Hepatomegaly

Introduction Liver enlargement can be caused by many diseases and is an important clinical sign. Including hepatitis B, hepatitis A, hepatitis C, cirrhosis, fatty liver, liver cancer, alcohol liver and many other liver diseases. It is a common and extremely harmful disease and should be based on active prevention. Pathological hepatomegaly should be determined in combination with medical history, liver location, morphology, texture, respiratory mobility, tenderness, and other findings.

Cause

infection:

(1) Viral infections: A, B, C, D and E viral hepatitis, infectious mononucleosis, yellow fever, rubella, cytomegalovirus, herpes simplex virus, Coxsackie Virus, adenovirus, herpes zoster virus, measles virus and other infections. (2) Chlamydia infection: such as parrot fever. (3) Rickett infection: typhus, Q fever, etc. (4) bacterial infection: acute obstructive suppurative cholangitis, chronic cholangitis, primary sclerosing cholangitis, bacterial liver abscess, liver tuberculosis. (5) spirochete infection: leptospirosis, relapsing fever, liver syphilis, Lyme disease, etc. (6) Fungal infections: actinomycosis, blastomycosis, coccidioidomycosis, cryptococcosis, histoplasmosis, candidiasis, aspergillosis, mucormycosis, etc. (7) protozoal infection: amoebic liver abscess, kala-azar, malaria, toxoplasmosis, trypanosomiasis, pear-shaped flagellate disease. (8) helminth infection: schistosomiasis, clonorchiasis, biliary ascariasis, aphid liver abscess, hydatidosis, post-test schistosomiasis, liver schistosomiasis, bow rickets, capillary nematode , faecal disease, paragonimiasis, etc.

Poisoning:

Can be carbon tetrachloride, chloroform, ethanol, phenol, naphthalene, benzene, acetaminophen, sodium valproate, heavy metals, phosphorus, arsenic, isothiocyanate, trinitrotoluene, monoamine oxidase inhibitor, p-amino water Salicylate, pyrazinamide, ethionamide, azathioprine, methotrexate, dicyclohexylpyridinium, amiodarone, aminophenol quinoline, cerium oxide, polyvinyl chloride, aflatoxin, Toadstool, isoniazid, cinchon, phenylbutazone, rifampicin, tetracycline, bisphenol phenolphthalein, chlorpromazine, methyltestosterone, oral contraceptive, ketoconazole, methyldopa, phenytoin, phenobarbital Prosperous, furopyrazine, sulfa drugs, thioureas, phenformin, etc.

Hepatobiliary lesions:

(1) cirrhosis: portal vein, schistosomiasis, post-necrosis, primary biliary, secondary biliary, cardiogenic cirrhosis. (2) Tumors and cysts: primary liver cancer, secondary liver cancer, hepatoblastoma, carcinoid, hepatic mixed tumor, hepatic adenoma, cystadenoma, hepatic angiosarcoma, hepatic vascular endothelioma, hepatic cavernous blood vessel Tumor, adult liver polycystic disease, non-parasitic liver cysts, etc. (3) biliary stasis: intrahepatic cholestasis, extrahepatic cholestasis, common bile duct stones, cholangiocarcinoma, pancreatic head cancer, ampullary cancer. (4) Metabolic disorders: fatty liver, Relye syndrome, acute fatty liver in pregnancy, hepatic amyloidosis, hepatolenticular degeneration, hemochromatosis, porphyria, hepatic glycogenism, increased lipid cell Disease, familial spleen anemia, cholesterol ester storage disease, gangliosideosis, mucopolysaccharidosis, galactosemia, hereditary fructose intolerance, cystic fibrosis, 1 antitrypsin deficiency, tyrosine Acid metabolism disorders and the like.

other factors:

Congestive heart failure, tricuspid stenosis or regurgitation, myocarditis or cardiomyopathy, congenital heart disease, constrictive pericarditis, pericardial tamponade, hepatic vein occlusion, various blood diseases, multiple myeloma, myelofibrosis, AIDS and so on.

Pathogenesis:

1. Infection: various pathogenic microorganisms, toxic hepatitis, vascular congestion, tissue edema, inflammatory cell infiltration and other inflammatory substances exudation, or hepatocyte degeneration, swelling, or liver network The endothelium is stimulated and a large number of hyperplasias cause liver enlargement, and viral hepatitis is common among various infections.

2. Congestion: In congestive heart failure, pericardial tamponade, constrictive pericarditis, pericardial effusion and hepatic venous return obstruction, the liver is swollen due to congestion, the appearance is purple, and the edges are blunt.

3. Cholestatic: In primary biliary cirrhosis, pancreatic head cancer, intrahepatic and extrahepatic biliary obstruction, resulting in cholestasis, resulting in liver enlargement.

4. Poisoning: Certain drugs and hepatic toxins, when various systemic infections, pathogens can directly invade the liver, and can also cause toxic hepatitis through toxemia, hyperthermia, malnutrition, hypoxia and other factors, so that hepatocytes Necrosis, microcapsule-type fat deposition, hepatitis-like damage, liver fibrosis, hepatic vein occlusion, capillary bile duct, etc., causing liver enlargement.

5. Metabolic abnormalities: Fatty liver, liver amyloidosis and other diseases, fat, glycogen, lipidoids, amyloid, copper or iron deposits in the liver to enlarge.

6. Tumors and cysts: Liver cancer, sarcoma, benign tumors and various cysts infiltrate liver cells to enlarge them.

7. Others: immune damage, connective tissue diseases, blood diseases, etc. can cause liver enlargement.

an examination

Related inspection

Liver function test ring egg sediment test parasite excreta and secretions check parasite blood test abdominal CT

1. Blood test: leukocytosis during bacterial infection or amebic liver abscess, leukopenia when viral infection or hypersplenism, rupture of esophageal vein, decreased spleen function or folate deficiency, red blood cell and hemoglobin, cirrhosis, severe hepatitis, Long-term obstructive jaundice, liver protein synthesis disorder or disseminated intravascular coagulation caused abnormal blood coagulation mechanism, viral diseases can be diagnosed by increased serum antibody titer or virus isolation, leptospirosis, syphilis, fungal disease, trematode disease Such as the detection of specific antibodies in serum, hydatidosis, trematode disease, tuberculosis, etc. can be done intradermal test.

2. Fecal examination: eggs or trophozoites can be found in the feces.

3. Duodenal drainage: It is helpful for the diagnosis of hepatomegaly caused by biliary tract infection, and pathogenic bacteria can be found in the drainage fluid.

4. Liver function test

(1) Test of protein metabolism:

1 plasma protein: albumin and pre- albumin can be used as an indicator to judge the prognosis of chronic liver disease; if the increase of 1 globulin in liver disease reflects milder disease, the decrease often indicates that the condition is heavier, and the liver cancer is significantly increased; Increased lipids and lipoproteins; gamma globulin is normal or slightly higher in acute hepatitis, and is significantly elevated in cirrhosis; alpha-fetoprotein is elevated in liver disease, reflecting hepatocyte regeneration, associated with disease activity, alpha-fetoprotein Positive is not unique to liver cancer, viral hepatitis, cirrhosis, teratoma, gastric cancer, pancreatic cancer, colon cancer, pregnancy and other serum alpha-fetoprotein may also increase.

2 serum flocculation test: cephalin cholesterol cholesterol test (CCFE) is an indicator for the diagnosis of acute hepatitis, hepatitis prognosis, many other diseases can also be positive and false positive reaction, zinc sulfate turbidity test (znTT) can identify hepatitis and liver Hardening, judging the diagnosis and prognosis of chronic hepatitis and cirrhosis, thymol turbidity test (TTT), is not a special liver function test, can only reflect liver cell degeneration, but the false positive rate is high.

Although some of the above tests have been eliminated, it is still practical to understand this knowledge.

3 ammonia tolerance test: This test has certain diagnostic value for judging the presence or absence of collateral circulation in patients with cirrhosis, but it has the risk of causing hepatic encephalopathy.

(2) Test of sugar: Insulin resistance test is one of the characteristics of glucose metabolism disorder in chronic liver disease; hepatocyte hypoxia can block the metabolism of galactose in liver, which is a special factor of liver disease.

(3) Lipid metabolism test: Serum phospholipid determination is meaningful for the identification of hepatic and obstructive jaundice.

(4) Enzymology test: It is a clinically indispensable biochemical examination method for liver diseases. It is of great significance for discovering hepatobiliary diseases, clarifying the nature of disease processes, and clarifying the intracellular localization of lesions.

1 enzymes mainly used for liver parenchymal damage:

A. Transaminase mainly includes aspartate aminotransferase (GOT), alginotransferase (GPT), and GOT isoenzyme.

B. Adenosine deaminase (ADA), which has the advantage of diagnosis of acute hepatitis recovery, assists in the diagnosis of chronic liver disease, and distinguishes between hepatic jaundice and obstructive jaundice.

C. Glutamate dehydrogenase (GDH), which reflects the activity and severity of liver disease.

D. Amylase, elevated serum amylase in acute necrosis of hepatocytes, often parallel to elevated aminotransferase.

2 enzymes mainly used to diagnose cholestasis:

A. Alkaline phosphatase (ALP) for the identification of jaundice, diagnosis of intrahepatic space-occupying lesions and biliary lesions without jaundice.

B. -glutamyltransferase (GGT), which can screen hepatobiliary diseases, assist in the diagnosis of liver cancer, identify obstructive jaundice and hepatocellular jaundice, diagnose the recovery period of acute hepatitis, determine the activity and prognosis of chronic liver disease, and diagnose alcohol Sexual liver damage.

3 enzymes for the diagnosis of liver fibrosis:

A. Monoamine oxidase (MAO), other diseases and certain extrahepatic diseases can also cause changes in this enzyme activity.

BN-acetyl-beta glucosaminidase helps to reflect fibrotic activity.

C. Prolyl hydroxylase (PHO), whose activity is parallel to progressive fibrosis.

4 enzymes mainly used to diagnose liver tumors:

A.5' nucleotide phosphodiesterase, which combines AFP and clinically is one of the effective methods for diagnosing liver cancer.

B.1 anti-chymotrypsin (ACT) can be used as a diagnostic tool for liver cirrhosis, especially liver cancer.

(5) bilirubin and bile acid metabolism test: serum bilirubin determination can be used to determine the presence or absence of jaundice, jaundice and the evolution process, reflecting the degree of liver damage and prognosis, urine bilirubin qualitative test can be found early Liver damage, identification of early extrahepatic biliary obstruction and identification of jaundice, early detection of mild liver damage in serum bile acids, can identify hepatitis, cirrhosis and intrahepatic or extrahepatic cholestasis and normal liver function .

(6) Pigment excretion test: The sulfonium bromide sodium (BSP) excretion test can reflect the amount of hepatic blood flow and the state of hepatocyte function. This test is a sensitive indicator for discovering and judging the degree of liver disease. Indocyanine green ICG excretion test It is the best and most practical dye for testing liver function. It is safer than BSP and superior to BSP test in chronic liver disease application.

(7) Hormone metabolism test: In the case of excluding endocrine diseases or other related factors, serum, urine hormones or other metabolites can be measured to reflect the functional status of the liver. In liver disease, serum T3 is decreased, and anti-T3 is increased accordingly. .

(8) Vitamin metabolism test: Vitamin metabolism in liver disease and a series of in vivo biochemical reactions associated with it can be abnormal. The detection of vitamin metabolism in the body not only has guiding significance for nutritional therapy of patients with liver disease, but also helps to understand And in the understanding of the occurrence of various clinical manifestations of liver disease, in a few cases, can also be used to determine liver function, to assist in diagnosis, liver disease and obstructive jaundice, vitamin E absorption decreased, plasma concentration decreased, but not proportional to liver disease severity The blood transketolase assay can reflect the metabolic state of vitamin B1 in the body.

(9) Test of drug conversion function: The drug conversion function is consistent with the change of liver synthesis function. When the plasma albumin is decreased, the prothrombin time is prolonged, and the drug conversion function is also reduced, and the sensitivity is higher than that. Determination of plasma protein, bilirubin and prothrombin time, similar to sodium sulfonium bromide excretion, galactose clearance test, but not as good as GPT and indocyanine green excretion test, mild liver damage, drug conversion function test is still normal The range, moderate or severe liver damage is reduced, which is helpful for judging the prognosis of liver disease.

5. Ultrasound examination: Ultrasound can be used to measure the location, size, morphology and observation of hepatic vein, portal vein and its branches in the diagnosis of hepatobiliary diseases; determine the nature, location and extent of hepatobiliary diseases, confirm clinical diagnosis And solve special problems; percutaneous transhepatic cholangiography and drainage, liver biopsy can be performed under the guidance of ultrasound exploration; follow-up observation of confirmed hepatobiliary diseases; further verification of the results of radionuclide examination, determination The nature and depth of the lesion, the relationship between hepatobiliary disease and the neighboring organs, B-ultrasound is more meaningful for the diagnosis of intrahepatic space-occupying lesions, and the space-occupying lesions with a diameter of more than 1 cm can be detected.

6. X-ray inspection

(1) Chest penetration: The position, shape and movement of the right ankle can be determined.

(2) Gastrointestinal barium meal: Esophageal varices can be found, and it can be helpful for finding biliary obstruction caused by pancreatic head cancer or ampullary cancer.

(3) Gallbladder or cholangiography: Diagnostic value for gallbladder lesions or biliary obstruction, but not suitable for patients with jaundice. At this time, percutaneous transhepatic cholangiography should be performed to determine whether there is calculus or tumor obstruction. The sharpness of the image is better than that of endoscopic retrograde cholangiopancreatography, which is better than excretion angiography, but the prothrombin time is prolonged. The effect of retrograde cholangiography with duodenal fiber endoscopy is similar to that of percutaneous puncture. .

7. CT and MRI The diagnosis of liver cirrhosis, fatty liver and hepatic adenoma is not as good as CT, but the diagnosis of hepatic cyst and hepatic hemangioma is better than CT.

8. Radionuclide scanning: It can dynamically observe the radioactivity concentration and passage in the liver, bile duct and gallbladder. It can display the size, position and shape of the liver. It is mainly used for the diagnosis of intrahepatic space-occupying lesions. The blood pool is filled with blood vessels. Tumors have a diagnostic significance, and can also help identify intrahepatic cholestasis or extrahepatic obstructive jaundice, which is superior to X-ray hepatobiliary angiography.

9. Laparoscopy: It is helpful for the diagnosis and differential diagnosis of various liver diseases, for the diagnosis of hepatitis, hepatitis, hepatitis complications; the cause, nature and extent of liver cirrhosis; the nature, location and extent of the tumor; Decide whether a laparotomy should be performed and whether the tumor can be removed; it is also helpful in identifying extrahepatic obstruction and intrahepatic cholestasis.

10. Hepatic angiography: splenic portal vein angiography, hepatic venography, hepatic angiography, umbilical vein angiography, splenic portal vein angiography can understand portal venous obstruction and measurement of portal pressure, hepatic venography can understand the hepatic vein Obstruction, hepatic angiography has some help in the possibility of surgical resection of liver tumors and the scope of resection. MRI can replace some invasive angiographic examinations.

11. Liver blood flow map: It is a non-invasive method for examining liver and blood vessel function. By measuring the impedance change of liver tissue to high frequency current, it reflects the blood circulation state of the liver, and judges liver function and Pathological changes, diagnosis and understanding of disease evolution, prognosis and outcomes, liver blood flow map is not specific to the cause, but has a significance for the degree of liver lesions, for chronic hepatitis, cirrhosis, early portal hypertension, cardiac origin The judgment of sexual liver congestion has a certain value in the diagnosis and localization of liver cancer.

12. Liver biopsy of liver biopsy: its indications are unexplained hepatomegaly, providing a reliable scientific basis for definitive diagnosis, judging efficacy and prognosis, and understanding the evolution of various liver diseases, in severe jaundice, ascites or coagulopathy When it is taboo.

Differential diagnosis

Diagnostic criteria

1. History: The medical history often provides diagnostic clues for liver disease. It is necessary to pay attention to the history of exposure to infectious diseases, to receive a history of blood products, and to travel to areas of epidemics, which may help diagnose infectious diseases and parasitic diseases, drugs or The history of exposure to poisons can cause toxic hepatomegaly. Patients with cirrhosis often have history of hepatitis, jaundice, chronic alcoholism, etc., and those with pain in the liver area are more common in intrahepatic inflammation, acute hepatic congestion, intrahepatic space-occupying lesions, and more. It is dull and painful, but the pain of liver cancer can be quite severe. It is often accompanied by fever, suggesting hepatitis, liver abscess, biliary tract infection, liver cancer or other acute infectious diseases, blood diseases, connective tissue diseases, etc., viral or drug-induced hepatitis with difference.

2. Clinical manifestations.

3. Laboratory and other auxiliary inspections.

Differential diagnosis

1. Viral hepatitis: viral hepatitis causes liver enlargement often in close contact with patients with viral hepatitis, unclean diet or blood transfusion, history of drug injection, clinical manifestations of fatigue, loss of appetite, nausea, bloating, pain in the liver area, etc. Signs of liver enlargement, pain in the liver area, jaundice, etc., liver enzyme function serum enzyme activity increased, serological examination can detect various types of hepatitis (A, B, C, D, E, hex, G) virus antigen Or antibody.

2. Toxic hepatitis: There is often a history of exposure to drugs or poisons before onset, followed by hepatomegaly, fever, rash, liver pain, jaundice and other symptoms. Toxic hepatitis is also accompanied by other organ dysfunction, peripheral blood. Eosinophilia, and the detection of serum antigens or antibodies in various types of viral hepatitis is mostly negative. Normally, the drug can be returned to normal after stopping the drug or stopping contact with the related drugs, but the same symptoms occur again when the drug or poison is contacted again.

3. Liver abscess: liver abscess is generally slow onset, because of obvious inflammation, often chills, fever, then liver pain, liver enlargement, smooth liver surface, tenderness, snoring pain, corresponding abdominal wall Often edema, peripheral blood leukocytes and neutrophil counts increased, ultrasound, radionuclide, CT scan and other auxiliary examinations can assist in diagnosis, if necessary, diagnostic puncture.

4. Primary or metastatic liver cancer: Primary liver cancer patients are more than 40 years old, more common in men, slow onset, clinical manifestations of weight loss, loss of appetite, liver pain, fever, jaundice, etc., the liver can be significant Swelling, tough texture, sputum and nodules, serum alpha-fetoprotein value is often elevated in patients with primary liver cancer, serum AKP, -GT, carcinoembryonic antigen can also be elevated, abdominal B-ultrasound, CT, radionuclide MRI and other auxiliary examinations can detect cancerous lesions; in metastatic liver cancer, B-ultrasound and other examinations often show multiple cancerous lesions of different sizes in the liver parenchyma.

5. Liver cysts: Patients with hepatic cysts often have no obvious symptoms or only non-specific symptoms such as upper abdominal discomfort. Most of them are congenital formation, and a few are acquired. Ultrasound, CT, MRI and other tests can find liquid darkness in the liver. Area, the edge is clear, and strong echoes are visible when calcification occurs.

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