INTRODUCTION AND EPIDEMIOLOGY
This is the case of patient X, 75 years old, female residing in Tagudin, Ilocos Sur. Admitted in
Ilocos training and regional medical center surgical ward with a case of Hepatomegaly.
The liver is a large, wedge-shaped organ in the right upper abdomen. In adults, the liver
measures about 14 centimeters (5.5 inches) from top to bottom, with some variability depending
on sex or body size.
Hepatomegaly is the condition of having an enlarged liver. It is a non-specific medical
sign having many causes, which can broadly be broken down into infection, hepatic tumours,
or metabolic disorder. Often, hepatomegaly will present as an abdominal mass. Depending on the
cause, it may sometimes present along with jaundice. Obstructive jaundice is a condition in
which there is blockage of the flow of bile out of the liver. This results in redirection of excess
bile and its by-products into the blood, and bile excretion from the body is incomplete. Bile
contains many by-products, one of which is bilirubin, a pigment derived from dead red blood
cells.
Bilirubin is yellow, and this gives the characteristic yellow appearance of jaundice in the skin,
eyes, and mucous membranes. Symptoms of obstructive jaundice include yellow eyes and skin,
abdominal pain, and fever.
Obstructive jaundice is the illness of elderly population which is also confirmed by the
information on the average age of our patients. The frequency of illness is higher among female
population, and the most frequent cause of obstructive jaundice are gallstones (54.1% of
patients). In 29.8% of patients the primary or secondary malignant disease was the cause of
blockage in gall flow and subsequent jaundice, and the most frequent malignant cause of
obstructive jaundice is pancreas cancer in 11.5% of patients
Symptoms
It is important to note that liver enlargement itself is usually a symptom of some other underlying
condition, and any given patient’s experience may depend on what is actually causing
hepatomegaly. For example, jaundice (yellowing of the eyes or skin) and poor appetite are
symptoms that may occur with many types of liver disease. Dark urine and light-colored stools
may also occur. 1
Patients with acute viral hepatitis may experience nausea, vomiting, fevers, and abdominal pain.
Patients with chronic viral hepatitis often have nonspecific symptoms including fatigue, malaise
(generally feeling unwell), or muscle and joint pains.
Causes
A wide range of diseases can cause hepatomegaly. These include infections (like viral hepatitis),
toxins (such as alcohol), genetic diseases, or autoimmune disease (in which your immune system
attacks its own tissues). Benign and cancerous tumors may also cause liver enlargement. 1
Occasionally, normal anatomic variations of the liver can be confused for hepatomegaly.
Because the range of possibilities is so broad, your doctors may order additional tests once liver
enlargement is discovered.
Diagnosis
Hepatomegaly is often found during a routine physical examination. Your doctor will take a
history and perform a physical examination in search of risk factors for liver disease. He/she will
also be looking for signs and symptoms that may reveal the cause of hepatomegaly.
Imaging tests may be used to confirm liver enlargement. Blood tests can be used to determine
whether there is ongoing liver inflammation. Both imaging and bloodwork may also lend some
additional insight as to why your liver is enlarged.
If imaging tests are ordered, the first study is usually an abdominal ultrasound. This type of study
uses sound waves to create images of your organs. During the examination, a sonographer will
place a device on your skin surface and record the resulting images. Abdominal ultrasounds are
painless, non-invasive, fast, and inexpensive. They also give physicians a wealth of information
about the size and structure of the liver.3
If necessary, your doctor may order additional, more complex imaging tests, including an
abdominal computed tomography (CT) scan or magnetic resonance imaging (MRI). Both
examinations are more complex than ultrasound, but can sometimes answer questions that
ultrasound cannot.3
More invasive testing is sometimes necessary depending on the results of blood tests and
imaging. If, for example, fluid is discovered in your abdomen, your doctor may prescribe the
removal of some fluid for analysis. This procedure, called a paracentesis, can be performed
bedside under local anesthesia.
Occasionally, a biopsy of the liver is required to reach a final diagnosis. A biopsy is a procedure
in which a small amount of tissue is removed for examination under a microscope. Like a
paracentesis, this procedure is also often performed bedside, using a local anesthetic, during
which a small needle is placed into the liver through the skin and a tiny piece of tissue removed.
Anatomy of the biliary system
The biliary system consists of the organs and ducts that help to make and transport bile. These
include the bile ducts, gallbladder, and related structures.
Illustration of biliary system
The transportation of bile follows this sequence:
When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through
the right and left hepatic ducts.
These ducts ultimately drain into the common hepatic duct.
The common hepatic duct then joins with the cystic duct from the gallbladder to form the common
bile duct. This runs from the liver to the first section of the small intestine (the duodenum).
But not all bile runs directly into the duodenum. About 50% of the bile produced by the liver is first
stored in the gallbladder. This is a pear-shaped organ located directly below the liver.
Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to
help break down the fats.
Functions of the biliary system
The biliary system's main function includes the following:
To drain waste products from the liver into the duodenum
To help in digestion with the controlled release of bile
Bile is the greenish-yellow fluid (made of waste products, cholesterol, and bile salts) that is secreted
by the liver cells to do these 2 main functions:
Carry away waste
Break down fats during digestion
Bile salt is the actual component that helps break down and absorb fats. Bile, which is excreted from
the body in the form of feces, is what gives feces its dark brown color.
