STUDY - Technical - New Dacian's Medicine
Hepatomegaly
(Classical / Allopathic Medicine)
Hepatomegaly, an
enlarged liver, indicates potentially reversible primary or
secondary liver disease. This sign may stem from diverse
pathophysiologic mechanisms, including dilated hepatic
sinusoids (with heart failure), persistently high venous
pressure leading to liver congestion (with chronic
constrictive pericarditis), dysfunction and engorgement of
hepatocytes (with hepatitis), fatty infiltration of
parenchymatous cells causing fibrous tissue (with cirrhosis),
distention of liver cells with glycogen (with diabetes), and
infiltration of amyloid (with amyloidosis).
Hepatomegaly is
seldom a patient's chief complaint. It usually comes to light
during palpation and percussion of the abdomen and may be
confirmed by imaging studies and further palpation and
percussion. Also, hepatomegaly may be mistaken for the
displacement of the liver by the diaphragm in a patient with a
respiratory disorder; by an abdominal tumor; by a spinal
deformity, such as kyphosis; by the gallbladder; or by fecal
material or a tumor in the colon.
Percussing for
liver size and position
With the patient
in a supine position, begin at the right iliac crest to
percuss up the right midclavicular line (MCL), as shown below.
The percussion note becomes dull when you reach the liver's
inferior border - usually at the costal margin, but sometimes
at a lower point in a patient with liver disease. Mark this
point and then percuss down from the right clavicle, again
along the right MCL. The liver's superior border usually lies
between the fifth and seventh intercostal spaces. Mark the
superior border.
The distance
between the two marked points represents the approximate span
of the liver's right lobe, which normally ranges from 23/8″ to
4¾″ (6 to 12 cm).
Next, assess the
liver's left lobe similarly, percussing along the sternal
midline. Again, mark the points where you hear dull percussion
notes. Also, measure the span of the left lobe, which normally
ranges from 1½″ to 31/8″ (4 to 8 cm). Record your findings for
use as a baseline.
HISTORY:
If you suspect hepatomegaly, ask the patient about his use of alcohol and possible ways he could have been exposed to hepatitis.
Ask the patient if he's currently ill or taking any prescribed drugs.
If the patient complains of abdominal pain, ask him to locate the pain and describe how it feels.
HISTORY:
If you suspect hepatomegaly, ask the patient about his use of alcohol and possible ways he could have been exposed to hepatitis.
Ask the patient if he's currently ill or taking any prescribed drugs.
If the patient complains of abdominal pain, ask him to locate the pain and describe how it feels.
PHYSICAL
ASSESSMENT:
Inspect the skin and sclera for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (common with cirrhosis).
Inspect the contour of the abdomen. Note if it's protuberant over the liver or distended (possibly from ascites). Measure abdominal girth.
Percuss the liver, but be careful to identify structures and conditions that can obscure dull percussion notes, such as the sternum, ribs, breast tissue, pleural effusions, and gas in the colon. (See Percussing for liver size and position.) Next, during deep inspiration, palpate the liver's edge.
Take the patient's baseline vital signs, and assess his nutritional status.
Evaluate the patient's level of consciousness. Watch for personality changes, irritability, agitation, memory loss, inability to concentrate, and - in a severely ill patient - coma.
Inspect the skin and sclera for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (common with cirrhosis).
Inspect the contour of the abdomen. Note if it's protuberant over the liver or distended (possibly from ascites). Measure abdominal girth.
Percuss the liver, but be careful to identify structures and conditions that can obscure dull percussion notes, such as the sternum, ribs, breast tissue, pleural effusions, and gas in the colon. (See Percussing for liver size and position.) Next, during deep inspiration, palpate the liver's edge.
Take the patient's baseline vital signs, and assess his nutritional status.
Evaluate the patient's level of consciousness. Watch for personality changes, irritability, agitation, memory loss, inability to concentrate, and - in a severely ill patient - coma.
SPECIAL
CONSIDERATIONS:
The patient with hepatomegaly may experience dyspnea, so position him in a semi-Fowler position.
The patient with hepatomegaly may experience dyspnea, so position him in a semi-Fowler position.
PEDIATRIC
POINTERS:
Childhood hepatomegaly may stem from Reye's syndrome; biliary atresia; a rare disorder, such as Wilson's, Gaucher's, or Niemann-Pick disease; or poorly controlled type 1 diabetes mellitus.
Childhood hepatomegaly may stem from Reye's syndrome; biliary atresia; a rare disorder, such as Wilson's, Gaucher's, or Niemann-Pick disease; or poorly controlled type 1 diabetes mellitus.
PATIENT
COUNSELING:
Advise the patient to remain on bed rest, avoid stress, and get adequate nutrition by going on a low-protein diet. Tell him to avoid alcohol to help protect the liver cells from further damage and to promote the regeneration of functioning cells. Also, instruct him on what to expect from diagnostic testing, which may include blood studies, X-rays, liver scans, celiac arteriography, computed tomography scan, and ultrasonography.
Advise the patient to remain on bed rest, avoid stress, and get adequate nutrition by going on a low-protein diet. Tell him to avoid alcohol to help protect the liver cells from further damage and to promote the regeneration of functioning cells. Also, instruct him on what to expect from diagnostic testing, which may include blood studies, X-rays, liver scans, celiac arteriography, computed tomography scan, and ultrasonography.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)