The liver is a sponge, filtering portal blood from, while secreting bile into, the gastrointestinal (GI) tract, and in between metabolising drugs and synthesising proteins such as vital clotting factors. But it is this vascularity, location, and function that also make the liver susceptible to several conditions that result in its enlargement beyond its normal size, usually palpably so, but otherwise discovered on abdominal imaging.
The liver is a colossal organ, in both size (1.5 kg in men) and function. Apart from the kidneys, it is the unsung hero of the body, and it typically extends in location from the fifth intercostal space to the right costal margin in the mid-clavicular line. At this juncture, ultrasonography measures the liver span to under 16 cm: median liver span 14.5 cm in adult males and 13.4 cm in adult females; with 12% of individuals having a span > 16 cm.¹
Consider that the palpable liver may be displaced and not enlarged, in Obstructive Lung Disease (Asthma, COPD), with an adjacent mass (Cholecystitis, abscess), or in thin patients. Otherwise, the nature of the consistency on palpation might be a clue to the cause of hepatomegaly. In an epoch of Hepatitis B (and C) pandemics, primary liver cancer, or hepatocellular carcinoma (HCC), is also a significant cause of hepatomegaly.
[Bold indicates common urban causes of a combined hepatosplenomegaly. Malaria and leishmaniasis are common non-urban causes of hepatosplenomegaly.]
Regular consistency:
- fatty liver
- haematological:
- myeloproliferative disease
- chronic myeloid leukaemia (CML)
- lymphoma
± Tenderness:
- hepatitis, including alcoholic, autoimmune, or viral, toxin, malaria, leishmaniasis
- congestive – right heart failure / constrictive pericarditis, tricuspid valve disease
- haematoma – trauma, ruptured haemangioma
- biliary obstruction – PSC, cholestasis
Firm and/or irregular:
- cirrhosis
- metastatic disease – intra-abdominal malignancy, pancreatic cancer, other
- hydatid disease, granuloma, amyloid
Other causes to consider include heritable conditions such as inborn errors of metabolism causing cellular accumulation of lipids or certain complex carbohydrates (mucopolysaccharides or glycosaminoglycans), such as in Gaucher’s disease and Hurler syndrome, or the abnormal deposition of iron (Haemochromatosis) or copper (Wilson’s disease), often unrecognised causes of a cirrhosis.
References
- Kratzer W, Fritz V, Mason RA, Haenle MM, Kaechele V; Roemerstein Study Group. “Factors affecting liver size: a sonographic survey of 2080 subjects.” J Ultrasound Med. 2003 Nov;22(11):1155-61. doi: 10.7863/jum.2003.22.11.1155.
- Wolf DC. “Evaluation of the Size, Shape, and Consistency of the Liver.” In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd Edn. Boston: Butterworths; 1990. Chapter 94. Available from: https://www.ncbi.nlm.nih.gov/books/NBK421/.
Further:
Kyle K. Jensen, Karen Y. Oh, Neel Patel, Evan R. Narasimhan, Alexei S. Ku, and Roya Sohaey. “Fetal Hepatomegaly: Causes and Associations.” 2020 40:2, 589-604. https://doi.org/10.1148/rg.2020190114.
Telega, Grzegorz W. “14 – Hepatomegaly.” In (Eds) Robert M. Kliegman, Patricia S. Lye, Brett J. Bordini, Heather Toth, Donald Basel. Nelson Pediatric Symptom-Based Diagnosis, Elsevier, 2018: 244-254.e1.
https://doi.org/10.1016/B978-0-323-39956-2.00014-5.
