Liver Flashcards
• mental status- portal encephalopathy
- Type A: Hepatic encephalopathy associated with acute liver failure
- Type B: Hepatic encephalopathy associated with portal-systemic bypass with no intrinsic hepatocellular disease –
- Type C: Hepatic encephalopathy associated with cirrhosis and portal hypertension or portal-systemic shunts.
Portosystemic encephalopathy Grades
- Subclinical portosystemic encephalopathy (minimal): patients perform poorly on psychometric testing (tasks that require rapid reaction times) Judgment also may be mildly affected.
- Grade 1 portosystemic encephalopathy: difficulty with memory, mild confusion, agitation, irritability; restlessness or sleeping during the day and insomnia at night; tremor, incoordination
- Grade 2: a slowing of mentation and speech, with the appearance of lethargy; difficulty with orientation to time, and loss of inhibition; asterixis (flapping tremor), dysarthria, ataxia, hypoactive deep- tendon reflexes
- Grade 3: Patients are drowsy but can be woken up; they remain markedly confused, aggressive behavior; asterixis persists, but the deep-tendon reflexes become hyperactive as they are disinhibited, a process that culminates in the development of the decerebration, Babinski sign
- Grade 4: hepatic coma
Skin and mucosa changes
– Jaundice SCLERA !!! • Pre-hepatic jaundice • Hepatic jaundice – Pallor (hypersplenism, sec.to hemorrhage) – Liver palms – Spider nevi- upper part of the body – Purpura – Scratch marks- sec.to pruritus
Subcutaneous tissue
– Edema lower limbs, ascites; anasarca
– Collateral circulation
– Clubbing- cirrhosis
– Gynecomastia (hormonal changes, spironolactone)
– Terry’s nails= leuconychia- due to hypoalbuminaemia
– Dupuytrene contracture
Involuntary movements
Flapping tremor
Face
Kaiser fliescher ring Xanthelasma
Respiratory
Pleural syndrome
Cardiac
Diastolic dysfunction Pericarditis
Liver Palpation Description of hepatomegaly
– Size (cm/fingers below the last rib) – Consistence- firm/normal-soft – Surface- regular, irregular – Pain while palpating – The edge: sharp/ rounded – The hepato-jugular reflux
Inspection
– Foetor hepaticus- a specific smell due to methylmercaptans (severe liver disease)
– Distension of the abdomen- ascites
– Hernia
Causes of hepatomegaly
• chronic parenchymal liver disease
– Alcoholic liver disease
– Autoimmune hepatitis
– Viral hepatitis – Primary biliary cirrhosis
• Malignancy
– Primary hepatocellular cancer
– Secondary metastatic cancer
• Right heart failure
– Lymphoma
– Leukaemia
– yelofibrosis
– Polycythaemia
• Rarities
– Amyloidosis
– Budd-Chiari syndrome
– Glycogen storage disorders
Peculiar aspect
– Sharp edge, irregular surface, firm- cirrhosis
• In cirrohis: normal, increased or decreased size of the liver!
– Presence of reflux- hepatomegaly due to cardiac failure
– Asymmetrical hepatomegaly: hydatid cyst, tumor, abscess
– Painful: abscess, possible- acute hepatitis
Askultation of the liver
– Friction rub – Venous hum- portal hypertension
Gallbladder Palpation
– murphy sign: abrupt interruption of inspiration while palpating due to severe pain= cholecystitis
– Hydrops :
• with jaundice
1 Carcinoma of the head of pancreas= ourvoisier gallbladder
2 Carcinoma of the ampulla of Vater
3 In-situ gallstone formation in the common bile duct
• without jaundice
1 empyema of the gallbladder.
2 Carcinoma of the gallbladder (stone hard, irregular swelling)
3 Acute cholecystitis
Hydrops Def causes
an overdistended gallbladder filled with mucoid or clear and watery content
• Causes:
– Impacted stone in the gallbladder neck or cystic duct
– Tumors
– Extrinsic compression of the neck or cystic duct by lymph nodes, fibrosis, by adjacent malignancies in the liver, duodenum, or colon
– Prolonged total parenteral nutrition or ceftriaxone therapy
– Congenital narrowing of the cystic duct
– Parasites, such as ascaris
Inspection gallbladder
possible mass in the right hypocondrium: hydrops
Manifestation of hydrops
– Pain: severe
• persistence of pain and tenderness on RQ longer than 6 hours indicates possible acute cholecystitis
– Nausea, vomiting
– Fever, chills- empyema
• bilirubinuria
reflects the presence of conjugated bilirubin in urine
– acute viral hepatitis or other hepatobiliary disorders, even before jaundice appears.
PT and INR
– Are a valuable measure of the liver’s ability to synthesize fibrinogen and vitamin K
– dependent clotting factors: factors II (prothrombin), V, VII, and X
. – Abnormalities indicate severe hepatocellular dysfunction, in acute liver disorders.
• In chronic liver disorders, an increasing PT or INR indicates progression to liver failure.
– The PT or INR does not increase in mild hepatocellular dysfunction and is often normal in cirrhosis.
Causes for abnorma pt inr
–Fat malabsorption, cholestasis, can cause vitamin K deficiency.
–In chronic cholestasis, marked hepatocellular dysfunction can be ruled out if vitamin K replacement corrects PT (by ≥ 30% within 24 h).
Serum albumin
Commonly decreased sin chronic liver disorders
Portal hypertension
Portal hypertension = portal pressure gradient of 12 mm Hg or greater
• pathoph.:
– Increase in vascular resistance to the portal flow
– Increase in portal blood flow
Preheating causes for portal hypertension
– Portal vein thrombosis
– Splenic vein thrombosis
– Congenital atresia or stenosis of portal vein
– Extrinsic compression (tumors)
– Splanchnic arteriovenous fistula
Intrane hepatic causes for portal hypertension
– Hepatic cirrhosis – Acute alcoholic hepatitis – Schistosomiasis – Primary biliary cirrhosis (advanced stage) – Idiopathic portal hypertension (advanced stage) – Acute and fulminant hepatitis – Congenital hepatic fibrosis – Vitamin A toxicity- pericellular fibrosis – Budd-Chiari syndrome
