1. FAHAD AL ZAMIL Professor & Consultant Paediatric Infectious Diseases King Khalid University Hospital King Saud University, Riyadh

2.  Mean liver span:  In the Newborn: 4.5 – 5 cm  12 years: boys: 7 – 8 cm  12 years: girls: 6 – 6.5 cm  Extends from 5 th intercostal space in the midclavicular line 5 – 8 cm

3.  Lower edge not more than 2 cm below the costal margin in infancy (1 cm in childhood)  A normal-size liver may be displaced downward (e.g. pulmonary hyperinflation)

4.  Tip of spleen is normally palpable in 1/3 of full-term infants  May be felt up to 5 years of age.  After that a palpable spleen is presumed to be enlarged

5.  Fever, jaundice, pallor, bleeding, tea-colored urine, bone & joint pains, weight loss, abnormal sweating, anorexia, abdominal distention, pain, trauma, food or drug exposure  Exposure to infections (hepatitis, mononucleosis, TB, amebiasis)  Hematological disease (SCA, Thalassemia), cardiac disease, collagen vascular disorder, storage diseases

6.  Measure liver span  Determine liver’s contour & consistency  Is the surface smooth, irregular or nodular?  Is the edge rounded or sharp?  Is palpation painful? DO NO HARM!  Listen for bruit

7.  Any ascites ?  Increased portal venous pressure, tissue infiltration, or reticuloendothelial cell hyperplasia  In newborns: do fundoscopy for chorioretinitis  Congenital infections  Note: skin lesions, subcutaneous nodules, lymphadenopathy, spider angiomata or stigmata of storage disease

8.  Infective:  Viral:  Hepatotrophic (A,B,C,D,E)  Other viruses (herpes, cytomegalo, Ebstein-Barr, varicella, HIV, rubella, adenovirus, enterovirus, arbovirus)

9.  Infective:  Protozoal: malaria, kalazar, amoebic, toxoplasma  Bacterial: sepsis; tuberculosis, brucellosis, syphilis  Helminths: hydatid, visceral larva migrans  Fungal: histoplasmosis

10.  Hematological:  Haemolytic: haemolytic disease of newborn, thalassaemia  Metabolic:  Nieman-Pick, Gaucher, gangliosidosis, mucopolysaccharidosis, glycogen storage

11.  Malignancies:  Leukemia, histiocytic syndromes, myeloproliferative syndromes, lymphomas  Immunological:  Chronic granulomatous disease, hereditary neutrophilia, Ommen syndrome.

12.  Developmental:  Congenital hepatic fibrosis  Congestive:  Hepatic vein obstruction, constrictive pericarditis

13. According to the case, may include:  CBC, retics  Blood film  Malaria smear  LFT, PT, Ammonia  Hepatitis tests  Monospot test  PPD

14.  TORCH  α-fetoprotein  Bone Marrow Aspiration  Urinalysis  Ultrasound  CT scan  Angiography  Needle aspiration