Causes of Hepatomegaly

Abstract:

Hepatomegaly is  enlargement of the liver  detected during medical examination. Both palpation and percussion techniques are used during abdominal examination to assess the size of the liver. O

Hepatomegaly is enlargement of the liver detected during medical examination. Both palpation and percussion techniques are used during abdominal examination to assess the size of the liver. On percussion the normal liver span is 7 cm for women and 10.5 cm for men. Hepatomegally is diagnosed when the liver size is found to be 2 to 3 cm larger than the above mentioned values.
Enlargement of the liver can be an apparent enlargement or true enlargement which can be due to several disease conditions. The disease conditions can be classified as cirrhosis, inflammatory conditions, cysts, metabolic conditions, haematological conditions, tumors, venous congestion and biliary obstruction.

Diseases which can cause apparent enlargement of the liver are low lying diaphragm and Reidel’s lobe. The liver is situated just below the right hemidiaphragm. Chest pathologies such as pneumothorax, emphysema, chronic obstructive pulmonary disease etc. push the right hemidiaphragm down along with the liver. This is noted as hepatomegaly on abdominal examination. Reidel’s lobe is defined as downward tongue-like projection of the anterior edge of the right liver lobe to the right of the gallbladder. This condition is commonly seen in women and can be an accessory lobe or a normal variant, which may extend up to the right iliac fossa. On palpation and percussion this can also be detected as enlarged liver.
One of the commonest causes of hepatomegaly is early cirrhosis which is the final outcome of most of the liver pathologies. Some of the causes of cirrhosis are Hepatitis C, alcoholic liver disease, non alcoholic fatty liver disease, hepatitis B, autoimmune hepatitis, primary and secondary biliary cirrhosis, primary sclerosing cholangitis, haemochromatosis, Wilson’s disease,  Alpha-1 antitrypsin deficiency, Sarcoidosis, Type IV glycogen storage disease, Drug-induced liver disease etc.
Cysts which cause hepatomegaly are Hydatid cysts and cysts seen in patients with polysystic kidney disease. Hydatid cysts are caused by the larval stage of the tapeworm Echinococcus granulosus. The cysts can occur in many organs but the liver is commonly involved. These cysts increase in size at an average rate of approximately 1-1.5 cm/year. The disease manifests as hepatomegaly when these cysts enlarge up to a detectable size.
Metabolic diseases causing hepatomegaly are fatty liver, Amyloid and glycogen storage disease. Fatty liver can occur with (alcoholic fatty liver disease) or without (non-alcoholic fatty liver disease) alcohol consumption. It is caused by accumulation of triglycerides and other fats in the liver cells. The ultimate outcome of the disease can be liver inflammation and cell death. Its prevalence is increasing worldwide along with the increasing number of obese people.  Liver is a commonly affected organ in Amyloidosis and can rarely cause massive hepatomegaly. The next metabolic disease causing hepatomegaly is glycogen storage disease which is a disease characterized by defective metabolism of glycogen.

Haematological diseases causing hepatomegaly are leukaemia, lymphoma, myeloproliferative disorders, and thalassaemia. In leukaemia, extra-medullary infiltration by leukemic cells may cause hepatomegaly along with Lymphadenopathy and splenomegaly. In patients with thalassaemia hepatomegaly occurs due to engorgement of hepatic paranchymal and phagocytic cells with hemosiderin deposits.

Tumors causing hepatomegaly can be either primary or secondary. Liver is one of the commonest sites for secondary deposits, especially from malignancies from the gastro-intestinal tract. Venous congestion caused by heart failure, hepatic vein occlusion can also lead to enlargement of the liver. Biliary obstruction particularly caused by an extra-hepatic cause is also an important cause of hepatomegaly.

Since there are a lot of causes of hepatomegaly, careful history taking, examination and investigations plays a vital role in detecting the correct eatiology and planning the future management.

Cause for Left Side Abdominal Pain in Females

There are several pathologies which can cause left side abdominal pain in a female. They can be mainly divided in to two categories. They are pathologies limited to females and pathologies affecting both males and females. The pain can arise from any structure that is situated in the left abdomen. These structures include the abdominal wall, peritoneum, colon, small intestine, omentum, left kidney, left ureter, spleen, and pancreas. Sometimes pathologies in the left lung and the heart can also present as left side abdominal pain. All the above mentioned pathologies are common to both females and males. Pathologies restricted to females are those arising from the female reproductive organs. Female reproductive organs which can give rise to left side abdominal pain are left ovary, left fallopian tube, and the uterus.

Ovarian diseases causing left side abdominal pain are mid cycle pain, benign and malignant ovarian cysts, ruptured ovarian cyst, twisting of the ovary, chocolate cyst, and ovarian carcinoma.  Mid cycle pain occurs at the midpoint of the woman’s menstrual cycle. This occurs as a result of ovulation. During ovulation, the ovarian capsule is broken and the ovum is released in to the peritoneal cavity. This can cause little amount of bleeding which gives rise to abdominal pain. In a woman who has 28 day cycles, ovulation occurs at the 14th day. This is the middle of the menstrual cycle. So, pain arising at the middle of the menstrual cycle is referred to as mid cycle pain. As a rule, ovulation occurs in every woman 14 days prior to the next expected day of menstruation. If you are having left side abdominal pain on this particular day, it can be due to ovulation. This is a physiological phenomenon and therefore, does not require special treatment. If the pain is disturbing, you can take simple analgesics. Ovarian cysts and tumors are major causes of abdominal pain. When they occur in left ovary, they cause left side lower abdominal pain.   There are many types of ovarian cysts. Chocolate cysts arise from the presence of endometrial tissues in the ovary. These endometrial tissues undergo cyclical bleeding in to the ovary. As there is no pathway for blood to drain, they accumulate within the ovary, causing abdominal pain during menstruation. The accumulated blood looks exactly like chocolate, hence the name chocolate cyst.

Diseases of the fallopian tube causing abdominal pain are ectopic pregnancies, fallopian tube tumors, infection etc. Ectopic pregnancy occurs when the blastocyst implants within the fallopian tube. The embryo slowly grows and becomes larger. Finally, the fallopian tube ruptures when it cannot accommodate the enlarging embryo, giving rise to severe abdominal pain and circulatory collapse. This is a gynecological emergency and therefore need immediate surgical intervention.

Diseases of the uterus causing abdominal pain are fibroids, Braxton Hicks contractions during pregnancy, labour pain etc. There are several types of fibroid. They are sub-mucosal, intramural, sub-serosal, pedunculated and parasitic fibroids. They cause pain when they become very large. Pedunculated fibroids can give rise to severe pain if they become twisted. The blood supply to the fibroid is cut off when it gets twisted. This causes ischemia to the fibroid, which ultimately give rise to pain.

Two of the common diseases involving the pelvic cavity are pelvic inflammatory disease and endometriosis. Pelvic inflammatory disease is inflammation of the pelvic cavity and it can be either acute or chronic. This occurs mainly due to infection. Chlamydia and gonococci are the commonest organisms causing pelvic inflammatory disease. Endometriosis is the presence of endometrial tissue in places other than the endometrium of the uterus. Chocolate cyst is also a type of endometriosis. Same as in chocolate cyst, the endometrial tissues in all other places undergo cyclical bleeding and give rise to abdominal pain.

Above mentioned are the commonest causes of abdominal pain specific to females. Apart from that abdominal pain also occur due to other common pathologies such as bowel diseases (irritable bowel syndrome), urinary tract infections, urinary tract stones, pancreatitis, pneumonia, musculoskeletal pain, etc.  

Ankylosing Spondylitis

A 23 year old male patient was presented to the medical ward with one year history of joint pains. He was mainly complaining of large joint involvement. He complained of back pain, shoulder, elbow, hip and knee joint pains, but there was no small joint involvement. The pain was more in the morning and there was significant morning stiffness.  He was having the symptoms for a long period of time hasn't got any regular treatment up until now.

On examination, he had restricted movements of his spine, but there were no joint deformities. Schoeber's test was positive indicating the presence of significant spinal stiffness. Schoeber's test is performed by marking a spot on the back, at the mid line, at the level of iliac crest. Then two points vertically 10 cm above and 5 cm below this point is marked while the patient is standing. The the patient is asked to bend as much as he can and the distance between the two marked point is measured. A reading less than 5 cm implies spinal stiffness. The reading of this particular patient was only 2 cm. The patient also had reduced chest expansion as a result of costochondral junction involvement (normal chest expansion should be at least 5 cm at the nipple level).

With all these findings, the patient is clinically diagnosed to have ankylosing spondylitis. Three out of four of following clinical criteria should be there to diagnose a patient as having ankylosing songilitis. These clinical features are,

1. Morning stiffness lasting more than 30 min. 
2. Improvement of back pain with movements but not with rest.
3. Awakening because of back pain during second half of the night only
4. Alternating buttock pain.

Ankylosing spondylitis, as the name implies, is a inflammatory disorder of the spine. This is mainly seen among young males who are in their late teen or early twenties. Even though both men and women (2.5: 1) can be affected but symptoms are more prominent in men. The disease has a strong association with HLA B27 gene. These patients are also more susceptible to develop iritis also.

Investigations are performed to confirm the diagnosis.

1. ESR - elevated
• The patient's ESR was 112 mm/1st hour
2. CRP (C reactive proteins) - elevated
• The patients CRP level was 24
3. HLA B 27 testing 
4. MRI - shows sacroilitis before it is seen on X rays
5. X rays 
• X ray lumbar spine
• The fusion of vertebra leads to a
  bamboo spine
• X ray sacroiliac joint
• The following radiograph is taken from our patient. There is sclerosis of either sides of the joint with irregular joint space suggestive of sacroilitis, but there is no ankylosis of the sacroiliac joint.

Ankylosing sondylitis - Sacroilitis

Treatment

• Exercising - Exercising plays a major role in preventing the progression of the disease and improving the symptoms.
• NSAIDs - Sometimes, the pain makes it impossible for the patient to carryout exercises. This is where NSAIDs come in to play. An evening dose of slow releasing NSAID, oral or as a suppository will reveal pain and help in carrying out an active lifestyle and improve sleep.
• Methrotexate is helpful if there is peripheral joint involvement, but will not improve spinal disease.
• Sustained and dramatic reduction of inflammation can be achieved by TNF alpha blocking drugs.
• Rituximab does not help in seronegative arthritis.

Prognosis

The prognosis is good with adequate exercises. Fifty percent of the HLA B27 positive patients have the risk of transmitting the gene to their offspring. Thirty percents of these offspring may get the disease eventually. 

Pneumothorax

Case History

A 30 year old, previously well male patient was admitted to the casualty ward with sudden onset of left side chest pain. The pain was severe in the beginning. On admission the patient was complaining of pleuritic type of chest pain. On examination, his respiratory rate was 18 breaths per minute, and saturation was 100% without oxygen. His vocal fremitus and air entry was reduced on left side of the chest. His heart sounds were difficult to auscultate too. The clinical diagnosis of pneumothorax was made and an emergency chest x ray was taken. The chest x ray showed a left sided pneumothorax. The patient was immediately referred to the chest physician who put an intercostal tube to the left side of the chest to take out the air.

Pneumothorax

Air in the pleural space is called pneumothorax. Air can accumulate within the pleural space as a result of injury to the chest wall or as a result of injury to the lungs.

Spontaneous pneumothorax

Spontaneous pneumothorax is commonly seen among young, tall and thin men. This is mainly due to a rupture of a pleural bleb. The male to female ratio of spontaneous pneumothorax is 6:1.

Pneumothorax in a diseased lung

Pneumothorax is common among people with an already diseased lung. Patients with COPD, asthma, carcinoma of the lung, bronchopulmonary fistula etc are at a higher risk of developing pneumothorax. Pneumothorax in such patients should be taken seriously regardless of the size.

The following x ray shows a right sided small pneumothorax in a COPD lung. This lung also shows a band of bronchiectasis in the right upper zone.

Right sided pneumothorax in a COPD lung

Tension Pneumothorax

Sometimes a valve mechanism develops which allows air to fill in the plueral space during inspiration and prevents air from getting out of pleural space during expiration. As a result, each time the patient breaths, the air accumulates within the pleural space and the pressure gradually increases causing the mediustinum to shift to the other side. The patient gradually becomes breathless and tachycardic and can even die unless the pressure is not relieved immediately. This is an emergency and requires immediate aspiration of the air.

Aspiration of pneumothorax

Aspiration of a pneumothorax is performed by first taking informed consent from the patient. Then 2% lidocaine is injected in to the pleural space. Then 3-4 cm of 16 french guage needle is inserted in to the pleural space in the second intercostal space midclavicular line. The cannula is connected to a three way tap and 50 cc syringe. Upto 2.5 liters of air can be aspirated through the syringe.