Differential diagnosis of hepatomegaly and splenomegaly

1. Big picture

Hepatomegaly and splenomegaly are physical signs, not final diagnoses. The exam approach is to answer three questions:

1. Is the liver enlarged, the spleen enlarged, or both?
2. Is the cause hepatic/portal, hematologic, infectious, congestive, malignant, infiltrative, or storage/metabolic?
3. Are there red flags: fever, weight loss, cytopenias, jaundice, ascites, severe pain, shock, or suspected malignancy?

The most practical first investigation is usually abdominal ultrasound, because it confirms organ size, detects focal lesions, ascites, portal hypertension signs, biliary dilatation, and splenic/portal vein thrombosis.