Hepatomegaly

Possible scenarios: Fatigue, weight loss, anaemia, jaundice, abdominal pain.
Palpation of a liver: Mass in the right hypochondrium which is dull to percussion, you cannot get above it or ballot it, it moves down on inspiration to the right iliac fossa. Note if there are co-existent signs of chronic liver disease (palmar erythema, pupura, spider naevi, gynaecomastia, axillary hair loss), hepatic decompensation (encephalopathy, ascites, coagulopathy, jaundice) or portal hypertension (caput medusae, splenomegaly).
Classic cases:

1. Hepatocellular cancer or secondary malignancy: Cachexia, pale palmar creases and conjunctivae, lymphadenopathy (esp.left supraclavicular fossa – Virchow’s node), scar from biopsy, ascites.
2. Polycystic liver disease: Either in isolation or with polycystic kidneys so look for signs of chronic renal failure and renal replacement therapy.
3. Hydatid cyst: Case in a farmer, on individuals from higher prevalence areas (i.e.: Wales), history of anaphylaxis, jaundiced, tender hepatomegaly.

Further investigations:

• Bedside tests: Urine dipstick (haematuria may be seen in ADPCKD).
• Bloods: FBC (anaemia, white cell count, eosinophil count; platelets prior to invasive procedures), LFTs (hepatic or obstructive picture, albumin for synthetic function), INR (synthetic function and prior to invasive procedures)U&Es (co-existent renal impairment), ESR/CRP (may be raised in infection or malignancy), virology (HIV, hepatitis B, hepatitis C), serological examination for echinococcus (for hydatid disease).
• Imaging: Abdominal USS (mass lesions, cirrhosis, cystic lesions, potential for biopsy, co-existent lymphadenopathy), CT CAP (to stage and identify primary and biopsy sites if malignancy suspected).
• Special tests: Biopsy (for histological diagnosis if cancer likely, or diagnosis remains unclear after the above, and hydatid cysts excluded).

Referral:
Consider gastroenterology.
Possible questions:

1. What are the commonest causes of HCC? 
   
   Most cases arise in individuals with chronic liver disease, particularly chronic hepatitis B and C, alcoholism, hereditary haemochromatosis, and primary biliary cirrhosis. In some countries there is a link with aflatoxins.
   
   
2. What primary sites metastasise to the liver? 
   
   ​GI tract tumours including stomach, pancreas and colon; in addition to lung, breast, ovarian and melanomas.