By the end lecture we will be able
 1.To know what is normal liver and Spleen .
 2. To know about various causes of
 3.How to do the clinical examination of the
 4. How will we do the workup of the
 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
 What is your diagnosis?
 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?
 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?
 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?
 A man of 45 consults his general practitioner
(GP) with a 6-month history of reduced
appetite with dragging pain in right
 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?
 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 lineNormal-12-15 cm
The spleen is a functionally diverse
organ with active roles in
immunosurveillance and
 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
 Poulin et al defined splenomegaly as
moderate if the largest dimension is
11-20 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?
Is there any yellowing of the skin (jaundice)?
Is there any vomiting?
Is there any unusual-colored or 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
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)
Haemotological – AI, ITP, Thalassemia and HS
Chronic malaria
Massive Splenomegaly (>8 cm)
Chronic malaria
Kala-azar (visceral leshmaniasis)
Others(Gaucher’s, rapidly progressive lymphoma)
 Massive Liver
 HCC/Secondaries/myeloprolif
 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
Tender Liver
Liver abscess/infective (viral/bacterial/parasitic)
Right Heart Failure/Budd chiari
Pulsatile Liver
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
 Pallor, cachexia, Cx LNs, PRV
 Toxic, rashes, tonsils
 Chronic ethanol ingestion
 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 Hepatospenomegaly
 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
 Ultrasound of the liver (must be done to
confirm the condition if the doctor thinks
your liver feels enlarged during a physical
 CT scan of the abdomen
 Other tests for suspected causes
Investigations to consider (based on history and examination)
Liver blood tests (“LFT’s”)
Prothrombin time
Viral serology (hepatitis A,B,C,D,E, CMV, EBV and HIV, Herpes simplex)
Amoebic and hydatid serology. Consider toxoplasmosis and
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 ↑
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
Cirrhotic liver found on USS incidentally
 Jaundice (a sign not a diagnosis)
 Haemolytic (pre hepatic)
 Congenital
 Cholestatic (liver parenchymal and CBD
 “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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