Evaluation of the Patient With a Liver Disorder
History and physical examination often suggest a cause of potential liver disorders and narrow the scope of testing for hepatic and biliary disorders.
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.
(See also Liver Structure and Function.)
Risk Factors for Liver Disorders
Category |
Risk Factors |
|
Acquired |
Alcohol use Blood transfusions (particularly before 1992)* Body piercing* Exposure to other liver toxins Exposure to hepatitis* Needlesticks* Parenteral drug use* Tattoos* |
|
Familial |
Family history of disorders such as primary biliary cholangitis, 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 liver 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 |
Passive venous congestion Liver hemorrhage (into a cyst or the parenchyma) |
— |
|
Palpable mass |
Cancer |
— |
|
Liver firmness, irregular shape, blunt edges, and few if any individual nodules |
— |
|
|
Tenderness |
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) |
Tumor Hereditary hemorrhagic telangiectasia (Osler Webber Rendu) |
— |
Extrahepatic abnormalities |
||
|
Alcoholic hepatitis if chronic or severe Peritoneal carcinomatosis 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) |
Inferior vena cava obstruction |
— |
|
Splenomegaly |
Nonalcoholic cirrhosis |
— |
|
Asterixis |
Uremia Heart failure if severe |
Bilateral, asynchronous flapping of dorsiflexed hands with the arms outstretched |
|
Fetor hepaticus |
Sweet, pungent smell |
|
|
Drowsiness and confusion |
Drugs Brain or systemic disorders |
Nonspecific |
|
Wasted extremities plus protuberant abdomen with ascites (cirrhotic habitus) |
Cirrhosis if advanced Cancers with peritoneal metastases if advanced |
— |
|
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 |
Alcohol abuse if chronic Drugs Endocrine disorders |
Gynecomastia differentiated from pseudogynecomastia (in overweight men) by examination |
|
Gynecomastia plus testicular atrophy |
Alcohol abuse if chronic Pituitary or other endocrine disorders |
— |
|
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 |
Feminization (in men) Pregnancy 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 |
— |
|
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 micromol/L) Affects sclerae (unlike carotenemia) |
|
|
Muddy skin pigmentation, excoriations caused by constant pruritus, and xanthelasmas or xanthomas (cutaneous lipid deposits) |
Cholestasis (including primary biliary cholangitis) 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 |
— |
|
Alcohol use if chronic Cigarette use Repetitive motion or vibration |
— |
|
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.
