Physical exam

Question: A 58 year old alcoholic male is supine on the examination table.  His abdomen is somewhat obese, and is without stigmata of portal hypertension.  A firm liver edge is palpated three cm below the right costal margin, and there is no appreciable left lobe hypertrophy.  All of the following should explain this finding except…

A. alcoholic cirrhosis

B. alcoholic hepatitis

C. non-alcoholic steatohepatitis

D. hereditary hemochromatosis

Answer: It is often helpful to delineate the hepatic margins on physical exam to help make an appropriate assessment.  This man is at risk for any of the above conditions, and most of them are associated with hepatomegaly.

Hereditary hemochromatosis and NASH are each depositional diseases of the liver (iron and fat, respectively); both can manifest with hepatomegaly.  Alcoholic hepatitis is classically associated with tender hepatomegaly, as there is marked hepatocyte swelling.  The edema can be severe enough at the sinusoidal level to cause a rise in portal pressure.

Alcoholic cirrhosis is the answer I’m looking for here.  In its classic form, alcoholic cirrhosis appears as a shrunken, nodular liver.  Of course some will be enlarged, particularly a hypertrophied left lobe.  Nevertheless, the other answer choices are more closely associated with hepatomegaly.

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