From the Guidelines
For borderline hepatomegaly found on CT abdomen, I recommend further evaluation with ultrasound abdomen as the initial imaging modality, as it is usually appropriate for patients with abnormal liver function tests with hepatocellular predominance with mild aminotransferase increase, according to the ACR Appropriateness Criteria 1. This approach is based on the most recent guidelines, which suggest that ultrasound abdomen and US duplex Doppler abdomen are complementary procedures that provide unique clinical information to effectively manage the patient’s care.
- The patient's laboratory tests, including liver function tests (ALT, AST, alkaline phosphatase, bilirubin), complete blood count, and coagulation studies, should be evaluated to determine the presence of hepatocellular or cholestatic predominance.
- A thorough history and physical examination focusing on risk factors for liver disease, such as alcohol use, viral hepatitis, or metabolic disorders, is essential to guide further management.
- If the patient is asymptomatic with minimal enlargement and normal lab values, watchful waiting with follow-up imaging in 3-6 months may be appropriate, as mild hepatic enlargement can represent normal anatomic variation in some individuals.
- For patients with abnormal liver function tests or concerning clinical features, referral to a gastroenterologist or hepatologist is warranted for possible liver biopsy, as borderline hepatomegaly may be the earliest sign of underlying liver disease such as fatty liver, hepatitis, or even malignancy.
- Lifestyle modifications, including weight loss, alcohol cessation, and management of metabolic risk factors, should be implemented when appropriate, as these can help mitigate the risk of progression to more severe liver disease.
From the Research
Borderline Hepatomegaly Found on CT Abdomen
- Borderline hepatomegaly found on CT abdomen may indicate a range of underlying conditions, including metabolic, congestive, neoplastic, infectious, toxic, and inflammatory diseases 2
- A diagnostic approach to hepatomegaly should consider the patient's history, physical exam, laboratory results, and imaging studies to identify potential causes 2
- Lysosomal storage diseases (LSDs) are a group of rare genetic disorders that can cause hepatomegaly, and early diagnosis and disease-targeted management can improve patient outcomes 2
- Coagulation disorders are common in patients with liver disease, and conventional coagulation tests may not accurately reflect the risk of bleeding 3, 4
- Global coagulation assays, such as thrombin generation and thromboelastography, may be useful in assessing bleeding risk and guiding therapy in patients with liver disease 4
Diagnostic Approach
- A thorough diagnostic workup, including history, physical exam, laboratory results, and imaging studies, is essential to determine the underlying cause of hepatomegaly 5
- Serum biomarkers, such as those used to diagnose viral hepatitis and hepatocellular carcinoma, may be helpful in identifying specific causes of liver disease 6
- Molecular testing and enzymatic testing may be necessary to confirm a diagnosis of LSDs or other genetic disorders 2
Management
- Management of hepatomegaly depends on the underlying cause and may involve medical or surgical interventions 5
- Prevention of bleeding should not be aimed at correcting conventional coagulation tests, and global coagulation assays may be useful in guiding therapy 4
- There is currently inadequate evidence to support the use of certain hemostatic therapies, such as recombinant FVIIa, prothrombin complex concentrates, or tranexamic acid, in acute variceal or other hemorrhage 4