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Hepatomegaly: David L. Simel, MD, MHS, discusses the clinical examination for hepatomegaly.
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Hepatomegaly: David L. Simel, MD, MHS, discusses the clinical examination for hepatomegaly.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives section. Today, I'm talking with Dr. David Simel about hepatomegaly, an important topic covered in the Rational Clinical Examination in a section co-authored by Dr. Simel. Dr. Simel, why don't you introduce yourself to our listeners? >> Hi, I'm Dave Simel. I'm the Editor of the Rational Clinical Examination Series. And I'm Chief of the Medical Service at the Durham Veterans Affairs Medical Center and Vice Chairman in the Department of Medicine at Duke University.
>> Dr. Simel, what are the anatomic and physiological features that affect how the liver enlarges and our ability to detect it? >> Well, the liver is actually hidden behind the rib cage. And in hiding behind the rib cage, most of the time, we can't detect liver enlargement if it's occurring until it emerges below the bottom of the rib cage where we can first palpate the liver edge. If we evaluate patients carefully and at the end of a held inspiration, we often can feel a normal liver edge.
>> Are there history and physical examination findings that are helpful for detecting an enlarged liver? >> Well, let me expand a little bit about what I mean by often detecting a liver edge in normal patients. If you examine a non-obese, easy to examine, cooperative patient, you can generally palpate a liver edge in about 60% of patients in the right upper quadrant. If you then concentrate on what you're doing and have them take a deep breath and hold it at the end of inspiration, you can pick up a liver edge in another 28% of patients.
And these are all entirely normal patients. But that feeling of palpating a liver edge can be a sign that the liver might be enlarged. Unfortunately, when considering all patients, about 50% will have a liver edge below the right costal margin. So, that's all patients, whether they're easy to examine or not. So, you wind up having to consider whether the liver is large, based on your physical exam in a lot of patients. >> Does liver palpability relate to hepatomegaly? >> Well, it does.
But the problem is that palpability does not prove that the liver is enlarged. The likelihood ratio for a large liver based on being able to feel the liver edge only is 2. So, that means the odds ratio increases twofold that a patient with a palpable liver will have an enlarged liver. When you don't feel a liver edge, the likelihood that the liver is enlarged decreases. But the likelihood ratio from that is only 0.41. So, these are not particularly strong likelihood ratios for palpability to either prove that the liver is enlarged or not enlarged.
>> Since a palpable liver edge is felt in so many normal patients, what do we know about the prevalence of true hepatomegaly and what features affect the prevalence? >> Well, this is an important question. Unlike most of our articles in this series, in the Rational Clinical Exam Series, this article starts with a physical exam finding and asks us whether or not there is a disease associated with it. And usually, in the Rational Clinical Exam, we start with a clinical question and try to figure out whether or not our history and physical exam change our impression about the likelihood of disease.
So, the prevalence of hepatomegaly when you feel a liver edge depends on whether there are underlying conditions associated with liver disease or liver involvement. But because these are so varied and there are so many possibilities, it is really impossible to come up with a single useful overall value for the prevalence of true hepatomegaly. But certainly, the presence of malignancy, certain infections, or even congestive heart failure are important features that may result in an enlarged liver.
And in all of those patients, you should examine them carefully for liver enlargement. >> Do you recommend evaluating all patients with palpable liver for hepatomegaly? >> Well, the first thing you need to do when you feel a palpable liver is consider whether or not there is an underlying condition that's associated with liver disease or liver involvement. And quite frankly, if there's not, most patients you really don't need to do any further assessment. But if for any reason you want to understand whether or not that palpable edge indicates an abnormality, you might first begin with percussion.
And in percussion, what you're trying to do is estimate the vertical liver span. And what you do is when you feel a palpable edge is you make a mark or remember where that edge is in terms of surface anatomy. And then, you percuss gently up in the mid-clavicular line for dullness. And when the dullness ends as you're percussing upwards and becomes resonant, you know you're over the lung. And you make a mark on the skin and measure that vertical distance. Now, it's generally accepted that a liver span of greater than 15 centimeters indicates true enlargement.
But that's a rigorous standard. And that rigorous standard is made necessary because of interobserver variability and an understanding that the liver span increases with body size. So, in general, we recommend considering whether or not there's a condition that might cause liver enlargement and then, proceeding with evaluating the vertical liver span in the mid-clavicular line. >> What are the reference standards for hepatomegaly? >> Well, the least invasive and probably easiest test to get is going to be an ultrasound in which the span is measured, and the volume of the liver can be assessed.
In older studies, you'll see that a liver-spleen scan is used. So, a nuclear medicine study. And although that works well, it can have some motion artifacts that can make the measurement a little less precise. >> Is there anything else you would like to tell our listeners about hepatomegaly? >> Well, yes. And there's two important things to remember. First off, some patients with advanced liver disease, for example, cirrhosis, may present with a small liver rather than a large liver.
The physical exam is just not going to be very useful for detecting a small liver. The second is a finding that our students and health staff often ask us about which is the scratch test. And there actually has been a good study that shows that scratching the liver doesn't allow you to figure out the vertical span. And basically, what happens with the scratch test is you're scratching over the abdomen. And then, as you scratch up and get over the liver, just like percussion changes, the resonance of the scratch changes.
And the study shows that there is just absolutely no correlation between the findings of the scratch test for liver enlargement and actual liver enlargement itself. >> Thank you, Dr. Simel, for this overview of hepatomegaly. For additional information about this topic, JAMAevidence subscribers can consult the Rational Clinical Examination. This has been Joan Stephenson of JAMA talking with Dr. David Simel for JAMAevidence.
