Hepatomegaly

Published on 09/08/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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 Normal liver length 8-12 cm for men, 6-10 cm for women in midclavicular line

image But consider other dimensions and volume of liver
• Best imaging tool: Longitudinal US or coronal CT or MR

TOP DIFFERENTIAL DIAGNOSES

• Riedel lobe
• Caudate hypertrophy in Budd-Chiari or primary sclerosing cholangitis
• Liver displacement by COPD
• Lobar regeneration after major liver resection

CLINICAL ISSUES

• Most common signs/symptoms

image Palpable liver edge below costal margin
• Other signs/symptoms

image Jaundice, RUQ pain, fever, abnormal liver function tests
• Prognosis: Benign outcome to fulminant liver failure
• Biopsy often required for definitive diagnosis

DIAGNOSTIC CHECKLIST

• Hepatitis, steatosis, passive congestion, and diffuse tumor are most common causes
• Image interpretation pearls

image Consider triphasic CT to detect and characterize mass lesions
image Can also assist in diagnosing other etiologies
image e.g., passive hepatic congestion, steatosis
image
(Left) Longitudinal ultrasound in a 44-year-old man with a history of hepatitis B infection shows marked enlargement of the right lobe of the liver image, extending caudally below the level of the kidney image.

image
(Right) Longitudinal ultrasound in a 38-year-old woman with nonalcoholic steatohepatitis reveals marked hepatic enlargement. Note the right hepatic lobe image extending below the level of the right kidney image as well as echogenicity greater than that of the kidney due to diffuse steatosis.
image
(Left) Coronal CECT reformation of a 52-year-old man with metastatic colon cancer shows marked enlargement of the liver with diffuse metastases throughout the right lobe image.

image
(Right) Venous phase coronal CECT of a 27-year-old woman with leukemia and new onset of RUQ pain shows an enlarged and heterogeneous liver with distended hepatic veins image and IVC image due to passive congestion of the liver. Drug toxicity accounted for the cardiac dysfunction.

TERMINOLOGY

Definitions

• Enlargement of liver due to underlying pathologic process

IMAGING

General Features

• Best diagnostic clue

image Hepatic length and volume are increased
• Location

image Liver protrudes beyond costal margin
• Size

image > 15 cm measured from midhepatic line

– Normal liver length 8-12 cm for men in midclavicular line, 6-10 cm for women
• Morphology

image Focal enlargement due to mass lesion
image Diffuse enlargement due to infection, passive hepatic congestion, or infiltrative disorder

Imaging Recommendations

• Best imaging tool

image Longitudinal US or coronal triphasic CT

– Detect and characterize underlying mass
• Protocol advice

image CECT or MR to detect and characterize focal or diffuse disease

– Coronal reformations on CT
image In- and out-of-phase MR or NECT to detect steatosis

Radiographic Findings

• Radiography

image Displacement of right kidney and hepatic flexure on plain radiographs

CT Findings

• Diffuse enlargement best demonstrated on coronal views

image May have hyper- or hypovascular masses, focal lesions, or metastatic abscess

MR Findings

• In- and out-of-phase MR

image Lipid with signal dropout on out-of-phase imaging

Ultrasonographic Findings

• Length in midhepatic (midclavicular) line > 15 cm
• Liver tip extends beyond right kidney

DIFFERENTIAL DIAGNOSIS

Riedel Lobe

• Anatomic variant (not true hepatic lobe), not pathologic
• Tongue-like caudal protrusion of right lobe of liver
• May be palpable; misdiagnosed as hepatomegaly from pathologic cause
• More common in females (4-19%) than males (2-6%)

Caudate Hypertrophy in Budd-Chiari Syndrome

• Caudate lobe has separate venous drainage into inferior vena cava
• Caudate hypertrophies in response to necrosis of more peripheral segments of liver
• Similar caudate hypertrophy seen in primary sclerosing cholangitis (PSC)

Liver Displacement by Chronic Obstructive Pulmonary Disease (COPD)

• Caudal margin of liver displaced inferiorly by inverted diaphragm
• Hyperinflated lungs

Lobar Regeneration After Major Liver Resection

• Remainder of liver undergoes regeneration after major hepatic resection
• Occurs in children and adults

PATHOLOGY

General Features

• Etiology

image Infection

– Viral hepatitis (acute or chronic)
– Abscess (pyogenic or amebic)
– Other pathogens

image Cytomegalovirus, malaria, Epstein-Barr virus (mononucleosis), parasitic infestation, tuberculosis
image Infiltrative disorder

– Metastatic disease
– Hepatocellular carcinoma (especially if multifocal)
– Amyloid, carcinoid, granulomatous hepatitis
image Metabolic disorder

– Hemochromatosis, Wilson disease, glycogen storage disease, nonalcoholic steatohepatitis

image All causes of fatty liver (steatosis)
image Hematologic  causes

– Sickle cell anemia, hemolytic anemia, myeloma, leukemia, lymphoma
image Vascula r causes

– Congestive heart failure, right heart failure, constrictive pericarditis
– Signs of passive hepatic congestion

image Distended hepatic veins and IVC, retrograde opacification of IVC on arterial phase CECT, mottled liver enhancement
image Biliary causes

– Intra-/extrahepatic obstruction

image e.g., primary biliary cirrhosis, PSC
image Drugs

– Alcohol and drug-induced hepatitis

image Statins, amiodarone, toxins (e.g., mushrooms)

Gross Pathologic & Surgical Features

• Variable depending on etiology

Microscopic Features

• Variable depending on etiology

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Palpable liver edge below costal margin
• Other signs/symptoms

image Jaundice, RUQ pain, fever, abnormal liver function tests

– Acutely swollen liver may stretch hepatic capsule and causes RUQ pain and tenderness

Demographics

• Age

image Any age

Natural History & Prognosis

• Depends on etiology
• Ranges from benign outcome to fulminant liver failure

Treatment

• Depends on etiology
• Biopsy often required for definitive diagnosis

DIAGNOSTIC CHECKLIST

Consider

• Underlying infiltrating tumor or storage disease

Image Interpretation Pearls

• Consider triphasic CT to detect and characterize mass lesions and other causes
image
Sagittal grayscale ultrasound of the spleen in the same patient illustrates massive splenomegaly, measuring ∼ 18 cm in length.

image
Sagittal grayscale ultrasound of a 62-year-old man presenting with painless hepatosplenomegaly and a 2-year history of known Gaucher disease reveals marked enlargement of the liver, measuring > 20 cm in length, with relatively normal parenchymal echogenicity.

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