PE - Approach to Chronic Liver Disease

Question 1

List the peripheral signs seen on the upper limbs

Answer 1

1) Clubbing
2) Leukonychia (hypoalbuminemia)
3) Palmar erythema (vasodilated state in cirrhosis)
4) Duputyren’s contracture (alcoholic)
5) IV puncture marks (IVDU risk of HBV, HCV)
6) Tattoos (risk of HBV, HCV)
7) Petechiae and ecchymoses (thrombocytopenia, coagulopathy)
8) Reduced triceps skinfold thickness (cachexia)

Question 2

List the peripheral signs seen on the the head

Answer 2

1) Conjunctival pallor (anemia)
2) Scleral jaundice
3) Parotid enlargement (alcoholic)
4) Wasted temporalis (cachexia)

Question 3

List gastrointestinal differentials for clubbing

Answer 3

1) Chronic liver disease
2) Inflammatory bowel disease
3) Celiac disease
4) GI lymphoma

Question 4

List differentials for anemia in chronic liver disease

Answer 4

1) Portal hypertensive gastropathy –> esophageal varices
2) Alcoholic bone marrow suppression
3) Malnutrition

Question 5

List differentials for palmar erythema

Answer 5

1) Chronic liver disease
2) Hypercapnia
3) Thyrotoxicosis
4) Rheumatoid arthritis
5) Fever
6) Exercise
7) Pregnancy

Question 6

Explain why there are petechiae and ecchymoses in chronic liver disease

Answer 6

1) Coagulopathy –> impaired production of clotting factors
2) Thrombocytopenia
1. Hypersplenism secondary to portal HT
2. Alcoholic bone marrow suppression

Question 7

Outline how to distinguish between portal HT and inferior vena cava obstruction

Answer 7

Portal HT –> blood flow in veins away from umbilicus

IVC obstruction –> blood flow in veins towards umbilicus

Question 8

List differentials for tender hepatosplenomegaly

What is the clinical significance of this sign?

Answer 8

Tender hepatosplenomegaly means RECENT hepatic enlargement; differentials would then include

1) Infective hepatitis
2) Alcoholic hepatitis
3) Malignancy

Question 9

Describe the liver edge in malignancy

Answer 9

hard + irregular

Question 10

In all patients with ascites, what must be assessed?

Answer 10

Volume status as ascites occurs in patients with cirrhosis which is a state of systemic vasodilation –> there is thus reduced preload into the heart which may limit cardiac output

Question 11

List differentials for hepatic venous hum

Answer 11

1) Portal HT

2) Hepatocellular carcinoma

Question 12

Outline how hepatic venous hum is formed

Where is it best heard?

Answer 12

Collateral formation between portal system and remnant of umbilical vein best heard over the epigastrium

Question 13

List differentials for hepatic bruit

Answer 13

1) Alcoholic hepatitis
2) Hepatic carcinoma
3) Hepatic AVM
4) Intestinal AVM
5) Hepatic hemangioma
6) Transjugular intrahepatic portosystemic shunt (TIPS)

Question 14

Explain the mechanism of edema in chronic liver disease

Answer 14

1) Hypoalbuminemia means a shift of fluid out from intravascular space into extravascular space
2) Resultant drop in effective circulating volume activates the renin-angiotensin-aldosterone system to increase Na uptake worsening water retention

Question 15

Outline the progression of hepatic encephalopathy

Answer 15

1) Disturbed diurnal sleep pattern (insomnia and hypersomnia)
2) Bradykinesia
3) Asterixis (flapping tremor)
4) Hyperreflexia
5) Decerebrate posture
6) Coma

Question 16

List specific signs of alcohol induced chronic liver disease

Answer 16

1) Dupuytren contracture
2) Parotid enlargement
3) Cachexia
4) Tremor
5) Cerebellar syndrome
6) Peripheral neuropathy
7) Myopathy

Question 17

List specific signs of chronic HBV/HCV infection

Answer 17

1) Tattoos
2) IVDU
3) Palpable purpura –> HCV porphyria cutanea tarda
4) Livedo reticularis –> HCV type II cryoglobulinemia

Question 18

List specific signs of primary biliary cirrhosis

Answer 18

1) Hyperpigmentation
2) Xathelesma
3) Tendon xathomata
4) Excoriation marks

Question 19

List specific signs of hemochromatosis

Answer 19

1) Bronze pigmentation
2) Arthropathy
3) Finger tip skin pricks (CBG for DM)

Question 20

List specific signs of congestive heart failure induced chronic liver disease

Answer 20

1) Raised JVP
2) 3rd heart sound
3) Tricuspid regurgitation
4) Pulsatile liver

Question 21

List specific signs of Wilson disease

Answer 21

1) Slit lamp examination Kayser-Fleischer rings

2) Akinetic rigid syndrome

Question 22

List specific signs of antitrypsin deficiency

Answer 22

1) Lower zone emphysema

Question 23

List specific signs of Budd-Chiari syndrome

Answer 23

1) Loss of hepatojugular reflux

Question 24

LIst the causes of cirrhosis

Answer 24

1) Alcoholic
2) VIral (HBV/HCV)
3) Autoimmune
1. Primary Biliary Cirrhosis (PBC)
2. Primary Sclerosing Cholangitis (PSC)
3. Autoimmune hepatitis
4) Metabolic
1. Non-alcohlic steatohepatitis (NASH)
2. Hemochromatosis
3. α1-antitrypsin deficiency
4. Wilson’s disease
5. Cystic fibrosis
5) Drugs (IMAP)
1. Isoniazid
2. Methotrexate
3. Amiodarone
4. Pheyntoin

Question 25

List complications of portal HT

Answer 25

1) Esophageal varices
2) Ascites
3) Hypersplenism induced thrombocytopenia

Question 26

List complications of impaired liver function

Answer 26

1) Coagulopathy
2) Hepatic encephalopathy
3) Jaundice
4) Hypoalbuminemia

Question 27

List causes of acute liver decompensation in cirrhosis

Answer 27

1) Infection
2) Spontaneous bacterial peritonitis
3) Hypokalemia –> reduces renal NH3 clearnace
4) Gastrointestinal bleeding
5) Sedatives
6) Hepatocellular carcinoma

Question 28

Outline the classification of hepatic encephalopathy

Answer 28

Grade 1 –> reversed diurnal rhythm
Grade 2 –> lethargy + disorientation
Grade 3 –> somnolescence + confusion
Grade 4 –> coma

Question 29

Outline the Childs-Pugh score to grade cirrhosis severity

Answer 29

ABCDE
Albumin –> 28-35g/L (35 = 1)
Bilirubin –> 35-52mmol/L (>52 = 3; 35-52 = 2; 4-7s (>7 = 3; 4-7 = 2; mild = 2; moderate = 3
Encephalopathy –> Grade 1/2 = 2; Grade 3/4 = 3

Grade A = 5-6 = 90% 5y survival
Grade B = 7-9 = 80% 5y survival
Grade C = >10 = 33% 1y mortality

Question 30

List the principles of cirrhosis management

Answer 30

1) Slowing or reversing liver disease
- this depends on the underlying cause of liver disease
- e.g. alcoholic hepatitis –> abstain from alcohol
- e.g. viral hepatitis –> antiviral therapy
- e.g. autoimmune hepatitis –> immunosupppresants

2) Preventing superimposed liver damage
- e.g. viral hepatitis –> avoid alcohol
- e.g. alcoholic hepatitis –> vaccinate against hepatitis A + B
- also consider PPV23 and yearly influenza vaccine

3) Preventing complications
- 6m USG + AFP for hepatoma surveillance
- OGD for esophageal varices surveillance
- varices in Child C require treatment w/non-selective beta blockers for primary prophylaxis
- after an episode of spontaneous bacterial peritonitis give prophylactic antibiotics

4) Considering liver transplant
- selection is based on balancing severity of liver disease against presence of comorbidities which affect outcome
- most centres require 6m alcoholic abstinence + patients less than 65y/o
- primary biliary cirrhosis (PBC) has intractable pruritus as indication for liver transplant
- primary sclerosing cholangitis (PSC) has recurrent cholangitis as indication for liver transplant