Clinical Hepatology

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Clinical Hepatology

• Esther Unitt
• Consultant Hepatologist

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Abdominal examination

• Visual survey whilst positioning patient
• Hands (BRIEFLY!)
• Dupuytrons contracture, clubbing, leuconychia,
  palmar erythema, flapping termor
• Eyes
• Anaemia, jaundice, xanthalasma
• Neck and supraclavicular fossa
• Cervical lymph nodes
• Lips
• Cyanosis, telangiectasis, pigmentation, ulcers
• Chest
• Spider naevi, gynaecomastia, scratch marks,
  axillary hair

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Abdomen

• Stand back and Observe
• Pulsations, distension, abdominal veins
• Palpation structured approach, light then deep
• Organs
• Remember to start in RIF
• Can you get above it? Percussion? Bimanual
  palpation?
• Shifting dullness
• Auscultation (bowel sounds, bruits)
• Comment that you would like to examine the
  external genitalia and perform a rectal
  examination

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Discussing findings

• Know how to describe or defend your findings
• Keep it simple!
• What are the characteristics of.
• Liver
• Mass in RUQ, dull to percussion, moves with
  respiration
• Smooth or hard, (pulsatile)
• Spleen
• Left hypochondrium, notch, moves diagonally
  across abdomen on inspiration, cannot get above,
  dull to percussion
• Kidney
• Mass in the flank, bimanually ballotable, can get
  above, percussion resonant

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Likely cases!

• Chronic liver disease
• Ascites
• Jaundice
• Alcohol dependence
• Isolated hepatomegaly
• Isolated Splenomegaly

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Chronic liver disease

• Peripheral stigmata
• Clubbing, leuconychia, palmar erythema,
  Dupytrons, Spider naevi, Excoriations, Icterus,
  Pallor, Cyanosis, Xanthomata, Muscle wasting,
  tattoos
• Hepatic flap
• Liver may be large or small
• Signs of portal hypertension
• Splenomegaly
• Ascites

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Causes

• Alcohol (commonest)
• Viral hepatitis (B and C)
• ?risk factors blood transfusion, tattoos, ivdu
• NASH (non-alcoholic fatty liver) (Cryptogenic)
• Diabetes
• Primary biliary cirrhosis
• Female, excoriations , xanthomata
• Haemochromatosis
• Male, slate grey pigmentation
• Auto-immune hepatitis

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Liver antibodies
Primary biliary cirrhosis
Auto-immune hepatitis
Raised IgM Anti-mitochondrial antibodies (AMA)
Raised IgG Anti-smooth muscle antibodies (SMA)
Prednisolone Azathioprine
Ursodeoxycholic acid
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Complications of chronic liver disease

• Portal hypertension
• Ascites
• Variceal haemorrhage
• Hepato-renal failure
• Synthetic failure
• Encephalopathy
• Jaundice, coagulopathy
• Risk of infection (SBP)

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Jaundice
Pain, Duration, Weight loss Alcohol, travel,
drugs, Partners, transfusion, FH
History important

• Hepatocellular or cholestatic

(ALTgtALP)
(ALPgtALT)
Ultrasound scan
Ultrasound scan
No Dilated ducts
Dilated ducts
Hepatitis serology Ferritin Liver
antibodies Immunoglobulins Caeruloplasmin
Obstructive cause Gallstones Pancreatic
Ca Cholangioca
Intrahepatic cholestasis Consider drugs
(antibiotics) PBC, PSC
Further imaging (CT, EUS) ERCP, surgery
? Liver biopsy
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Ascites

• Chronic liver disease
• Intra-abdominal malignancy
• CCF (right sided)
• Tuberculous peritonitis
• Hypoalbuminaemia (malnutrition, malabsorption,
  nephrotic syndrome)
• Constrictive pericarditis
• Myxoedema
• Pancreatic disease
• Budd-Chiari syndrome

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Ascites (diagnosis)

• Diagnostic tap is key!
• Protein content (transudate or exudate (gt25))
• Ascitic-serum albumin gradient
• gt11 portal hypertension
• Microscopy (WCCgt250 (neutrophils) SBP)
• If lymphocytic, think of TB
• Cytology
• Imaging (USS or CT), consider echo

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Ascites (management)

• Depends on underlying cause
• Commonly liver disease treat cause!
• Low salt diet (no added salt)
• Spironolactone (aldosterone antagonist)
• Monitor renal function, risk of high K
• Paracentesis
• Shunts, Transplant

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Alcohol dependence

• Distinguish between misuse, dependence
• Alcohol history, past and present
• Evidence of tolerance
• Withdrawal symptoms (DTs, fits, blackouts)
• Impact on family, work, driving
• Continued drinking despite harmful consequences
• Willing to accept help?

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Alcohol

• Affects nearly every system NOT just the liver!
• CVS
• hypertension, cholesterol, AF, cardiomyopathy
• Neurology
• Blackouts, seizures, dementia, alcohol psychosis
• Peripheral neuropathy, cerebellar degeneration
• Wernickes encephalopathy, Korsakoff pychosis
  (Thiamine deficiency, cerebellar signs and
  confusion)
• Pancreatitis, acute and chronic
• GI
• Malnutrition, diarrhoea, ulcers, oesophagitis
• Respiratory
• Aspiration pneumonia, TB

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Isolated splenomegaly

• Cirrhosis
• Haematological
• Lymphoproliferative, myeloproliferative disorders
• Haemolytic anaemias, pernicious anaemia, ITP
• Infectious
• SBE, glandular fever, (Malaria, Kala-azar, TB)
• Inflammatory
• Sarcoid, Feltys syndrome (RA)
• Infiltrative (Storage disorders)
• Glycogen storage, Gauchers, amyloid
• Metabolic
• Thyrotoxicosis

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Isolated hepatomegaly

• Cirrhosis (there will be other stigmata)
• Fatty liver
• Secondary carcinoma
• CCF pulsatile - ?Tricuspid regurgitation
• Lymphoproliferative disorders
• Sarcoid, Amyloid

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Case 1

• 55yr old lady presents with pruritus and lethargy
  and has abnormal LFTs
• What are you going to ask?

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Key history points

• Exclude obstructive symptoms/Weight loss
• No alcohol history, risk factors ?bld trans
• PMH thyroid disease
• Varices on OGD
• FH?
• Any thoughts?

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Examination

• Palmar erythema
• Facial telangiectasia
• Xanthelasma
• Muscle wasting
• Hepatomegaly
• Splenomegaly

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Diagnosis?
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Diagnosis?

• PBC
• Ask for mitochondrial antibodies

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Case 2

• A 40 year old man presents with abdominal pain,
  fever and jaundice

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History

• Nature of pain
• Colicky, intense, RUQ. May last several hours
• Rigors?
• Cholestatic symptoms pale stools, dark urine,
  pruritus
• Weight loss

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• Examination
• Tender RUQ or NAD, Fever?
• What investigations do you do?
• Biochemical
• Radiological
• Treatment?

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Bloods

• WCC 20 , neut 15
• Bili 80, ALP 450, ALT 100, Alb 38
• How do you describe these?
• INR 1.0
• UEs normal
• Amylase normal

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Tests?

• Ultrasound
• Dilated ducts, stones in gallbladder and single
  gallstone in lower CBD
• Diagnosis?

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Tests?

• Ultrasound
• Dilated ducts, stones in gallbladder and single
  gallstone in lower CBD
• Diagnosis?
• Choledocholithiasis
• Cholangitis

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Treatment

• Antibiotics
• ERCP (endoscopic retrograde cholangio-pancreatogra
  m)
• Cholecystectomy

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Remember

• Hepatology is easy!
• Thank you and good luck!