Page 190 - Medicine and Surgery

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186 Chapter 5: Hepatic, biliary and pancreatic systems

obstructionnobilereachesthebowel.Thisresultsindark expansion of the thorax in chronic obstructive airways
urine and pale stools. Liver function tests are usually ab- disease, a subdiaphragmatic collection or a Riedel’s lobe
normal. Obstruction of the bile system causes alkaline (an enlarged tongue-like growth of the right lobe of the
phosphatase to rise first and proportionally more than liver which is a normal variant). To define the size of the
the aminotransferases. liver its span should be percussed. A diseased liver may
not always be enlarged, and in late cirrhosis it is more
Clinical features common for it to become small and scarred.
Acarefulhistoryshouldbetakenincludingthefollowing: If the liver is palpable, other features should be elicited
Prodromal ‘flu-like’ illness up to 2 weeks before onset such as whether it feels soft or hard, regular and smooth

of jaundice suggests viral hepatitis. or irregular, tender or non-tender, and pulsatile or non-
Other risk factors for infectious causes include pre- pulsatile. The liver should be auscultated for a bruit.

vious blood transfusions, intravenous drug use, body Associated features, depending on the underlying cause,
piercing, tattoos and high-risk sexual practice. may include splenomegaly, signs of chronic liver disease,
Patients should also be asked about jaundiced con- lymphadenopathy and/or a raised jugular venous pres-

tacts. sure.
Previous or present biliary colic/gallstones suggest ob- The most common causes of a palpable liver in the

structive jaundice. developed world:
Adrug history including prescribed and non- Cardiac failure – right heart failure leads to a smooth,

prescribed medication, herbal remedies, alcohol and firm, tender liver due to congestion.
recreational drugs. Cirrhosis – particularly in early alcoholic cirrhosis.
Examination may reveal hepatomegaly and/or splen- The liver is non-tender and firm.
omegaly, signs of chronic liver disease and portal hy- Cancer – metastases in the liver cause a hard, craggy,
pertension. irregular or nodular surface.
Less common causes:
Investigations Haematological malignancies (chronic leukaemia,
Routine tests: lymphoma) and myeloproliferative disease can cause
U&Es, LFTs (see page 189), FBC, blood film and retic- massive hepatomegaly.

ulocytes, clotting profile. Infections such as acute hepatitis (smooth, tender),
Viral serology: EBV, CMV, hepatitis A, B and C. liver abscess or hydatid cysts.

Anultrasoundshouldbeperformedtolookfordilated Primary hepatocellular carcinoma (may be tender and

bileducts,gallstonesorothercausesofbiliaryobstruc- may have an arterial bruit).
tion. Further imaging including ERCP and CT scan of Fatty liver.
the abdomen may be required. Haemochromatosis.
Other investigations should be considered for specific Sarcoid, amyloid.

causes such as autoimmune hepatitis, haemochro- Atender liver indicates recent stretching of the liver cap-
matosis, primary biliary cirrhosis and Wilson’s dis- sule by enlargement, such as caused by cardiac failure
ease. or acute hepatitis. A pulsatile liver is most commonly
caused by tricuspid regurgitation.
Signs

Hepatomegaly Signs of chronic liver disease
Hepatomegaly is the term used to describe an enlarged There are many signs of chronic liver disease, but in
liver. Normally, the liver edge may be just palpable below some cases examination can be entirely normal, despite
the right costal margin on deep inspiration, particularly advanced disease (see Fig. 5.2).
in thin people. It may also be palpable without being The hands:
enlarged due to downward displacement, e.g. by hyper- Clubbing of the fingers (see page 92).