04/01/2026
APPROACH TO HEPATOMEGALY
Confirm TRUE hepatomegaly
Clinical
• Liver palpable >2 cm below right costal margin (mid-clavicular line)
• Increased liver span on percussion
• Normal adult: ≤12–13 cm
• Assess surface (smooth vs nodular), edge (sharp vs rounded), tenderness
Imaging
• Ultrasound (first-line)
• Increased craniocaudal length (>15–16 cm)
• CT / MRI if:
• Focal lesions
• Infiltrative disease
• Malignancy staging
Exclude pseudo-hepatomegaly
• Right pleural effusion
• Lung hyperinflation (COPD)
• Subdiaphragmatic abscess
• Riedel’s lobe (normal variant)
Decide: Tender vs Non-tender
Tender hepatomegaly Non-tender hepatomegaly
Acute hepatitis Fatty liver disease
Congestive cardiac failure Cirrhosis (early)
Liver abscess Malignancy
Budd–Chiari syndrome Storage / infiltrative
Look for ASSOCIATED CLUES
Feature Suggests
Fever Hepatitis, abscess, infection
Jaundice Hepatitis, obstruction
Weight loss Malignancy
RUQ pain Hepatitis, congestion
Ascites Portal HTN, cirrhosis
Splenomegaly Portal HTN
Stigmata of CLD Cirrhosis
Heart failure signs Congestive hepatomegaly
Categorize causes (MOST IMPORTANT STEP)
🟢 INFECTIOUS / INFLAMMATORY
• Acute viral hepatitis (A, B, C, E)
• Liver abscess (amoebic, pyogenic)
• EBV / CMV
• TB
• Sepsis-associated hepatomegaly
Tender + febrile liver → think infection
🟡 METABOLIC / STEATOTIC
• NAFLD / MAFLD (most common)
• Alcohol-associated liver disease
• Drug-induced liver injury
Smooth, soft, non-tender liver
🔵 VASCULAR / CONGESTIVE
• Right-sided heart failure
• Constrictive pericarditis
• Budd–Chiari syndrome
• Veno-occlusive disease
Tender + pulsatile liver + raised JVP → CCF
🔴 NEOPLASTIC
• Hepatocellular carcinoma
• Metastatic liver disease
• Cholangiocarcinoma
• Leukemia / lymphoma infiltration
Hard, nodular liver ± weight loss
🟣 STORAGE / INFILTRATIVE
• Hemochromatosis
• Wilson disease
• Amyloidosis
• Glycogen storage diseases
• Gaucher disease
• Sarcoidosis
Massive hepatomegaly + minimal symptoms
⚫ CHRONIC LIVER DISEASE / PORTAL HTN
• Cirrhosis (early: enlarged; late: shrunken)
• Portal vein thrombosis
Hepatosplenomegaly + ascites
INITIAL INVESTIGATIONS
Baseline
• LFTs (AST, ALT, ALP, bilirubin)
• CBC
• INR
• Albumin
• ESR / CRP
Directed
• Viral hepatitis serology
• Ultrasound abdomen ± Doppler
• AFP (if HCC suspected)
• Iron studies (hemochromatosis)
• Ceruloplasmin (young patient)
• Autoimmune markers (ANA, ASMA)
• Echocardiography (if congestive)
Assess for PORTAL HYPERTENSION
Triad
1. Hepatomegaly
2. Splenomegaly
3. Ascites / varices / thrombocytopenia
→ Think cirrhosis or portal vein pathology
