HEPATOSPLE NOMEGALY PBL 22 SUPERVISED BY DR WALAA

HEPATOSPLE NOMEGALY PBL 22 SUPERVISED BY: DR. WALAA SHABANA

1 2 OBJECTIVES 3 4 Definition Causes of hepatosplenomegaly Surface anatomy of liver and spleen How to approach patient with hepatosplenomegaly?

DEFINITION enlargement of liver and spleen beyond their normal size. Hepatosplenomegaly is an

1 2 OBJECTIVES 3 4 Definition Causes of hepatosplenomegaly Surface anatomy of liver and spleen How to approach patient with hepatosplenomegaly?

SURFACE ANATOMY OF LIVER • The limits of the normal liver are: a) Left 5 th intercostal space – below left nipple b) Right 5 th costal cartilage midclavicular line c) Right 7 th intercostal space midaxillary line – below right nipple d) Right 9 th intercostal space midaxillary line • Upper border in 5 th right intercostal space on full expiration • Lower border at the costal margin in the midclavicular line on full inspiration

NORMAL SPAN OF LIVER • Normal liver span in the midclavicular line ranges from 9 cm to 14 cm and in the midline from 4 to 8 cm • The size of the normal liver also varies with age, sex and body size • False positives for enlarged liver span: right pleural effusion, consolidated lung.

SURFACE ANATOMY OF SPLEEN • Lies in left hypochondrium • Long axis corresponds to the posterior part of the 10 th rib. • Upper border (A) corresponds to the upper border of the 9 th rib • Lower border (B) corresponds to lower border of 11 th rib. • Medial end (C) is 1. 5 inches lateral to the 10 th thoracic spine. • Lateral end (D) reaches to the midaxillary line.

1 2 OBJECTIVES 3 4 Definition Causes of hepatosplenomegaly Surface anatomy of liver and spleen How to approach patient with hepatosplenomegaly?

CAUSES OF HEPATOSPLENOMEGALY 1) Chronic liver disease with Portal HTN Liver Cirrhosis caused by: • Viral infection • Autoimmune liver disease • Alcoholic & Non-alcoholic steatohepatitis • Metabolic liver diseases

2) Infective 3) Hematological • Viral: - Hepatotrophic (A, B, C, D, E) - Other viruses (herpes, CMV, EBV, varicella, HIV, rubella, adenovirus, enterovirus) • Parasitic: shistosoma, malaria, leshmania, amoeba, toxoplasma • Bacterial: tuberculosis, typhoid, brucellosis, syphilis • Fungal: histoplasmosis • Haemolytic anemia: sickle cell anemia, thalassaemia • Myeloproliferative disease

4) Infiltration • Amyloidosis, sarcoidosis, glycogen storage disease 5) Congestive • Right sided heart failure, Budd Chiari syndrome, constrictive pericarditis 6) Connective tissue disease • SLE, Rheumatoid arthritis 7) Neoplastic • Hepatocellular carcinoma, Leukemia, lymphomas, metastasis 8) Miscellaneous • Thyrotoxicosis, Acromegaly

1 2 OBJECTIVES 3 4 Definition Causes of hepatosplenomegaly Surface anatomy of liver and spleen How to approach patient with hepatosplenomegaly?

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY? History taking General examination Abdominal examinations Investigations

i. History Taking • History of joint pain or rash We should ask about: (collagen disease) • Risk factors for hepatitis e. g. , medical stuff, history of blood • History of travel abroad (malaria)& contact to canal transfusion water (bilharziasis) • History of jaundice or chronic • History of T. B liver disease • History of alcohol abuse, drugs, contraceptive pills • Symptoms of Heart failure

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY? History taking General examination Abdominal examinations Investigations

ii. General examination Examine the patient for: • Signs of chronic liver disease e. g. , jaundice, ms wasting, oedema L. L, palmar erythema, clubbing, spider naevi, ascites • Signs of the heart failure • Enlarged lymph nodes (lymphoma) • Arthritis, rash, hair falling, hand deformities( collagen diseases) • Marked loss of weight (malignancy)

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY? History taking General examination Abdominal examinations Investigations

iii. Abdominal examination Palpation of Liver • Border: • Rounded border in congestion and infection • Sharp border in cirrhosis and malignancy • Consistency: • Soft in congestion& infection • Firm in cirrhosis • Hard in malignancy • Tender liver in infection, congestion and malignancy

Palpation of spleen • The spleen has to be enlarged 2 or 3 times its usual size to be palpable under the costal margin • Mild splenomegaly : just below costal margin • Moderate splenomegaly : midway between costal margin and umbilicus • Huge splenomegaly: below umbilicus Percussion • Splenomegaly causes dull Traub’s area

HOW TO APPROACH PATIENT WITH HEPATOSPLENOMEGALY? History taking General examination Abdominal examinations Investigations

iv. Investigations Laboratory Investigations • Serum electrolytes and BUN • CBC with differential and peripheral blood smear • Hepatitis serology e. g. , HBs. Ag &HCV Abs • Liver functions: AST, ALT, GGT, alkaline phosphatase, bilirubin, total protein, albumin

Imaging • Abdominal ultrasound with Doppler • Chest x-ray (T. B) • Abdominal CT or MRI (hepatic masses, biliary tree, anatomical obstructions) • Echocardiogram ( heart failure)

Liver biopsy • Liver biopsy is a procedure in which a small needle is inserted into the liver to collect a tissue sample. • Performed to help identify the cause of: • Persistent abnormal liver blood tests (liver enzymes) • A liver abnormality found on ultrasound, CT scan • Unexplained enlargement of the liver • Can also be used to estimate the degree of liver damage and determine the best treatment for the damage or disease.

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