1. Esther Unitt Consultant Hepatologist
Clinical Hepatology
Esther Unitt
Consultant Hepatologist

2. Abdominal examination
Visual survey whilst positioning patient
Hands (BRIEFLY!)
Dupuytron’s 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

3. 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”

4. 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

5. Likely cases! Chronic liver disease Ascites Jaundice
Alcohol dependence
Isolated hepatomegaly
Isolated Splenomegaly

6. Chronic liver disease Peripheral stigmata Hepatic flap
Clubbing, leuconychia, palmar erythema, Dupytron’s, Spider naevi, Excoriations, Icterus, Pallor, Cyanosis, Xanthomata, Muscle wasting, tattoos
Hepatic flap
Liver may be large or small
Signs of portal hypertension
Splenomegaly
Ascites

7. 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

8. 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

9. Complications of chronic liver disease
Portal hypertension
Ascites
Variceal haemorrhage
Hepato-renal failure
Synthetic failure
Encephalopathy
Jaundice, coagulopathy
Risk of infection (SBP)

10. Jaundice Hepatocellular or cholestatic History important
Pain, Duration, Weight loss
Alcohol, travel, drugs,
Partners, transfusion, FH
History important
Hepatocellular or cholestatic
(ALT>ALP)
(ALP>ALT)
Ultrasound scan
Ultrasound scan No
Dilated ducts
Dilated ducts
Hepatitis serology
Ferritin
Liver antibodies
Immunoglobulins
Caeruloplasmin
Intrahepatic cholestasis
Consider drugs (antibiotics)
PBC, PSC
Obstructive cause
Gallstones
Pancreatic Ca
Cholangioca
Further imaging (CT, EUS)
ERCP, surgery
? Liver biopsy

11. 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

12. Ascites (diagnosis) Diagnostic tap is key!
Protein content (transudate or exudate (>25))
Ascitic-serum albumin gradient
>11 = portal hypertension
Microscopy (WCC>250 (neutrophils) = SBP)
If lymphocytic, think of TB
Cytology
Imaging (USS or CT), consider echo

13. 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

14. 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?

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

16. Isolated splenomegaly
Cirrhosis
Haematological
Lymphoproliferative, myeloproliferative disorders
Haemolytic anaemias, pernicious anaemia, ITP
Infectious
SBE, glandular fever, (Malaria, Kala-azar, TB)
Inflammatory
Sarcoid, Felty’s syndrome (RA)
Infiltrative (Storage disorders)
Glycogen storage, Gaucher’s, amyloid
Metabolic
Thyrotoxicosis

17. Isolated hepatomegaly
Cirrhosis (there will be other stigmata)
Fatty liver
Secondary carcinoma
CCF – pulsatile - ?Tricuspid regurgitation
Lymphoproliferative disorders
Sarcoid, Amyloid

18. Case 1
55yr old lady presents with pruritus and lethargy and has abnormal LFTs
What are you going to ask?

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

20. Examination: Palmar erythema Facial telangiectasia Xanthelasma
Muscle wasting
Hepatomegaly
Splenomegaly

21. Diagnosis?

22. PBC Ask for mitochondrial antibodies
Diagnosis?
PBC
Ask for mitochondrial antibodies

23. Case 2:
A 40 year old man presents with abdominal pain, fever and jaundice

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

25. What investigations do you do?
Examination:
Tender RUQ or NAD, Fever?
What investigations do you do?
Biochemical
Radiological
Treatment?

26. Bloods WCC 20 , neut 15 Bili 80, ALP 450, ALT 100, Alb 38 INR 1.0
How do you describe these?
INR 1.0
U&Es normal
Amylase normal

27. Tests? Ultrasound Diagnosis?
Dilated ducts, stones in gallbladder and single gallstone in lower CBD
Diagnosis?

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

29. Treatment Antibiotics
ERCP (endoscopic retrograde cholangio-pancreatogram)
Cholecystectomy

30. Remember
Hepatology is easy!
Thank you and good luck!