What Is Hepatomegaly?

There are many potential causes for liver enlargement

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Liver, illustration
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The liver is a large, wedge-shaped organ in the right upper abdomen. In adults, the liver measures about 14 centimeters (5.5 inches) from top to bottom, with some variability depending on sex or body size.

Hepatomegaly is a general medical term that means “enlarged liver.” Liver enlargement has many different causes, and by itself, the term “hepatomegaly” does not suggest a specific diagnosis or disease. Instead, it could indicate a variety of different conditions.

Symptoms

Patients with an enlarged liver may not have any symptoms. Occasionally, patients may experience pressure or tenderness in their right upper abdomen.

Hepatomegaly that has developed quickly is more likely to have symptoms than hepatomegaly of slow onset.

It is important to note that liver enlargement itself is usually a symptom of some other underlying condition, and any given patient’s experience may depend on what is actually causing hepatomegaly. For example, jaundice (yellowing of the eyes or skin) and poor appetite are symptoms that may occur with many types of liver disease. Dark urine and light-colored stools may also occur. 

Patients with acute viral hepatitis may experience nausea, vomiting, fevers, and abdominal pain. Patients with chronic viral hepatitis often have nonspecific symptoms including fatigue, malaise (generally feeling unwell), or muscle and joint pains.

Causes

A wide range of diseases can cause hepatomegaly. These include infections (like viral hepatitis), toxins (such as alcohol), genetic diseases, or autoimmune disease (in which your immune system attacks its own tissues). Benign and cancerous tumors may also cause liver enlargement. 

Occasionally, normal anatomic variations of the liver can be confused for hepatomegaly. Because the range of possibilities is so broad, your doctors may order additional tests once liver enlargement is discovered.

Diagnosis

Hepatomegaly is often found during a routine physical examination. Your doctor will take a history and perform a physical examination in search of risk factors for liver disease. He/she will also be looking for signs and symptoms that may reveal the cause of hepatomegaly. In many cases, the cause of liver enlargement may be clear from your medical history alone.

Imaging tests may be used to confirm liver enlargement. Blood tests can be used to determine whether there is ongoing liver inflammation. Both imaging and bloodwork may also lend some additional insight as to why your liver is enlarged.

If imaging tests are ordered, the first study is usually an abdominal ultrasound. This type of study uses sound waves to create images of your organs. During the examination, a sonographer will place a device on your skin surface and record the resulting images. Abdominal ultrasounds are painless, non-invasive, fast, and inexpensive. They also give physicians a wealth of information about the size and structure of the liver.

If necessary, your doctor may order additional, more complex imaging tests, including an abdominal computed tomography (CT) scan or magnetic resonance imaging (MRI). Both examinations are more complex than ultrasound, but can sometimes answer questions that ultrasound cannot.

More invasive testing is sometimes necessary depending on the results of blood tests and imaging. If, for example, fluid is discovered in your abdomen, your doctor may prescribe the removal of some fluid for analysis. This procedure, called a paracentesis, can be performed bedside under local anesthesia.

Occasionally, a biopsy of the liver is required to reach a final diagnosis. A biopsy is a procedure in which a small amount of tissue is removed for examination under a microscope. Like a paracentesis, this procedure is also often performed bedside, using a local anesthetic, during which a small needle is placed into the liver through the skin and a tiny piece of tissue removed.

Treatment

Remember that hepatomegaly is usually a symptom of an underlying disease that may or may not require treatment. Your treatment plan will ultimately be determined by what is causing your liver enlargement. There are many causes of liver enlargement. Some of the most common ones include hepatitis, steatosis, drinking excessive amounts of alcohol, liver tumors, or storage disorders of the liver.

Common Causes of Hepatomegaly

  • Hepatitis
  • Steatosis
  • Drinking excessive amounts of alcohol
  • Liver tumors
  • Storage disorders of the liver

Hepatitis

Hepatitis is the inflammation of the liver, which can be caused by viruses. The most common types of hepatitis are hepatitis A, B, C, D, or E. Of these, the most common cause of chronic (long-lasting) hepatitis are hepatitis B and C viruses. If you are diagnosed with chronic hepatitis B virus, your doctor may recommend antiviral treatment if an initial evaluation reveals that you have severe active disease.

Most patients with chronic hepatitis C will be considered for therapy. As always, your doctor’s specific recommendations will depend on your medical and treatment history. Antiviral agents for hepatitis B and C include interferon or other agents which act directly to stop the virus (medications whose names end in -vir such as entecavir, ledipasvir, among others).           

Steatosis

Also called "fatty liver," steatosis occurs when liver cells accumulate fat in response to injury. Non-alcoholic fatty liver disease (NAFLD) refers to an accumulation of fat in the liver not caused by alcohol, viral infection, medications, or genetic disease. A related term is non-alcoholic steatohepatitis (NASH), which refers to steatosis associated with inflammation. 

Just like patients with other types of liver disease, patients with NAFLD can progress to advanced liver disease and cirrhosis. Obesity, type 2 diabetes, and hyperlipidemia place you at higher risk for NAFLD. Treatment often centers upon lifestyle modification such as diet, exercise, and weight loss. Medications are reserved mainly for patients with more severe disease.

Drinking Too Much Alcohol

Drinking excessive amounts of alcohol can cause a range of liver conditions, including alcoholic hepatitis, alcoholic fatty liver disease, or cirrhosis. If your doctor suspects that you may have alcohol-related liver disease, he/she will take a thorough history and perform a physical examination to determine how much alcohol you consume and look for signs of advanced liver disease. The workup may also include blood tests or imaging.

It is critical to recognize the signs and symptoms of alcohol abuse early because patients often do not develop symptoms until they have life-threatening liver disease. Treatment for alcohol abuse may take many different forms, including counseling, residential treatment, or support groups. Occasionally, medications can be used as an adjunct to other types of therapy.

Liver Tumors

Both benign and malignant liver tumors may cause enlargement of the liver. The most common types of benign liver tumors include cysts, hemangiomas, adenomas, or focal nodular hyperplasia. Often, these entities can be distinguished by imaging (CT or MRI) alone. Occasionally, a biopsy may be required to make a final diagnosis. 

Usually, no treatment is necessary for benign liver tumors, unless they are causing severe symptoms such as abdominal pain or bleeding. Rarely, liver adenomas can degenerate into a cancerous tumor, and your doctor may recommend periodic imaging to make sure no changes have occurred in your liver.

Malignant liver tumors can be divided into primary or secondary liver tumors. Primary liver tumors are tumors which arise directly from the liver tissue. The most common examples are hepatocellular carcinoma or cholangiocarcinoma. The treatment arsenal for primary liver tumors may include chemotherapy, radiation, surgery or other liver-directed procedures. Some patients with hepatocellular carcinoma may qualify for curative liver transplantation. Your specific treatment plan will depend on your diagnosis and specific circumstances.

A secondary liver tumor is a tumor from some other part of the body which has involved the liver. Tumors may grow directly into the liver (known as direct invasion) or may spread to the liver via the bloodstream (known as metastasis). Almost any tumor can spread to the liver, and treatment is variable. When your doctors create a treatment plan for secondary liver tumors, they will consider your overall health, the behavior of your disease, other coexisting diseases, and your own treatment goals.

Storage Disorders of the Liver

This refers to a group of disease where the liver stores too much carbohydrate, minerals, or other biological molecules. Often, the cause is genetic and may be exacerbated by diet or other factors in your environment. There are numerous liver storage diseases—examples include hemochromatosis (in which the liver stores too much iron), Wilson’s disease (too much copper), or glycogenosis (glycogen, a molecule related to sugar). 

If left untreated, these diseases can cause life-threatening liver failure. Treatment is variable and can include dietary changes or medications which capture the offending molecules.

Coping

It may be frightening to learn that your liver is enlarged. However, most of the causes of liver enlargement are benign and treatable. Your medical history and symptoms will guide the appropriate workup. Open communication with your health care workers will ensure that you understand the diagnostic and treatment plan and will help mitigate any anxiety you might have.

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