Evaluation of the Patient With a Liver Disorder

By Steven K. Herrine, MD, Thomas Jefferson University;Jefferson Medical College

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Approach to the Patient With Liver Disease
Liver Structure and Function
Evaluation of the Patient With a Liver Disorder
The Asymptomatic Patient With Abnormal Laboratory Test Results
Acute Liver Failure
Ascites
Crigler-Najjar Syndrome
Fatty Liver
Gilbert Syndrome
Inborn Metabolic Disorders Causing Hyperbilirubinemia
Jaundice
Nonalcoholic Steatohepatitis (NASH)
Portal Hypertension
Portosystemic Encephalopathy
Spontaneous Bacterial Peritonitis (SBP)
Postoperative Liver Dysfunction
Systemic Abnormalities in Liver Disease

History

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

Category	Risk Factors
Acquired	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* Needlesticks* Parenteral drug use* Shellfish ingestion* Tattoos*
Familial	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

Finding	Possible Causes	Comments
Hepatic abnormalities
Hepatomegaly	Acute hepatitis Fatty liver Alcoholic liver disease Passive venous congestion Liver hemorrhage (into a cyst or the parenchyma) Metastatic cancer Biliary obstruction	—
Palpable lump	Cancer	—
Liver firmness, irregular shape, blunt edges, and few if any individual nodules	Cirrhosis	—
Tenderness	Acute hepatitis Passive congestion Liver hemorrhage Cancer	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)	Tumor	—
Extrahepatic abnormalities
Ascites	Portal hypertension 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	—
Splenomegaly	Portal hypertension Nonalcoholic cirrhosis Splenic disorders	—
Asterixis	Portosystemic encephalopathy Uremia 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 Drugs Brain or systemic disorders	Nonspecific
Wasted extremities plus protuberant abdomen with ascites (cirrhotic habitus)	Cirrhosis if advanced Cancers with peritoneal metastases if advanced	—
Male hypogonadism	Alcoholic cirrhosis Hemochromatosis Drugs 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	Cirrhosis Alcohol abuse if chronic Drugs Endocrine disorders Chronic kidney disease	Gynecomastia differentiated from pseudogynecomastia (in overweight men) by examination
Gynecomastia plus testicular atrophy	Cirrhosis Alcohol abuse if chronic Anabolic steroid use Pituitary or endocrine disorders	—
Spider angiomas	Cirrhosis Feminization (in men) Pregnancy 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	Cirrhosis Feminization (in men) Hyperthyroidism Pregnancy RA 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 Stroke Inflammatory bowel disease	—
Jaundice	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 Diabetes Peyronie disease	—

Testing

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.

Last full review/revision May 2016 by Steven K. Herrine, MD