PBL 22 SUPERVISED BY: DR. WALAA SHABANA HEPATOSPLENOMEGALY PBL 22 SUPERVISED BY: DR. WALAA SHABANA

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

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

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

SURFACE ANATOMY OF LIVER The limits of the normal liver are: Left 5th intercostal space – below left nipple Right 5th costal cartilage midclavicular line Right 7th intercostal space midaxillary line – below right nipple Right 9th intercostal space midaxillary line Upper border in 5th 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 10th rib. Upper border (A) corresponds to the upper border of the 9th rib Lower border (B) corresponds to lower border of 11th rib. Medial end (C) is 1.5 inches lateral to the 10th thoracic spine. Lateral end (D) reaches to the midaxillary line.

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

1) Chronic liver disease with Portal HTN 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 3) Hematological Haemolytic anemia: sickle cell anemia, thalassaemia Myeloproliferative disease

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

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

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