Write a short note on the clinical approach to hepatomegaly and splenomegaly.

Definition and Clinical Assessment

The liver is normally palpable up to 1–2 cm below the right costal margin in thin individuals and in children, and normal liver span is 12–15 cm in the midclavicular line by percussion. A palpable liver edge is not synonymous with hepatomegaly — it may be displaced downwards by hyperinflated lungs in COPD or by a subdiaphragmatic collection, which is why percussion of the upper border is essential before declaring enlargement.

The normal spleen is NOT palpable — it must enlarge to about twice its size before becoming palpable. It is distinguished from a renal mass by: enlarging towards the right iliac fossa, having a notch on its medial border, being dull to percussion, having no palpable upper border (you cannot get above it), moving early and markedly with respiration, and not being ballotable.

Grading of splenomegaly: just palpable; moderate (up to the umbilicus); massive (crossing the midline or reaching the pelvis).

Causes of Hepatomegaly

Causes of Splenomegaly

CAUSES OF HEPATOSPLENOMEGALY (both together)

• Portal hypertension / cirrhosis — the commonest
• Haematological malignancy — leukaemia (acute and chronic), lymphoma, myeloproliferative neoplasms
• Infections — kala-azar, malaria, enteric fever, brucellosis, infective endocarditis, EBV, CMV, HIV, disseminated tuberculosis
• Haemolytic anaemias — thalassaemia major, sickle cell disease, hereditary spherocytosis
• Storage and infiltrative disorders — Gaucher's, Niemann–Pick, amyloidosis, sarcoidosis
• Congestive — right heart failure, constrictive pericarditis
• Autoimmune — SLE, adult-onset Still's disease

Clinical Approach

History:

• duration and rate of onset
• fever and its pattern
• travel to and residence in endemic areas (kala-azar belt, malaria)
• weight loss and night sweats (B symptoms)
• alcohol and drug history
• risk factors for viral hepatitis
• bleeding, bruising and recurrent infection (marrow disease)
• jaundice, dark urine and pallor (haemolysis)
• family history and consanguinity (storage disease, haemoglobinopathy)
• cardiac symptoms.

Examination:

• Characterise the organs — size, consistency, surface, edge, tenderness, and any bruit or rub.
• Look for the company they keep: lymphadenopathy (lymphoma, leukaemia, infection), stigmata of chronic liver disease and ascites, pallor, jaundice, purpura, raised JVP and cardiac signs, skin changes (hyperpigmentation in kala-azar and haemochromatosis), joint signs, and fundoscopy.

Investigations

• CBC with peripheral smear — the single highest-yield test: blasts, the myeloid spectrum with basophilia (CML), tear-drop cells (myelofibrosis), atypical lymphocytes (EBV), parasites (malaria), spherocytes, target cells, pancytopenia.
• Liver function tests, INR, albumin; renal function; LDH and uric acid.
• Infective screen — malaria smear and rapid test, rK39 for kala-azar, blood cultures, Widal, brucella serology, viral hepatitis serology, HIV, EBV and CMV serology, Mantoux/IGRA.
• Ultrasound abdomen with Doppler — organ size and texture, focal lesions, portal vein diameter and flow, splenic vein, ascites, lymph nodes.
• CECT abdomen for masses, lymphadenopathy and staging.
• Bone marrow aspiration and biopsy — for haematological malignancy, marrow infiltration, and to demonstrate LD bodies in kala-azar.
• Lymph node biopsy where there is lymphadenopathy; liver biopsy in selected cases.
• Specific tests as directed: haemoglobin electrophoresis, autoimmune profile, serum ACE, enzyme assays for storage disorders, and upper GI endoscopy for varices where portal hypertension is suspected.

Management

Treat the underlying cause — this is the whole of management. Additional considerations:

• Avoid contact sports and trauma with significant splenomegaly, because of the risk of splenic rupture — advice that is regularly forgotten.
• Manage hypersplenism (cytopenias) — treat the cause; splenectomy or splenic artery embolisation in selected cases.
• If splenectomy is performed: vaccinate against pneumococcus, meningococcus and *Haemophilus influenzae* type b at least 2 weeks beforehand, give lifelong penicillin prophylaxis, and provide a patient alert card — overwhelming post-splenectomy infection is rapidly fatal and entirely preventable.