Hepatomegaly: Differential diagnosis and evaluation
- Michael P Curry, MD
Michael P Curry, MD
- Associate Professor of Medicine
- Harvard Medical School
- Alan Bonder, MD
Alan Bonder, MD
- Department of Gastroenterology and Hepatology
- Harvard Medical School
- Section Editor
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology
- Section Editor — Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
Hepatomegaly is enlargement of the liver beyond its normal size and occurs mainly as a consequence of pathologic conditions (table 1).
This topic will review how to determine the size of the liver, the differential diagnosis of hepatomegaly, and the approach to the evaluation of a patient with hepatomegaly. More detailed discussions of many of the conditions that cause hepatomegaly are presented elsewhere. (See "Alcoholic hepatitis: Clinical manifestations and diagnosis" and "Autoimmune hepatitis: Clinical manifestations and diagnosis" and "Clinical manifestations and natural history of chronic hepatitis C virus infection" and "Clinical manifestations and natural history of hepatitis B virus infection" and "Epidemiology, clinical features, and diagnosis of nonalcoholic fatty liver disease in adults" and "Overview of inherited disorders of glucose and glycogen metabolism" and "Wilson disease: Clinical manifestations, diagnosis, and natural history" and "Clinical manifestations and diagnosis of hereditary hemochromatosis" and "Congestive hepatopathy".)
Normal size — The liver is wedge-shaped and is present in the right upper quadrant of the abdomen (figure 1). The liver typically extends from the fifth intercostal space to the right costal margin in the midclavicular line. The size of the liver increases with age, from an average span of 5 cm at the age of five years, to 15 cm in adulthood . The size of the normal liver also varies with sex and body size [2-4]. The normal liver weighs 1.4 to 1.5 kg in men and 1.2 to 1.4 kg in women . Relative to body size, the liver is larger in the fetus (1/18 of total body weight) than in the adult (1/36 of total body weight) .
By ultrasound, a normal liver is less than 16 cm in the midclavicular line . In a study of 2080 patients who underwent transabdominal ultrasonography, the average liver span in the midclavicular line was 14.0 +/- 1.7 cm, with 74 percent having a liver span of 15 cm or less . Fourteen percent had a liver span of 15 to 16 cm, and 12 percent had a liver span of >16 cm. On multivariable analysis, liver span correlated directly with height and body mass index and was greater in men.
Normal anatomy — Classically, the liver is divided into right and left lobes (figure 2). In the normal liver, the right lobe is larger than the left lobe and occupies the right hypochondrium. The smaller left lobe is flatter and is situated in the epigastrium and left hypochondrium.
- Wolf DC. Evaluation of the size, shape, and consistency of the liver. In: Clinical methods: The history, physical, and laboratory examinations, 3rd edition, Walker HK, Hall WD, Hurst JW. (Eds), Butterworths, Boston 1990.
- Naylor CD. The rational clinical examination. Physical examination of the liver. JAMA 1994; 271:1859.
- Walker H, Hall W, Hurst J. The history, physical and laboratory examinations, 3rd, Butterworths, Boston 1990.
- Kratzer W, Fritz V, Mason RA, et al. Factors affecting liver size: a sonographic survey of 2080 subjects. J Ultrasound Med 2003; 22:1155.
- Sham R, Sain A, Silver L. Hypertrophic Riedel's lobe of the liver. Clin Nucl Med 1978; 3:79.
- Kudo M. Riedel's lobe of the liver and its clinical implication. Intern Med 2000; 39:87.
- Sapira JD, Williamson DL. How big is the normal liver? Arch Intern Med 1979; 139:971.
- Niederau C, Sonnenberg A, Müller JE, et al. Sonographic measurements of the normal liver, spleen, pancreas, and portal vein. Radiology 1983; 149:537.
- Zoli M, Magalotti D, Grimaldi M, et al. Physical examination of the liver: is it still worth it? Am J Gastroenterol 1995; 90:1428.
- Joshi R, Singh A, Jajoo N, et al. Accuracy and reliability of palpation and percussion for detecting hepatomegaly: a rural hospital-based study. Indian J Gastroenterol 2004; 23:171.
- Tucker WN, Saab S, Rickman LS, Mathews WC. The scratch test is unreliable for detecting the liver edge. J Clin Gastroenterol 1997; 25:410.
- Gupta K, Dhawan A, Abel C, et al. A re-evaluation of the scratch test for locating the liver edge. BMC Gastroenterol 2013; 13:35.
- Castell DO, O'Brien KD, Muench H, Chalmers TC. Eastimation of liver size by percussion in normal individuals. Ann Intern Med 1969; 70:1183.
- Gosink BB, Leymaster CE. Ultrasonic determination of hepatomegaly. J Clin Ultrasound 1981; 9:37.
- Karlo C, Reiner CS, Stolzmann P, et al. CT- and MRI-based volumetry of resected liver specimen: comparison to intraoperative volume and weight measurements and calculation of conversion factors. Eur J Radiol 2010; 75:e107.
- Farraher SW, Jara H, Chang KJ, et al. Liver and spleen volumetry with quantitative MR imaging and dual-space clustering segmentation. Radiology 2005; 237:322.
- Dello SA, van Dam RM, Slangen JJ, et al. Liver volumetry plug and play: do it yourself with ImageJ. World J Surg 2007; 31:2215.
- Heymsfield SB, Fulenwider T, Nordlinger B, et al. Accurate measurement of liver, kidney, and spleen volume and mass by computerized axial tomography. Ann Intern Med 1979; 90:185.
- Zhou XP, Lu T, Wei YG, Chen XZ. Liver volume variation in patients with virus-induced cirrhosis: findings on MDCT. AJR Am J Roentgenol 2007; 189:W153.
- Schiano TD, Bodian C, Schwartz ME, et al. Accuracy and significance of computed tomographic scan assessment of hepatic volume in patients undergoing liver transplantation. Transplantation 2000; 69:545.
- Wolf AD, Lavine JE. Hepatomegaly in neonates and children. Pediatr Rev 2000; 21:303.
- Chau TN, Lai ST, Tse C, et al. Epidemiology and clinical features of sporadic hepatitis E as compared with hepatitis A. Am J Gastroenterol 2006; 101:292.
- Bernstein DL, Hülkova H, Bialer MG, Desnick RJ. Cholesteryl ester storage disease: review of the findings in 135 reported patients with an underdiagnosed disease. J Hepatol 2013; 58:1230.
- Torbenson M, Chen YY, Brunt E, et al. Glycogenic hepatopathy: an underrecognized hepatic complication of diabetes mellitus. Am J Surg Pathol 2006; 30:508.
- Chatila R, West AB. Hepatomegaly and abnormal liver tests due to glycogenosis in adults with diabetes. Medicine (Baltimore) 1996; 75:327.
- Charrow J, Andersson HC, Kaplan P, et al. The Gaucher registry: demographics and disease characteristics of 1698 patients with Gaucher disease. Arch Intern Med 2000; 160:2835.
- Drebber U, Kasper HU, Ratering J, et al. Hepatic granulomas: histological and molecular pathological approach to differential diagnosis--a study of 442 cases. Liver Int 2008; 28:828.
- Maddrey W. Granulomas of the liver. In: Schiff' disease of the liver, 8th, Schiff E, Sorrell M, Maddrey W (Eds), Lippincott-Raven, Philadelphia 1989. Vol 1572.
- Park MA, Mueller PS, Kyle RA, et al. Primary (AL) hepatic amyloidosis: clinical features and natural history in 98 patients. Medicine (Baltimore) 2003; 82:291.
- Swerdlow SH, Campo E, Harris NL, et al. World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues, IARC Press, Lyon 2008.
- Cooke CB, Krenacs L, Stetler-Stevenson M, et al. Hepatosplenic T-cell lymphoma: a distinct clinicopathologic entity of cytotoxic gamma delta T-cell origin. Blood 1996; 88:4265.
- Greenberger N. History taking and physical examination in the patient with liver disease. In: Schiff's diseases of the liver, 8, Schiff E, Sorrell M, Maddrey W (Eds), Lippincott-Raven, Philadelphia 1999. Vol 193.
- Curry MP, Chopra S.. Hepatic Vascular Disorders. In: A practical approach, 1st, La Knawy B, Shiffman ML, Wisener R. (Eds), Elsevier, 2004. Vol 273.
- Long RG, Scheuer PJ, Sherlock S. Presentation and course of asymptomatic primary biliary cirrhosis. Gastroenterology 1977; 72:1204.
- Lazaridia K, Wiesner R, Porayko M, et al. Primary Scleroising Cholangitis. In: Schiff's Doseases of the Liver, 8th, Schiff E, Sorrell M, Maddrey W (Eds), Lippincot-Raven, Philadelphia 1999. Vol 649.
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009; 51:237.
- Gabow PA, Johnson AM, Kaehny WD, et al. Risk factors for the development of hepatic cysts in autosomal dominant polycystic kidney disease. Hepatology 1990; 11:1033.
- Newman KD, Torres VE, Rakela J, Nagorney DM. Treatment of highly symptomatic polycystic liver disease. Preliminary experience with a combined hepatic resection-fenestration procedure. Ann Surg 1990; 212:30.
- Schnelldorfer T, Torres VE, Zakaria S, et al. Polycystic liver disease: a critical appraisal of hepatic resection, cyst fenestration, and liver transplantation. Ann Surg 2009; 250:112.
- LIVER ANATOMY
- Normal size
- Normal anatomy
- Anatomic variations
- ESTIMATING LIVER SIZE
- Physical examination
- Cross-sectional imaging
- DIFFERENTIAL DIAGNOSIS
- Storage disorders
- - Disorders of lipid metabolism
- - Disorders of glycogen metabolism
- - Gaucher disease
- - Alpha-1 antitrypsin deficiency
- - Hemochromatosis
- Infiltration of the liver
- - Granulomatous disease
- - Hepatic amyloidosis
- - Hepatosplenic T cell lymphoma
- - Malignant tumors
- - Benign tumors
- Impaired venous outflow
- - Budd-Chiari syndrome
- - Right heart failure
- - Sinusoidal obstruction syndrome
- - Peliosis hepatis
- Biliary tract disorders
- CLINICAL MANIFESTATIONS
- DIAGNOSTIC APPROACH