A 63-year-old man comes to the physician after several weeks of vague abdominal pain and increased fatigability. His past medical history is not significant. The patient smokes a pack of cigarettes a day and consumes 5-6 cans of beer on weekends. His mother died of a stroke, and his father died of a myocardial infarction. Physical examination shows a mildly distended, soft abdomen. The liver edge is hard and is palpated 5 cm below the costal margin. Hepatojugular reflux is not appreciated. Trace ankle edema is present. Laboratory results are as follows: Coagulation studies are within normal limits. Chest x-ray reveals a small left-sided pleural effusion. Fecal occult blood test is positive. Which of the following is the most likely cause of hepatomegaly in this patient?

Question

A 63-year-old man comes to the physician after several weeks of vague abdominal pain and increased fatigability.  His past medical history is not significant.  The patient smokes a pack of cigarettes a day and consumes 5-6 cans of beer on weekends.  His mother died of a stroke, and his father died of a myocardial infarction.  Physical examination shows a mildly distended, soft abdomen.  The liver edge is hard and is palpated 5 cm below the costal margin.  Hepatojugular reflux is not appreciated.  Trace ankle edema is present.  Laboratory results are as follows:  Coagulation studies are within normal limits.  Chest x-ray reveals a small left-sided pleural effusion.  Fecal occult blood test is positive.  Which of the following is the most likely cause of hepatomegaly in this patient?

Quizplus · Accepted Answer

This patient-with abdominal pain, microcytic anemia, positive fecal occult blood, and hepatomegaly with a hard edge on liver palpation-has typical features of gastrointestinal malignancy, likely colon cancer, metastatic to the liver. The liver is the most common site of metastasis in colon cancer. The moderate abnormalities in hepatic markers in this case (elevated alkaline phosphatase and slightly elevated aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) are more suggestive of infiltrative or cholestatic disease than of hepatocellular injury. The patient also has a small pleural effusion on the left that may be malignant. (Hepatic hydrothorax due to cirrhosis usually occurs on the right.) This patient should have a CT of the abdomen with intravenous contrast to evaluate for malignancy. (Choice A) In alcoholic cirrhosis, the liver is often shrunken and the edge is not palpable. Also, in hepatocellular injury due to alcohol, AST is characteristically greater than ALT, usually by a multiple of 1.5-2.0. (Choice B) Autoimmune hepatitis is typically seen in young to middle-aged women and may present as acute or chronic hepatitis. There is significant hepatocellular injury, with transaminases often above 1,000 U/L. (Choice C) Hemochromatosis is an autosomal recessive disease resulting in multiorgan dysfunction from systemic iron overload. The most common sequelae include cirrhosis, heart failure, diabetes, hypogonadism, and arthritis. It is typically associated with significant elevations in transaminases. (Choices D and H) Left ventricular failure does not directly cause hepatomegaly, though it may eventually lead to right heart failure. Pulmonary hypertension and right heart failure may lead to congestive hepatopathy. In such cases, other signs of right ventricular failure will be present: peripheral edema, elevated jugular venous pressure, positive hepatojugular reflux, and an S3 on cardiac exam. (Choice F) Nonalcoholic steatohepatitis (NASH) is often asymptomatic and manifests as hepatomegaly with elevated transaminases. Imaging will reveal fatty infiltration of the liver. The leading causes of NASH are obesity, diabetes mellitus, and hypertriglyceridemia. This patient's hard hepatomegaly, anemia, and positive fecal occult blood in the setting of minimal transaminase elevations are more consistent with metastatic disease. (Choice G) Cirrhotic and noncirrhotic portal hypertension may result in ascites and significant peripheral edema. Other signs of portal hypertension include esophageal varices, spider nevi, palmar erythema, and caput medusa. Thrombocytopenia and coagulopathy are often seen. Educational objective: The most common site of colon cancer metastasis is the liver. Liver metastases manifest as right upper quadrant pain, mildly elevated liver enzymes, and firm hepatomegaly. The diagnosis is confirmed by CT of the abdomen.

A 63-Year-Old Man Comes to the Physician After Several Weeks