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“This 45 year old lady has complained of vague abdominal discomfort.  Please examine her abdominal system to determine the cause, then present your findings to the examiners.”

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  • What are your clinical findings?
  • How would you like to investigate this patient next?
  • What do you think the underlying cause of this patient’s pathology might be?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has isolated moderate hepatomegaly without obvious stigmata of chronic liver disease.  It is important to remember that not all patients with liver pathology in the MRCP PACES will necessarily have chronic liver disease.  Occasionally subjects attend from the ward as they are recovering from an acute illness.

The signs seen in this video are a mass in the right upper quadrant.  Typically liver edges can be identified by the fact that it is not possible to palpate above them, they are dull to percussion and they move with respiration.  There may be a bruit.

Any patient with a palpable liver should be examined for evidence of cirrhosis and decompensation.  You should test for:

  • A liver flap;
  • Ascites;
  • Altered consciousness (signalling encephalopathy).

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Clinical features:

Hepatomegaly is pathological enlargement of the liver beyond its normal size. An enlarged liver can be palpated near to the lower edge of the ribs on the right side. The associated symptoms and clinical signs depend upon the underlying disease that has caused hepatomegaly. Some common symptoms are fever, malaise, nausea, vomiting, jaundice, poor apetite, weight loss, secondary splenomegaly, and abdominal pain.

Initial investigations:

After history, examination of the patient and after measuring their liver span, some tests are run. Complete blood count and liver function profile are the basic laboratory tests that should be carried out. The liver function tests will show any abnormally increased enzymes of the liver that might point out towards a disease. Further investigations include imaging studies to check for any abnormality or mass lesion by ultrasound abdomen and CT scan. These imaging studies will show any other structural pathology that is present to rule out the etiology of hepatomegaly.

Underlying pathologies:

Liver is the metabolic center of the body and has a lot of activities going on in it. Since, it is involved in many functions of the body, it is affected by many medical conditions. Some of the diseases leading to hepatomegaly are:

  • Hepatitis
  • Glycogen storage Disease
  • Congestive heart failure
  • Alcoholic liver disease
  • Hepatocellular carcinoma
  • Sarcoidosis
  • Leukemia
  • Infectious mononucleosis
  • Niemann-Pick disease
  • Primary biliary Cirrhosis
  • Reye syndrome
  • Hydatid cyst
  • Malaria
  • Liver abscess
  • Leptospirosis etc

Common Treatment:

Since hepatomegaly is not a diagnosis but a sign of a disease it can only be treated if the underlying disease is known. If the disease is infectious, antibiotics or anti viral therapy should be started whereas if the case is of a tumor, then appropriate management option must be opted. It could be surgery, chemotherapy or radiation therapy depending upon the type of tumor.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]

“This patient has moderate hepatomegaly in the absence of peripheral stigmata of chronic liver disease.  Possible differentials for this include acute viral hepatitis, autoimmune causes, and malignancy.  I would like to investigate in the first instance by arranging initial venous bloods and an ultrasound scan of the upper abdomen.”

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