112 Hepatomegaly
Salient features
Examination
• Enlarged liver: comment on its size, tenderness, surface (smooth or irregular)
• Percuss the upper border (normally in the fifth intercostal space in the right midclavicular line) and auscultate for bruit (N Engl J Med 1962;266:554–5, JAMA 1968;206:2518–20, Postgrad Med 1977;62:131–4).
• How far the liver extends below the costal margin is of less importance than ‘liver span’ particularly in patients with emphysema or flattened diaphragms.
• By percussion, the mean liver size is 7 cm for women and 10.5 cm for men. A liver span 2–3 cm larger or smaller than these values is considered abnormal. The liver size depends on several factors including age, sex, body size, shape and the examination technique utilized (e.g. palpation versus percussion versus radiographic) (Ann Intern Med 1969;70:1183–9).
• Look for the following signs:
• Tell the examiner you would order an ultrasound of the abdomen.
• At this stage you may be asked to look for nervous system signs of alcoholism (peripheral neuropathy, proximal myopathy, cerebellar syndrome, bilateral sixth cranial nerve palsy as in Wernicke’s encephalopathy, recent memory loss and confabulation in Korsakoff’s psychosis).
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