Chronic liver disease and hepatomegaly

Question 1

Chronic liver disease and hepatomegaly

Answer 1

his man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen.

Question 2

Signs of chronic liver disease

Answer 2

• General: cachexia, icterus (also in acute), excoriation and bruising
• Hands: leuconychia, clubbing, Dupuytren’s contractures and palmar erythema
• Face: xanthelasma, parotid swelling and fetor hepaticus
• Chest and abdomen: spider naevi and caput medusa, reduced body hair,
gynaecomastia and testicular atrophy (in males)

Question 3

Signs of hepatomegaly

Answer 3

• Palpation and percussion:
⚬⚬ Mass in the right upper quadrant that moves with respiration, that you are not able
to get above and is dull to percussion
⚬⚬ Estimate size (finger breadths below the diaphragm)
⚬⚬ Smooth or craggy/nodular (malignancy/cirrhosis)
⚬⚬ Pulsatile (TR in CCF)
• Auscultation
⚬⚬ Bruit over liver (hepatocellular carcinoma)

Question 4

Evidence of an underlying cause of hepatomegaly

Answer 4

• Tattoos and needle marks Infectious hepatitis
• Slate‐grey pigmentation Haemochromatosis
• Cachexia Malignancy
• Mid‐line sternotomy scar CCF

Question 5

Evidence of treatment

Answer 5

• Ascitic drain/tap sites

* Surgical scars

Question 6

Evidence of decompensation

Answer 6

• Ascites: shifting dullness
• Asterixis: ‘liver flap’
• Altered consciousness: encephalopathy

Question 7

Causes of hepatomegaly

Answer 7

The big three:

1. Cirrhosis (alcoholic)
2. Carcinoma (secondaries)
3. Congestive cardiac failure
4. Plus:
   Infectious (HBV and HCV),
   Immune (PBC, PSC and AIH)
   Infiltrative (amyloid and myeloproliferative disorders)

Question 8

Investigations

Answer 8

• Bloods: FBC, clotting, U&E, LFT and glucose
• Ultrasound scan of abdomen
• Tap ascites (if present)

Question 9

Investigations If cirrhotic

Answer 9

• Liver screen bloods:
⚬⚬ Autoantibodies and immunoglobulins (PBC, PSC and AIH)
⚬⚬ Hepatitis B and C serology
⚬⚬ Ferritin (haemochromatosis)
⚬⚬ Caeruloplasmin (Wilson’s disease)
⚬⚬ α‐1 antitrypsin
⚬⚬ Autoantibodies and immunoglobulins (PBC)
⚬⚬ AFP (hepatocellular carcinoma)
• Hepatic synthetic function: INR (acute) and albumin (chronic)
• Liver biopsy (diagnosis and staging)
• ERCP (diagnose/exclude PSC)

Question 10

Investigations If malignancy

Answer 10

• Imaging: CXR and CT abdomen/chest
• Colonoscopy/gastroscopy
• Biopsy

Question 11

Complications of cirrhosis

Answer 11

• Variceal haemorrhage due to portal hypertension
• Hepatic encephalopathy
• Spontaneous bacterial peritonitis

Question 12

Child‐Pugh classification of cirrhosis

Answer 12

Prognostic score based on bilirubin/albumin/INR/ascites/encephalopathy
Class Score 1 year survival
A:         5–6    100%
B:          7–9     81%
C:         10–15   45%

Question 13

Causes of Ascites

Answer 13

• Cirrhosis (80%)
• Carcinomatosis
• CCF

Question 14

Treatment of ascites in cirrhotics

Answer 14

• Abstinence from alcohol
• Salt restriction
• Diuretics (aim: 1 kg weight loss/day)
• Liver transplantation

Question 15

Causes of palmar erythema

Answer 15

• Cirrhosis
• Hyperthyroidism
• Rheumatoid arthritis
• Pregnancy
• Polycythaemia

Question 16

Causes of gynaecomastia

Answer 16

• Physiological: puberty and senility
• Kleinfelter’s syndrome
• Cirrhosis
• Drugs, e.g. spironolactone and digoxin
• Testicular tumour/orchidectomy
• Endocrinopathy, e.g. hyper/hypothyroidism and Addison’s

Question 17

Autoantibodies in liver disease

Answer 17

• Primary biliary cirrhosis (PBC): antimitochondrial antibody (M2 subtype) in 98%, increased IgM
• Primary sclerosing cholangitis (PSC): ANA, anti‐smooth muscle may be positive
• Autoimmune hepatitis (AIH): anti‐smooth muscle, anti liver/kidney microsomal type 1 (LKM1) and occasionally ANA may be positive (pattern helps classify)