Enlarged liver (hepatomegaly): causes, symptoms and treatment

Patient's clinical reference says the most common causes of hepatomegaly in the UK are alcoholic liver disease, malignancy (particularly spread from cancers elsewhere) and congestive cardiac failure. It groups the many causes by mechanism.

The NHS lists the common types of liver disease and their possible causes: alcohol-related liver disease from regularly drinking too much; non-alcoholic fatty liver disease from being very overweight; hepatitis from a viral infection or too much alcohol; haemochromatosis from a gene that runs in families; and primary biliary cholangitis, which may be caused by a problem with the immune system. It says the 3 main causes of liver disease are obesity, undiagnosed hepatitis infection and alcohol misuse.

Patient says symptoms associated with hepatomegaly may be few or rather vague, for example loss of appetite, weight loss and lethargy. There may also be symptoms relating to liver dysfunction, such as jaundice, bruising, breast enlargement in men, spider-like blood vessels on the skin and fluid in the tummy (ascites), or symptoms relating to the underlying cause.

For fatty liver disease, the NHS says some people have symptoms including feeling very tired, feeling generally unwell, and liver pain or discomfort felt in the tummy under the right side of the ribs. Many people have no symptoms at all.

The NHS lists symptoms of cirrhosis, the stage of severe scarring, as tiredness and weakness, loss of appetite and weight loss, feeling or being sick, tummy pain, visible blood vessels on the skin, blotchy red palms, easy bleeding or bruising, itchy skin, yellow skin and eyes (jaundice), a swollen tummy, legs, ankles or feet, trembling hands, slurred speech, confusion, vomiting blood and very dark or black poo.

The NHS says to see a GP if you think you might have liver disease or cirrhosis. For jaundice (yellow skin or whites of the eyes), it says to ask for an urgent GP appointment or get help from 111, because it can be a sign of something serious such as liver disease. You may also have itchy skin, darker pee and paler poo.

For someone already diagnosed with cirrhosis, the NHS says to ask for an urgent GP appointment or call 111 if the skin or eyes look yellow, breathing is difficult or the tummy, legs, ankles or feet are swollen. It says to call 999 or go to A&E if you are vomiting blood, your poo is very dark or black, or you suddenly become confused or have slurred speech. Do not drive yourself.

Patient's reference says a doctor asks about alcohol, sexual activity, injecting drug use, blood transfusions, medicines (including herbal remedies), tattoos and recent travel, and examines for signs of chronic liver disease. A smooth enlarged liver suggests problems such as hepatitis or heart failure, while a craggy one suggests tumours.

If you do not need urgent admission, basic investigations include liver function tests, a full blood count, kidney tests, clotting, inflammatory markers, a hepatitis screen and an ultrasound scan of the liver. Further tests depend on the results and you may be referred to a specialist. The NHS says fatty liver disease is usually diagnosed after blood tests or scans done for another reason show signs of liver problems, and that a GP will ask how much alcohol you drink to rule out alcohol-related liver disease.

The liver size itself is not treated; the cause is. The NHS says treatment for liver disease depends on the type you have and how severe it is. Healthy lifestyle changes can help with some types, and alcohol-related liver disease may improve if you stop drinking. Some types, such as certain hepatitis, may need medicine, and severe damage with scarring (cirrhosis) may need a liver transplant.

For fatty liver disease, the NHS says healthy lifestyle changes can reduce the build-up of fat and help repair damage. Apart from that you will not need other treatment unless the liver has been damaged, in which case a liver specialist may consider a medicine called pioglitazone, or vitamin E. For cirrhosis, the NHS says it cannot be cured but treatment of the cause, such as antivirals for hepatitis B or C, and treatment of complications can help slow it down or stop it getting worse.

For fatty liver disease the NHS advises eating a healthy, balanced diet, exercising regularly (aiming for at least 150 minutes a week), losing weight if you are overweight, not drinking too much alcohol (no more than 14 units a week) and not smoking. For cirrhosis it also recommends a healthy balanced diet and exercise, keeping to a healthy weight, not drinking alcohol, not smoking, and checking with a pharmacist or doctor before taking any medicines, including herbal medicines.

The NHS also notes that you do not have to drink an excessive amount of alcohol to risk damaging your health: regularly drinking just over the recommended levels can be harmful. A dietitian may be part of the team supporting someone with cirrhosis.

The NHS describes non-alcoholic fatty liver disease (NAFLD), also known as MASLD, as a common condition where fat builds up in the liver, often linked to being overweight. You are more likely to get it if you are overweight (particularly around the waist), do not have a healthy diet or are not very physically active, or have type 2 diabetes, polycystic ovary syndrome, high blood pressure or high cholesterol, or are over 50.

It describes 4 stages: simple fatty liver, inflammation (MASH), fibrosis (damage that usually still works well) and cirrhosis. Most people only have the first stage. The NHS says people with NAFLD should have check-ups at least once a year and tests every 2 to 3 years.

On the NHS, an enlarged liver is usually found by a GP or on a scan, and investigated with blood tests and ultrasound. If a cause that needs specialist care is found, referral is to a liver specialist (hepatologist) or gastroenterologist, and to a cancer pathway if cancer is suspected.

Private care can speed up scans and specialist appointments, but the diagnostic steps are the same. Ask for results to be shared with your GP so that monitoring, such as repeat blood tests, stays joined up.