Chronic liver disease and hepatomegaly (A Case For MRCP PACES)

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

Clinical signs
Signs of chronic liver disease
• 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)

Signs of hepatomegaly
• 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)

Evidence of an underlying cause of hepatomegaly
• Tattoos and needle marks  - Infectious hepatitis
• Slate‐grey pigmentation  - Haemochromatosis
• Cachexia - Malignancy
• Mid‐line sternotomy scar -  CCF

Evidence of treatment
• Ascitic drain/tap sites
• Surgical scars

Evidence of decompensation
• Ascites: shifting dullness
• Asterixis: ‘liver flap’
• Altered consciousness: encephalopathy

Discussion

Causes of hepatomegaly
The big three:

• Cirrhosis (alcoholic)
• Carcinoma (secondaries)
• Congestive cardiac failure

Plus:

• Infectious (HBV and HCV)
• Immune (PBC, PSC and AIH)
• Infiltrative (amyloid and myeloproliferative disorders)

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

If cirrhotic
• 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)

If malignancy
• Imaging: CXR and CT abdomen/chest
• Colonoscopy/gastroscopy
• Biopsy

Complications of cirrhosis
• Variceal haemorrhage due to portal hypertension
• Hepatic encephalopathy
• Spontaneous bacterial peritonitis

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

Causes of ascites
• Cirrhosis (80%)
• Carcinomatosis
• CCF

Treatment of ascites in cirrhotics
• Abstinence from alcohol
• Salt restriction
• Diuretics (aim: 1 kg weight loss/day)
• Liver transplantation

Causes of palmar erythema
• Cirrhosis
• Hyperthyroidism
• Rheumatoid arthritis
• Pregnancy
• Polycythaemia

Causes of gynaecomastia
• 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

Autoantibodies in liver disease
• 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)