Enlarged liver
Definition
Epidemiology
Pathophysiology
Either, the there is venous congestion pushing the liver down or there is something attacking the liver itself (more common but venous congestion is still common) causing inflammation (i.e. hepatitis).
Clinical and Associated Features
Venous
- Right heart failure - hopefully, you'll get a whole bunch of symptoms. Bilateral oedema in the lower leg. In right heart failure, there will also be a raised JVP. In congestive heart failure, you will get all sorts of crazy: pulmonary oedema (bilateral crackles in the lung bases), orthopnoea, paroxysmal nocturnal dyspnoea, pulse abnormalities (tachycardia, pulsus alternans, reduced volume), hepatomegaly, ascites.
- Pericarditis - Chest pain, radiating to back and relieved by sitting up forward and worsened by lying down; dry cough, fever, fatigue, and anxiety.
- Budd-Chiari syndrome - severe upper abdominal pain, jaundice, hepatomegaly, ascites, elevated LFTs, and eventual encephalopathy.
Infection
Symptoms of hepatitis - anything from asymptomatic to fulminant liver failure. Symptoms include: malaise, muscle and joint ache, fever, nausea, vomiting, diarrhoea, jaundice, loss of appetite, abdominal pain.
Biliary tract disease
This essentially an obstructive jaundice - hepatomegaly, jaundice, colicky (classcially central) abdominal pain, rebound tenderness, shoulder tip pain.
Cancer
Hepatocellular carcinoma generally occurs in sufferers of hepatitis A; secondaries are more. However, both are usually asymptomatic until a late stage. Symptoms include: loss of appetite, weight loss, nausea, tiredness, upper abdominal discomfort.
Haematological
- Sickle cell and haemolytic anaemia both have very specific symptoms. Haematological cancers - easy bruising, bleeding, pallor, pancytopenia, tiredness, weight loss, bone pain, night sweats.
Metabolic
- Wilson's - tiredness, confusion (hepatic encephalopathy), splenomegaly, spider naevi, (can lead to [[cirrhosis). Neuro: tremor, ataxia, dystonia, seizures and migraine being more common. Kayser-Fleishcer rings, renal tubular acidosis and cardiomyopathy are all more common.
- Haemochromatosis - liver cirrhosis, jaundice, diabetes, cardiomyopathy, heart failure, bronze skin, tiredness, loss of libido
Drugs
Everybody's favourite, alcoholic liver disease, is the biggest culprit here - high alcohol intake, jaundice, possibly a tender and painful abdomen. Other drugs: statins, macrolides, amiodarone.
Differential Diagnosis
I hate livers. Why does stuff have to go wrong with them?
- Venous congestion - right heart failure, pericarditis, Budd-Chiari syndrome (obstruction of the hepatic vein)
- Infection - Hepatitis, EBV, CMV, malaria, (then crazy shit like helminth infection, pyogenic abscess)
- Biliary tract disease - obstructive jaundice, PBC, cholangitis
- Cancer - liver metastases, hepatocellular carcinoma, amyloidosis, sarcoidosis
- Haematological - sickle cell anaemia, haemolytic anaemia, myeloma, leukaemia, lymphoma
- Metabolic - haemochromatosis, Wilson's,
- Drugs - alcoholic liver disease, drugs (statins, macrolides, amiodarone, paracetamol
Investigations
You almost always do LFTs and often, if there's something to see, imaging is best done with ultrasound.