the liver beyond its normal size.  If both the liver and spleen are enlarged, it is called hepatosplenomegaly.

 Liver span  It is vertical distance between uppermost and lower most points of liver dullness-in Rt mid clavicular line- Normal cm

The spleen is a functionally diverse organ with active roles in immunosurveillance and hematopoiesis.  It lies within the left upper quadrant of the peritoneal cavity and abuts ribs 9-12, the stomach, the left kidney, the splenic flexure of the colon, and the tail of the pancreas.  A normal spleen weighs 150 g and is approximately 11 cm in craniocaudal length  Poulin et al defined splenomegaly as moderate if the largest dimension is cm, and severe if the largest dimension is greater than 20 cm.

 Questions  What are the causes?  How would you investigate?  How would you manage?

 The doctor will examine you and ask questions such as:  Did you notice a fullness or lump in the abdomen?  What other symptoms do you have?  Is there any abdominal pain?abdominal pain  Is there any yellowing of the skin (jaundice)?jaundice  Is there any vomiting?  Is there any unusual-colored or pale-colored stools?pale-colored stools  Have you had any fever?  What medications are you taking?  How much alcohol do you drink?

patient has hepatosplenomegaly.  (Determine which is the predominantly enlarged organ eg massive liver with small spleen or massively spleen with small liver; determine if there is any Cs liver findings such as pulsatile liver; if both are mildy enlarged then combine the causes)  Mildly Enlarged(4cm</1-2FB)  Acute malaria  Chronic haemolytic – Thalassemia, AI, HS, ITP  Myeloproliferative, Lymphoproliferative  Infections  Viral – CMV,EBV  SBE, splenic abscesses, leptospirosis, Meliodosis, TB, Typhoid, Brucellosis(farmer)  Infiltrative – Amylodosis, Sacoidosis  Endocrine – Acromegaly, thyrotoxicosis  Collagen vascular – SLE, Felty’s

 Moderately Enlarged (4 to 8 cm/ 2-4 FB)  Myeloproliferative  Lymphoproliferative  Haemotological – AI, ITP, Thalassemia and HS  Chronic malaria  Cirrhosis  Massive Splenomegaly (>8 cm)  CML  Myelofibrosis  PRV  Chronic malaria  Kala-azar (visceral leshmaniasis)  Others(Gaucher’s, rapidly progressive lymphoma)

 Massive Liver  HCC/Secondaries/myeloprolif  RVF  Alcoholic liver disease   Mild-moderate Liver  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

 Tender Liver  Liver abscess/infective (viral/bacterial/parasitic)  HCC/Secondaries  Right Heart Failure/Budd chiari   Pulsatile Liver  TR  HCC  AVM   Hard/Irregular Liver  Mitotic (primary/Secondary)  Macronodular cirrhosis (post hepatitis B/C, Wilson’s and AAT)  Amyloidosis/Hydatid cyst/granulomatous disease/gummatous disease/APCKD 

Palpation of the liver “One good feel of the liver is worth any two liver function tests” (F.M. Hanger, jr., 1971).

 Determining the liver size is considered to be the “simplest” and “cheapest” liver function test and, chronologically speaking, it is also the “first”

 The liver is enlarged  Size, edge, surface, consistency, tender, bruit or pulsatile  The spleen is enlarged  Size, edge, surface, consistency, tender  Kidneys are not enlarged and no associated ascites  Peripheral examination  CLD stigmata, jaundice, bruises  Hepatic encephalopathy  Causes  Pallor, cachexia, Cx LNs, PRV  Toxic, rashes, tonsils  Chronic ethanol ingestion  CCF  SBE, SLE, RA, Hemolytic anaemia 

 It would be a tremendous loss if palpation and percussion of the liver and spleen were inadequately learned, inappropriately performed and no longer mastered as a basic examination technique for interpretative purposes on account of ultrasound methods.

Workup of patients with Hepato- spenomegaly  Initial lab tests:  Complete blood count (CBC) with differential, platelet count, and peripheral blood smear in cases of splenomegaly.  Urea,creatinine,electrolytes,glucose

Tests to determine the cause of the hepatospleno-megaly  Liver function tests, including blood clotting tests Liver function tests  Ultrasound of the liver (must be done to confirm the condition if the doctor thinks your liver feels enlarged during a physical exam)  CT scan of the abdomen CT scan of the abdomen  Other tests for suspected causes

 Investigations to consider (based on history and examination) amination)  Liver blood tests (“LFT’s”)  FBC  Prothrombin time  Viral serology (hepatitis A,B,C,D,E, CMV, EBV and HIV, Herpes simplex)  Amoebic and hydatid serology. Consider toxoplasmosis and schistosomiasis.  Autoantibodies including LKM antibodies  Immunoglobulins (IgM/IgG)  Haematinics (particularly Iron/ferritin)  Copper, caeruloplasmin, α 1 Anti trypsin, α Feto-Protein  Imaging: Abdominal USS ± Microbubble USS, CT, MRI etc  ?admit via A+E (eg severe abdominal pain, jaundice, cachexia, haematemesis etc)

 Common presentations/diagnoses  NAFLD (mildly ↑ AST and ALP)  RUQ pain and stones on USS ( ↑ AST and ALP, sometimes ↑ bilirubin)  Possible haemangioma on USS (normal LFT’s)  Cystic disease seen on USS (normal LFT’s)  Autoimmune hepatitis ( ↑ ALT ± ALP and bilirubin)  Jaundice (Haemolytic (pre hepatic), Congenital, Cholestatic (liver parenchymal and CBD obstruction:  cholangiocarcinoma and carcinoma of the head of pancreas)  Cirrhotic liver found on USS incidentally

 Jaundice (a sign not a diagnosis)  Haemolytic (pre hepatic)  Congenital  Cholestatic (liver parenchymal and CBD obstruction)

 “Even though you read and learn so much, your learning does not mean that you know; let your eyes be your professors.”  (Theophrastus Bombastus von Hohenheim, known as PARACELSUS)

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