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

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

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

4. 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

5. 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

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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

13. 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

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

15. 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

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

17. 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)

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

19. 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

21. 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

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

23. 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

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

25. 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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