HEPATO‐SPLENOMEGALY
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NORMAL LIVER
• <4yrs : Liver normally palpable 2cm below Rt costal
margin in the mid clavicular line.
• <12yrs : 1 cm
• > 12 yrs : not palpable
• Smooth surface, Non tender, Round border
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• Upper border is made out by percussion and lower border by palpation.
LIVER SPAN
Upper border of the normal liver corresponds to 5th intercostal space in the Rt mid clavicular line.
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• At 1 wk of age ‐‐‐‐‐ 4.5‐5 cm
• At 12 yrs
boys‐‐‐‐‐ 7‐8 cm
girls ‐‐‐‐‐‐ 6‐6.5 cm NORMAL LIVER SPAN
The lower edge of the rt lobe extends downward and palpable as a broad mass in some normal people(Riedel lobe)
• > 12 yrs – liver usually not palpable
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ABNORMAL LIVER CLINICALLY
Firm liver Cirrhosis, TB
Hard liver Malignancy
Sharp border Cirrhosis,
liver
Tender liver infection (hepatitis, abscess),
ccf,trauma
Nodular liver Cirrhosis,neoplasm
Asymmetric Tumor/ cyst
enlargement
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DOWNWARD DISPLACEMENT OF THE LIVER
• Emphysema
• Pleural effusion/empyema
• Subdiaphramatic abscess
• Relaxation of the abdominal musculature
Generalized visceroptosis & Rickets
• Thoracic deformity like narrow costal angle
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HEPATOMEGALY IN NEWBORN
•Neonatal hepatitis
•Extrahepatic Biliary atresia, choledocal cyst
•Erythroblastosis Fetalis
•Intrauterine infections
•Septicemia
•Metabolic disorders like Galactosemia,Alpha‐
1Antitrypsin deficiency etc
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HEPATOMEGALY IN LATER INFANCY AND CHILDHOOD
• Viral • Viral Hepatitis A , B , Dengue,
infections infectious mononeucliosis,
• Bacterial • enteric fever, septicemia ,tuberculosis,
infections Rickketsial disease,
• Protozoal • Malaria & Hepatic Amoebiasis
• Spirochital • Leptospirosis,
• Infiltrative • Nutritional(fatty infiltration) , malignacy
like leukemia
• Storage • Reye syndrome, glycogen storage
disorders disease, galactosemia , wilson
disease ,etc
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• Miscellaneous • Cirrhosis, VOD , Budd‐chiari syndrome
CLUES IN THE HISTORY/PHYSICAL EXAMINATION FOR
CAUSE OF HEPATOMEGALY
• Onset • Acute : viral hepatitis
• Chronic: chronic hepatitis,
cirrhosis
• Fever • Typhoid, Dengue fever ,
Malaria, Tuberculosis
• Pruritis • Cholestasis
• Family History & • Wilson’s, Thalassemias
consanguinity
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• Hepatotoxic drugs • Anti TB , Anti‐Epileptic
drugs, Anticancer
drugs
• Anemia • Hemolytic disease,
Leukemias
• lymphadenopathy • Disseminated TB,
malignancy
• cataract • Galactosemia, Cong
Rubella syndrome
• microcephaly • Intra uterine infecton
like Rubella
• Tremors/ Flaccidity • Lipid storage disease
• K F Ring • Wilson’s disease
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CLUES IN THE HISTORY/PHYSICAL EXAMINATION FOR
CAUSE OF HEPATOMEGALY
hydrocephaly intra uterine infections like
Toxoplasmosis, cmv
Mental Retardation Galactosemia, lipid storage disorders
Sudden onset of Profound disturbances of Reye syndrome
sensorium, pernicious vomiting and
convulsions
Chronic diarrhea, repeated Respiratory Mucoviscidosis (cystic fibrosis)
infection with clubbing and failure to thrive
Grotosque facies mucopolysaccharidosis
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• A soft,thin spleen may be palpable in
15% of neonates
10% of normal children
05% of adolescents SPLENOMEGALY
• Spleen must be 2‐3 times its normal size before it is palpable
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DIRECTIONS OF ENLARGEMENT OF SPLEEN
Children
Infants
Rt iliac fossa Lt iliac fossa
In infants spleen enlarges vertically downward against its diagonally downward
enlargement in children and adults
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HOW TO DIFFERENTIATE SPLEEN FROM KIDENY IN THE
LEFT HYPOCHONDRIUM
• Upper margin of the spleen is concealed by the rib
cage( get above the swelling is absent).
• Medial border of the spleen has a characteristic
notch.
• Overlying bowel is absent in splenic enlargement.
• Splenic swelling tends to extend towards the
umbilicus( vertically downwards in infants), kidney
swelling enlarges vertically downwards towards left
iliac fossa.
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HOW TO DIFFERENTIATE SPLEEN FROM KIDENY IN THE
LEFT HYPOCHONDRIUM
• Splenic swelling moves freely with respiration.
Renal swelling does not.
• Splenic swelling is palpated from the anterior
aspect where as kidney enlargement is
palpable from the posterior aspect or
bimanually.
• Kidney swelling in not ballotable unlike kidney
swelling.
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CAUSES OF SPLENOMEGALY
infections BACTERIAL : Acute ‐ S.typhi, S.pneumoniae, H.influenzae
Chronic‐ infective endocarditis , TB,
Local infections‐ splenic abscess
Viral : Acute viral infections – hepatitis A ,B &C , Hiv
Others: Spirochetal, rickettsial,fungal and parasitic
Storage diseases Lipidosis,mucopolysaccharidosis,carbohydrat metabolism
defects( galactosemia,fructose interolance)
congestive Ccf, intrahepatic –cirrhosis or fibrosis
malignancies Primary; leukemia,lymphoma,hodgkin disease
Hematological Acute and chronic hemolysis
Immunologic and Rheumatoid arthritis, SLE,SYSTEMIC VASCULITIS,
inflammatory
processes
Miscellaneous Cysts ,hemagioma ,hematoma
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• Storage disorder (gaucher’s disease)
• Hemolytic Anemias
•
•
•
Kala‐azar
Tropical splenomegaly
Chronic myeloid leukemia
MASSIVE SPLENOMEGALY
• Myeloproliferative disease
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• Cirrhosis with PHT‐ H/O JAUNDICE, Chronic history, haemetemesis, malena,anorexia,wt loss
CONGESTIVE HSM
• Caput medussae
• Ascites
• Gynaecomastia
• Testicular atrophy
• Palmar erythema
• Spider nevi
• Vitamin deficiency (A,D,E,K)
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• Hepatomegaly / splenomegaly / hepatosplenomegaly to be evaluated based on the history and associated physical findings
•
DIAGNOSIS
to arrive at a reasonably good clinical diagnosis.
Definitive diagnosis is established by performing relevant investigations.
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THANK YOU
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