Acute liver disease
There may be few signs apart from jaundice and an enlarged liver. Jaundice is a yellow coloration of the skin and mucous membranes and is best seen in the conjunctivae. In the cholestatic phase of the illness, pale stools and dark urine are seen. Spider naevi and liver bpalms usually indicate chronic disease but they can occur in severe acute disease.
Chronic liver disease
The possible physical signs are shown . However, it is possible for the physical examination to be normal in patients with advanced chronic liver disease.
THE SKIN. The chest and upper body may show spider naevi. These are telangiectases that consist of a central arteriole with radiating small vessels. They are found in the distribution of the superior vena cava, i.e. above the nipple line. They are also found in pregnancy. In haemochromatosis the skin may have a slate-grey appearance. The hands may show palmar erythema, which is a nonspecific change indicative of a hyperdynamic circulation; it may also be seen in pregnancy, thyrotoxicosis or rheumatoid arthritis. Clubbing occasionally occurs, and a Dupuytren’s contracture is often seen in alcoholic cirrhosis.
Xanthomas (cholesterol deposits) may be seen in the palmar creases or above the eyes in primary biliary cirrhosis.
THE A B D0 MEN. Initial hepatomegaly will be followed by a small liver in well-established cirrhosis.
Splenomegaly is usually taken as an indication of portal hypertension.
THE ENDOCRINE SYSTEM. Gynaecomastia (occasionally unilateral) and testicular atrophy may be found in males.
The cause of gynaecomastia is complex, but it is probably related to altered oestrogen metabolism or to treatment with spironolactone.
IN DECOMPENSATED CIRRHOSIS, additional signs that can be seen are:
• Ascites with or without peripheral oedema
• Evidence of portosystemic encephalopathy (PSE) including drowsiness, stupor, fetor hepaticus and a flapping tremor of the outstretched hands
• Collateral veins and veins around the umbilicus (caput medusae) (rare)