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Evaluation of the Patient With a Liver Disorder

By Steven K. Herrine, MD, Professor of Medicine, Division of Gastroenterology and Hepatology, and Vice Dean for Academic Affairs, Sidney Kimmel Medical College at Thomas Jefferson University

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Various symptoms may develop, but few are specific for liver disorders:

  • Common nonspecific symptoms include fatigue, anorexia, nausea, and, occasionally, vomiting, particularly in severe disorders.

  • Loose, fatty stools (steatorrhea) can occur when cholestasis prevents sufficient bile from reaching the intestines. Patients with steatorrhea are at risk of deficiencies of fat-soluble vitamins (A, D, E, K). Common clinical consequences may include osteoporosis and bleeding.

  • Fever can develop in viral or alcoholic hepatitis.

  • Jaundice, occurring in both hepatocellular dysfunction and cholestatic disorders, is the most specific symptom. It is often accompanied by dark urine and light-colored stools.

  • Right upper quadrant pain due to liver disorders usually results from distention (eg, by passive venous congestion or tumor) or inflammation of the liver capsule.

  • Erectile dysfunction and feminization develop; however, these symptoms may reflect the effects of alcohol more than liver disorders.

Risk Factors for Liver Disorders


Risk Factors


Alcohol use

Blood transfusions (particularly before 1992)*

Body piercing*

Drug (prescription and nonprescription) and herbal product use

Exposure to other liver toxins

Exposure to hepatitis*


Parenteral drug use*

Shellfish ingestion*



Family history of disorders such as primary biliary cirrhosis, hemochromatosis, Wilson disease, or alpha-1 antitrypsin deficiency

*These factors increase risk of hepatitis in particular, as well as risk of liver disorders in general

Family history, social history, and drug and substance use history should note risk factors for liver disorders (see Table: Risk Factors for Liver Disorders).

Physical examination

Abnormalities detectable during a physical examination usually do not develop until late in the course of the disease. Some common findings suggest a cause (see Table: Interpretation of Some Physical Findings).

Interpretation of Some Physical Findings


Possible Causes


Hepatic abnormalities


Acute hepatitis

Passive venous congestion

Liver hemorrhage (into a cyst or the parenchyma)

Metastatic cancer

Biliary obstruction

Palpable lump


Liver firmness, irregular shape, blunt edges, and few if any individual nodules


Passive congestion

Liver hemorrhage


Because of patient anxiety, often overdiagnosed

True liver tenderness (a deep-seated ache) best elicited by percussion or compression of the rib cage

Occasionally, if severe, mimics peritonitis

Friction rubs or bruits (rare)


Extrahepatic abnormalities


Alcoholic hepatitis if chronic or severe

Hepatic vein obstruction

Peritoneal disorders

Generalized fluid retention (eg, heart failure, nephrotic syndrome, hypoalbuminemia)

Typically abdominal distention, shifting dullness, and fluid wave

May not be detectable if volume is < 1500 mL

Visibly dilated abdominal veins (caput medusae)

Portal hypertension

Inferior vena cava obstruction


Portal hypertension

Nonalcoholic cirrhosis

Splenic disorders



Heart failure if severe

Bilateral, asynchronous flapping of dorsiflexed hands with the arms outstretched

Fetor hepaticus

Portosystemic encephalopathy or shunting

Sweet, pungent smell

Drowsiness and confusion

Portosystemic encephalopathy


Brain or systemic disorders


Wasted extremities plus protuberant abdomen with ascites (cirrhotic habitus)

Cirrhosis if advanced

Cancers with peritoneal metastases if advanced

Male hypogonadism

Alcoholic cirrhosis



Pituitary, genetic, systemic, and endocrine disorders

Testicular atrophy, erectile dysfunction, infertility, and loss of libido

In men, gynecomastia, loss of axillary or chest hair, and female pattern of pubic hair


Alcohol abuse if chronic


Endocrine disorders

Chronic kidney disease

Gynecomastia differentiated from pseudogynecomastia (in overweight men) by examination

Gynecomastia plus testicular atrophy


Alcohol abuse if chronic

Anabolic steroid use

Pituitary or endocrine disorders

Spider angiomas


Feminization (in men)


Undernutrition if severe

Alcohol abuse if chronic (possibly)

After compression, peripherally directed blood flow (to the outside of the lesion)

Possibly increased risk of severe cirrhosis and variceal hemorrhage as number of angiomas increases

May occur as a normal variant (usually < 3)

Palmar erythema


Feminization (in men)




Hematologic cancers

Alcohol abuse if chronic (possibly)

Often most obvious on thenar and hypothenar eminences

In patients with cirrhosis, clubbing

Possibly advanced portosystemic shunting or biliary cirrhosis

Lung disorders if chronic

Cyanotic heart disease

Infection (eg, infective endocarditis) if chronic


Inflammatory bowel disease


Hyperbilirubinemia caused by conditions such as hepatic or biliary disorders, hemolysis, use of certain drugs, or inborn errors of metabolism

Visible when bilirubin level is > 2 to 2.5 mg/dL (> 34 to 43 μmol/L)

Affects sclerae (unlike carotenemia)

Muddy skin pigmentation, excoriations caused by constant pruritus, and xanthelasmas or xanthomas (cutaneous lipid deposits)

Cholestasis (including primary biliary cirrhosis) if chronic

Parotid gland enlargement

Alcohol use if chronic (often present with alcoholic cirrhosis)

Slate gray or bronze skin

Hemochromatosis with deposition of iron and melanin

Dupuytren contracture

Alcoholic cirrhosis

Alcohol use if chronic

Cigarette use

Complex regional pain syndrome

Repetitive motion or vibration


Peyronie disease


Testing for hepatic and biliary disorders, including blood tests, imaging, and sometimes liver biopsy, plays a prominent role in the diagnosis of liver disorders. Individual tests, particularly those of liver biochemistry and excretion, often have limited sensitivity and specificity. A combination of tests often best defines the cause and severity of disease.

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