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Make the Diagnosis: Hepatomegaly

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Prior Probability

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The probability that the liver edge can be felt below the right costal margin is about 50%. However, this does not correlate with the liver span in normal patients. Thus, the prior probability of hepatomegaly depends entirely on the possible underlying disease states.

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Population for Whom Hepatomegaly Should Be Considered

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  • Known or suspected liver disorders

  • Malignancy

  • Congestive heart failure

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Detecting the Likelihood of Hepatomegaly

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Palpating a liver edge below the right costal margin correlates poorly with the actual liver span, although it does increase the likelihood that the patient will have an enlarged liver (positive LR, 2.0). Likewise, the failure to identify the liver edge does not rule out the presence of an increased liver span (negative LR, 0.41). The effect of this finding depends on the previous suspicion of liver disease.

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When there is a suspicion of liver disease, we recommend that clinicians forgo the “scratch” test and use percussion to estimate the liver span (>15 cm = enlargement). Liver ultrasonography will be required to confirm the clinical findings.

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Reference Standard Tests

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Ultrasonography or scintigrams.

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Original Article: Does This Patient Have Hepatomegaly?

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Clinical Scenario

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The patient in your examining room is new to the practice. He is 52 years old, emigrated from Southeast Asia about 10 years ago, and has no specific complaints except fatigue. On examination you find little of note except that his liver edge is firm, is easily felt, and extends about 6 cm below the costal margin across much of the right upper quadrant. The span, by light percussion, is 17 or 18 cm. Should you be concerned? What does the research literature tell us about the meaning of these findings?

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Why Is the Clinical Examination Important?

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Ideally, the clinical meaning of physical examination findings should be established in research studies that account for the overall context, including other signs and details from the medical history. This approach is difficult in liver disease because the physical manifestations of hepatic dysfunction are protean, and many multisystem diseases affect the liver. Our focus, therefore, is on physical examination of the liver itself. This means, however, that we implicitly depend on the clinician's ability to make a baseline estimate of the likelihood of liver disease according to the medical history or other physical findings.

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Although many maneuvers recommended in liver examination are unproven, there is reasonable evidence that the presence or absence of hepatomegaly can be determined with moderate accuracy on physical examination. Descriptive studies suggest that other qualitative findings may help in clinical assessment of patients with possible liver disease. Liver examination, like most physical diagnosis maneuvers, is not dissimilar to a screening test; it ...

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