What is the diagnosis and management plan for a patient with hepatomegaly (enlarged liver), splenomegaly (enlarged spleen), coarsened liver echotexture, and mild micronodularity, with no focal liver lesions or gallbladder disease?

Diagnosis: Chronic Liver Disease with Portal Hypertension

This patient has imaging findings consistent with chronic liver disease (likely cirrhosis) with portal hypertension, evidenced by coarsened liver echotexture with micronodularity, hepatomegaly, and splenomegaly. 1

Diagnostic Interpretation

The ultrasound findings paint a clear picture of chronic parenchymal liver disease:

• Coarsened echotexture with micronodularity represents the hallmark sonographic appearance of cirrhosis, reflecting architectural distortion from fibrosis and regenerative nodules 1
• Splenomegaly (16 cm) is a specific sign of clinically significant portal hypertension (CSPH), present in approximately 83% of cirrhotic patients 1, 2
• Hepatomegaly (20 cm) can occur in cirrhosis despite the common teaching that cirrhotic livers shrink; early cirrhosis or specific etiologies (fatty liver disease, infiltrative processes) commonly present with enlargement 1, 3
• Patent portal vein rules out portal vein thrombosis, though the absence of reported flow velocity or diameter limits full hemodynamic assessment 1

The combination of abnormal liver contour with splenomegaly is 100% specific for CSPH (defined as hepatic venous pressure gradient ≥10 mmHg), even without direct pressure measurement 1

Immediate Management Steps

1. Laboratory Evaluation (Urgent)

• Complete metabolic panel including AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin, and INR to assess synthetic function and determine Child-Pugh score 3
• Complete blood count with particular attention to platelet count (thrombocytopenia suggests portal hypertension) and hemoglobin (anemia common in cirrhosis) 1, 4
• Calculate APRI and FIB-4 scores to non-invasively assess fibrosis severity 1, 3
• Hepatitis B and C serologies, autoimmune markers, iron studies, ceruloplasmin, and alpha-1 antitrypsin to identify the underlying etiology 3
• Alpha-fetoprotein (AFP) for hepatocellular carcinoma screening 1

2. Advanced Imaging

Multiphasic contrast-enhanced CT or MRI of the abdomen should be performed to: 1

• Definitively characterize the liver parenchyma and confirm cirrhosis
• Screen for hepatocellular carcinoma (HCC), as cirrhotic patients require surveillance
• Identify portosystemic collaterals and assess for varices
• Evaluate for focal lesions that may have been missed on ultrasound

3. Endoscopic Evaluation

Upper endoscopy (esophagogastroduodenoscopy) is mandatory to screen for esophageal and gastric varices, as splenomegaly strongly predicts their presence 1, 2. Progressive spleen enlargement correlates with an 84.6% probability of variceal formation over 5 years 2.

4. Non-Invasive Fibrosis Assessment

Transient elastography (FibroScan) should be performed if available, as liver stiffness >20-25 kPa confirms CSPH with high accuracy (AUROC 0.93) 1. This can guide prognosis and management intensity.

Etiology-Specific Considerations

The differential diagnosis for this presentation includes:

• Non-alcoholic fatty liver disease (NAFLD)/NASH - most common cause of cirrhosis in developed countries 3
• Alcohol-related liver disease - requires detailed alcohol history 1
• Chronic viral hepatitis (B or C) - serological testing essential 1
• Autoimmune hepatitis - check ANA, ASMA, immunoglobulins 3
• Hemochromatosis - iron studies and genetic testing 3
• Wilson disease - ceruloplasmin, 24-hour urine copper (if age <40) 3

Surveillance and Monitoring

Once cirrhosis is confirmed:

• HCC surveillance with ultrasound ± AFP every 6 months is mandatory, as cirrhosis is the primary risk factor for HCC 1
• Repeat upper endoscopy every 1-3 years depending on variceal grade 1
• Monitor for hepatic decompensation (ascites, encephalopathy, variceal bleeding, jaundice) 1
• Serial spleen measurements on ultrasound, as progressive enlargement predicts a 51.1% probability of first decompensation in compensated cirrhosis 2

Critical Pitfalls to Avoid

• Do not assume the absence of focal lesions on ultrasound excludes HCC - ultrasound sensitivity for small HCC is limited; multiphasic CT/MRI is required 1
• Do not delay endoscopy - variceal bleeding carries significant mortality, and primary prophylaxis with beta-blockers or endoscopic band ligation reduces this risk 1
• Do not overlook treatable etiologies - identifying viral hepatitis, autoimmune disease, or metabolic disorders allows disease-modifying therapy 1, 3
• Recognize that normal liver biochemistry does not exclude advanced disease - 82% of patients with Fontan-associated liver disease had normal liver function tests despite parenchymal changes 5, and similar patterns occur in other chronic liver diseases

Specialist Referral

Immediate hepatology referral is warranted given the imaging findings consistent with cirrhosis and portal hypertension 1, 3. If decompensated cirrhosis is confirmed, liver transplant evaluation should be considered 3.