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 and Hepatology
- Section Editor — General Hepatology; 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.
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- 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