Hepatomegaly is the term used to describe an enlarged liver. Normally, the liver edge may be just palpable below the right costal margin on deep inspiration, particularly in thin people. It may also be palpable without being enlarged due to downward displacement, e.g. by hyper expansion of the thorax in chronic obstructive airways disease, a subdiaphragmatic collection or a Riedel’s lobe (an enlarged tongue-like growth of the right lobe of the liver which is a normal variant). To define the size of the liver its span should be percussed. A diseased liver may not always be enlarged, and in late cirrhosis it is more common for it to become small and scarred.
If the liver is palpable, other features should be elicited such as whether it feels soft or hard, regular and smooth or irregular, tender or non-tender, and pulsatile or non-pulsatile. The liver should be auscultated for a bruit. Associated features, depending on the underlying cause, may include splenomegaly, signs of chronic liver disease, lymphadenopathy and/or a raised jugular venous pressure.
The most common causes of a palpable liver in the developed world:
· Cardiac failure – right heart failure leads to a smooth, firm, tender liver due to congestion.
· Cirrhosis – particularly in early alcoholic cirrhosis. The liver is non-tender and firm.
· Cancer – metastases in the liver cause a hard, craggy, irregular or nodular surface.
Less common causes:
· Haematological malignancies (chronic leukaemia, lymphoma) and myeloproliferative disease can cause massive hepatomegaly.
· Infections such as acute hepatitis (smooth, tender), liver abscess or hydatid cysts.
· Primary hepatocellular carcinoma (may be tender and may have an arterial bruit).
· Fatty liver.
· Sarcoid, amyloid.
A tender liver indicates recent stretching of the liver capsule by enlargement, such as caused by cardiac failure or acute hepatitis. A pulsatile liver is most commonly caused by tricuspid regurgitation.