Cases for PACES

Question 1

What are the clinical signs of chronic liver disease?

Answer 1

1. General

• Cachexia
• Icterus
• Excoriation (skin picking)
• Bruising

2. Hands

• Leuconychia
• Clubbing
• Dupuytren’s Contracture
• Palmar Erythema

3. Face

• Xanthelasma
• Parotid Swelling
• Fetor Hepaticus (breath of the dead - characteristic breath of patients with severe hepatic parenchymal disease, an odor likened to a mixture of rotten eggs and garlic)

4. Chest & Abdomen

• Spider Naevi
• Caput Medusa
• Gynaecomastia
• Testicular Atrophy

Question 3

What are the signs of hepatomegaly on examination?

Answer 3

Palpation + Percussion

1. RUQ mass
   
   • moves w respiration
   • cannot get above
   • dull percussion
   1. estimate size - finger breadths below diaphragm
   2. smooth OR craggy/nodular (malignancy vs cirrhosis)
   3. pulsatile? (tricuspid regurgitation in chronic cardiac failure)

Auscultation

1. Bruit over liver? (hepatocellular carcinoma)

Question 4

What evidence of treatment can be seen in chronic liver failure?

Answer 4

1. Ascitic Drain/Tap Sites
2. Surgical Scars

Question 5

What evidence can you look for to determine an underlying cause for hepatomegaly?

Answer 5

1. Tattoos + Needle Marks –> Infectious Hepatitis
2. Slate-Grey Pigmentation –> Haemochromatosis
3. Cachexia –> Malignancy
4. Mid-Line Sternotomy Scar –> Congestive Cardiac Failure (CCF)

Question 7

What is decompensated liver disease?

Answer 7

• Compensated = no cirrhosis signs/symptoms (may have portal hypertension –> oesophageal/gastric varices)
• Decompensated = symptomatic complications due to 1) hepatic insufficiency (jaundice, encephalopathy) + 2) portal hypertension (ascites, variceal haemorrhage)

Question 8

What are the evidence of decompensated liver disease?

Answer 8

3 A’s

1. Ascites - shifting dullness
2. Asterixis - liver flap
3. Altered consciousness (encephalopathy)

Question 9

What are the causes of hepatomegaly?

Answer 9

The Big 3 C’s

1. Cirrhosis –> alcohol
2. Carcinoma –> secondaries
3. Congestive Cardiac Failure

(and also)

The Small 3 I’s

1. Infectious –> HBV, HCV
2. Immune –> PBC, PSC, AIH
3. Inflitrative –> amyloid, myeloproliferative disorders (PRV)

Question 10

What are the investigations for hepatomegaly?

Answer 10

Bloods

1. FBC
2. Clotting
3. U&Es (creatinine produced in liver; urea decreases in liver disease)
4. LFTs
5. Glucose

USS –> abdomen

Ascites Tap (if present)