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Evaluation of the Patient With a Liver Disorder


Danielle Tholey

, MD, Thomas Jefferson University Hospital

Last full review/revision Jan 2021| Content last modified Jan 2021
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History and physical examination often suggest a cause of potential liver disorders and narrow the scope of testing for hepatic and biliary disorders.


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, usually due to imbalances in the normal estrogen/ testosterone ratio, with more estrogen being present than is typical.


Risk Factors for Liver Disorders


Risk Factors


Alcohol use

Blood transfusions (particularly before 1992)*

Body piercing*

Exposure to other liver toxins

Exposure to hepatitis*

High-risk sexual practices*


Parenteral or intranasal drug use*



Family history of disorders such as primary biliary cholangitis, hemochromatosis, Wilson disease, alpha-1 antitrypsin deficiency, and hepatitis B (which can be vertically transmitted)

* 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


Possible Causes


Hepatic abnormalities


Passive venous congestion

Liver hemorrhage (into a cyst or the parenchyma)

Palpable mass


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

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


Nonalcoholic cirrhosis



Heart failure if severe

Bilateral, asynchronous flapping of dorsiflexed hands with the arms outstretched

Fetor hepaticus

Sweet, pungent smell

Drowsiness and confusion


Brain or systemic disorders


Wasted extremities plus protuberant abdomen with ascites (cirrhotic habitus)

Cirrhosis if advanced

Cancers with peritoneal metastases if advanced


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

Gynecomastia differentiated from pseudogynecomastia (in overweight men) by examination

Gynecomastia plus testicular atrophy

Alcohol abuse if chronic

Pituitary or other endocrine disorders


Undernutrition if severe

Alcohol abuse if chronic (possibly)

After compression, blanching with 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

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 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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