Station 1.1: Chronic liver disease and hepatomegaly

Question 1

Clinical signs

What are the signs of chronic liver disease

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen.

Answer 1

*  General: cachexia, icterus (also in acute), excoriation and bruising
*  Hands: leuconychia, clubbing, Dupuytren’s contractures and palmar erythema
*  Face: xanthelasma, parotid swelling and fetor hepaticus
*  Chest and abdomen: spider naevi and caput medusa, reduced body hair,
gynaecomastia and testicular atrophy (in males

Question 2

Clinical signs

What are the signs of hepatomegaly

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 2

*  Palpation and percussion:
⚬ Mass in the right upper quadrant that moves with respiration, that you are not able
to get above and is dull to percussion
⚬ Estimate size (finger breadths below the diaphragm)
⚬ Smooth or craggy/nodular (malignancy/cirrhosis)
⚬ Pulsatile (TR in CCF)
*  Auscultation
⚬ Bruit over liver (hepatocellular carcinoma)

Question 3

Clinical signs

Provide evidence of an underlying cause of hepatomegaly

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 3

*  Tattoos and needle marks - Infectious hepatitis
*  Slate‐grey pigmentation - Haemochromatosis
*  Cachexia - Malignancy
*  Mid‐line sternotomy scar - CCF

Question 4

Clinical signs

Provide evidence of treatment

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 4

*  Ascitic drain/tap sites
*  Surgical scars

Question 5

Clinical signs

Provide evidence of decompensation

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 5

*  Ascites: shifting dullness
*  Asterixis: ‘liver flap’
*  Altered consciousness: encephalopathy

Question 6

Discussion

What are the causes of hepatomegaly?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 6

The big three:
Cirrhosis (alcoholic)
Carcinoma (secondaries)
Congestive cardiac failure
Plus:
Infectious (HBV and HCV)
Immune (PBC, PSC and AIH)
Infiltrative (am

Question 7

Discussion

What investigations do you recommend?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 7

*  Bloods: FBC, clotting, U&E, LFT and glucose
*  Ultrasound scan of abdomen
*  Tap ascites (if present)

Question 8

Discussion

What investigations If cirrhotic?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 8

*  Liver screen bloods:
⚬ Autoantibodies and immunoglobulins (PBC, PSC and AIH)
⚬ Hepatitis B and C serology
⚬ Ferritin (haemochromatosis)
⚬ Caeruloplasmin (Wilson’s disease)
⚬ α‐1 antitrypsin
⚬ Autoantibodies and immunoglobulins (PBC)
⚬ AFP (hepatocellular carcinoma)
*  Hepatic synthetic function: INR (acute) and albumin (chronic)
*  Liver biopsy (diagnosis and staging)
*  ERCP (diagnose/exclude PSC)

Question 9

Discussion

What investigations If malignancy?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 9

*  Imaging: CXR and CT abdomen/chest
* Colonoscopy/gastroscopy
*  Biopsy

Question 10

Discussion

What are the Complications of cirrhosis?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 10

*  Variceal haemorrhage due to portal hypertension
*  Hepatic encephalopathy
*  Spontaneous bacterial peritonitis

Question 11

Discussion

What investigations If malignancy?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 11

*  Imaging: CXR and CT abdomen/chest
* Colonoscopy/gastroscopy
*  Biopsy

Question 12

Discussion

Child‐Pugh classification of cirrhosis?
Prognostic score based on bilirubin/albumin/INR/ascites/encephalopathy

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 12

Score 1 year survival

A: 5-6 100%
B: 7-9 81%
C: 10-15 45%

Question 13

Discussion

What are the causes of ascites?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 13

*  Cirrhosis (80%)
*  Carcinomatosis
*  CCF

Question 14

Discussion

What are the treatments of ascites in cirrhotics?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 14

*  Abstinence from alcohol
*  Salt restriction
*  Diuretics (aim: 1kg weight loss/day)
*  Liver transplantation

Question 15

Discussion

What are the causes of palmar erythema?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 15

*  Cirrhosis
*  Hyperthyroidism
*  Rheumatoid arthritis
*  Pregnancy
*  Polycythaemia

Question 16

Discussion

What are the causes of gynaecomastia?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 16

*  Physiological: puberty and senility
*  Kleinfelter’s syndrome
*  Cirrhosis
*  Drugs, e.g. spironolactone and digoxin
*  Testicular tumour/orchidectomy
*  Endocrinopathy, e.g. hyper/hypothyroidism and Addison’s

Question 17

Discussion

What are the Autoantibodies in liver disease?

Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen

Answer 17

• Primary biliary cirrhosis (PBC): antimitochondrial antibody (M2 subtype) in 98%,
  increased IgM
• Primary sclerosing cholangitis (PSC): ANA, anti‐smooth muscle may be positive
• Autoimmune hepatitis (AIH): anti‐smooth muscle, anti‐liver/kidney microsomal type 1(LKM1) and occasionally ANA may be positive (pattern helps classify)