Evaluation of the Patient With a Liver Disorder: Approach to the Patient With Liver Disease: Merck Manual Professional

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 (see Male Reproductive Endocrinology and Related Disorders: Gynecomastia)
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	—

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 (see Male Reproductive Endocrinology and Related Disorders: Gynecomastia)
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	—