Chronic liver disease History and examination, Dr Huda Ahmed
Summary
This on-demand teaching session for medical professionals will explore important information on the physical examination of chronic liver disease. It will cover the different causes of cirrhosis, the common complications, and the history and systems that need to be taken into account to identify the cause of the disease. The session will also provide tips on taking a patient's history, such as the questions to ask and the symptoms to look out for. All of these topics and more will be discussed to help medical professionals better manage patients with chronic liver disease.
Learning objectives
Learning Objectives:
- Identify different common causes of chronic liver disease.
- Analyze various signs and symptoms of chronic liver disease, including jaundice, abdominal pain, joint swelling, and itching.
- Understand the common complications associated with chronic liver disease, such as variceal bleeding, hepatic encephalopathy, and hepatopulmonary syndrome.
- Understand how to evaluate a patient for chronic liver disease, including taking a thorough medical history.
- Understand the diagnosis and treatment of chronic liver disease, including liver transplantation in advanced cases.
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Computer generated transcript
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
Hey, doctor, whenever you're ready, we can start. I'm not sure what's wrong. I can't uh make it all. Um Can you see video iphone at the bottom? Right. Yeah. If you can press that, then I'm sure. No, the bottom, right. Bottom, right? Lower, right. Oh I think that that should be all right. If you cannot make it full screen, I think we can just start press the recording. We can start whenever you're ready. I'm sorry, I I'm just trying just all I need. Ok, perfect. Thank you, doctor. We can start. Ok, good. Uh Hi, everyone. My name is uh Ahmed. I'm uh acute medicine specialist doctor uh in North Ireland uh in a city called uh thank you with the Crisis Rescue Foundation and everyone who behind this uh initiative. I'm here today to talk about uh physical examination of uh chronic uh liver disease. Ok. Chronic liver disease is uh yes, it's a progressive destruction of, of the liver uh that happened over a period greater than six months uh leading to fibrosis and cirrhosis of the liver. Uh cirrhosis is, is representing uh the late stage of the progressive hepatic fibrosis and it's characterized by distortion of the hepatic uh architecture and formation of regenerative nodules. Uh It generally considered to be irreversible. Uh And uh especially if it is in the advanced stages. Uh at which point, that's the only option may liver transplant. Uh But in early spec stages, specific uh treatment, aiming at the underlying cause of the liver disease may improve or even sometimes may reverse the cirrhosis. There is numerous causes for a liver uh cirrhosis and uh maybe there is uh it is different, maybe uh from le to lesions. Um uh could be either caused by chronic hepatic inflammation or uh cholestasis. Uh The most common cause of liver cirrhosis are uh the chronic uh viral hepatitis, uh hepatitis B and C. Uh alcohol associated uh liver disease, uh hemochromatosis and non alcohol associated fat liver disease uh which called or nash uh non alcohol as a associated the hepatitis is the other name of this condition which associated with uh metabolic disorders like diabetes, dyslipidemia also with obesity and Polycystic Ovary and sleep apnea. As I mentioned before, it may be, uh we'll find a different uh common cause uh in different condition. Uh for example, and uh in uh uh western cultures, maybe uh alcohol uh as liver disease is the most common cause. There's also less common. Uh other causes are considered to be less common uh like a autoimmune hepatitis. Uh Second biliary cirrhosis sclerosing cholangitis, uh medications like uh the HEPA there is multiple or many hepatotoxic medications. Uh but uh the most common uh are um me like methotrexate isoniazid, uh amiodarone. Um also metabolic disorders and genetic disorders like uh we disease. This is a genetic disorders that lead to a combination of Coor uh in uh male in brain and uh liver alpha one antitoxin deficiency. And it's also a kind of genetic disorder that involve the respiratory tract and involve the liver as well. Uh granu as liver disease like sarcoidosis and as well, dry side heart failure. The major common complication of coral liver disease are the variceal bleeding. Asti is spontaneous bacterial reis hepatic encephalopathy, hepatocellular carcinoma heal syndrome and hepat Pulmonary Syndrome. When you're taking history of uh from patient of a cor liver disease, you mainly focus in two areas that identify the cause of the Coron liver disease and uh to identify whether the patient has any one of the complications. So I would be uh on those points while uh going through the history examination as usual. The first question we'll ask the patient uh about his presenting uh complaint and what brought him to the hospital today and what brought him to see the doctors today? Uh Let us take that patient who can put you on this patient. Uh You ask him after you breathing him, introduce yourself. Um Open question. What brought you today at the hospital? A vision uh said to you, I haven't uh felt well for around one month. I noticed my eyes become yellow and my abdomen is distended. Um The duration of uh one month is pointing to chronicity. As you know, jaundice has many causes, could be uh prehepatic causes, could be hepatic s it could be also post hepatic causes. Uh or it seems to have to identify while taking history and examine the patient. Um You have to ask the patient how like any symptoms analy the jaundice, how it started and how he noticed uh the jaundice. Some patients maybe they noticed by themselves sometimes, especially if it's chronic jaundice after the others, maybe told him that your eyes looked yellow and uh how it's progressed. How is the duration? What's the urine color? It's very important question because it helps us to distinguish uh the hepatic and post hepatic uh jaundice or post hepatic ja choles joins. Usually we will have dark as well as the color stool, color of the stool is very important as well as the post hepatic. The choles type is usually have a period uh stool, uh his fever always important. Um history of uh weight loss, uh loss of appetite is also pointing to chronic um fatigue, uh lower ly edema is pointing to the liver uh causes of uh jaundice. You're ask him uh have to ask him also about the history of bleeding bruising from me or bruising or bleeding from any side. His body. There is many reasons for uh patients to have bleeding. Uh they usually have thrombocytopenia that secondary to uh hyper and as well as the uh have coop due to vitamin K uh deficiencies that lead to vitamin K dependent coagulation factor deficiency disease, including factor two, factor seven, factor nine or factor 10. And they usually have prolonged BT and prolong I uh in R as well. Uh they are at risk for developing uh eg due to a va. Then we'll go to analyze uh the it uh system taking symptom one by one. Abdominal pain is a very important symptom in jaundice patients. Um like if patient is painful, uh jaundice and it's acute presentation is pointing to like for causes like uh cholangitis and cholecystitis and uh chronic pain is pointing to the patient is a malignancy, um is the patient's head and then you have to analyze the pain. Uh what is the inside and uh what is onset and uh what is the progression with the duration, the radiation? What's relieving or what is the exacerbating factors? Uh history of uh fever, jaundice and abdominal pain, especially for short period is called Charcot and suggest for cho um then we'll analyze the other uh the is uh ST symptoms like oral ulcers or ulcers. Um The settings of uh uh suspicion of chronic liver disease. You will, you point to the auto causes and I cause is very rarely, it could also be an inflammatory bowel disease, inflammatory bowel disease associated with uh as sclerosis, which is one of the uh post um hepatic uh liver jaundice and one of the cause of the liver cirrhosis. Uh A history of dysphagia is always important. And in my case, it's pointing to malignancies and nausea and vomiting as well. He is a very important question to ask about if the patient is vomiting. What's the color of the vomiting and how much the patients had? The vomiting? Very important cause hematemesis and G I bleeding is one of the medical emergencies. Um, bowel movement as well is very important to take in details of bowel movement to ask about history, fami and rectal bleeding is also pointing to varicel bleeding. And as I mentioned before, this is one of the medical emergencies G I bleeding um as well. Uh it's very important to ask about with patient has uh constipation, constipation with a risk factor uh to develop hepatic encephalopathy. It is one of the most important inhibiting encephalopathy to treat uh constipation. Every uh liver patients usually in medical ward are a to have uh two bowel motion in the brain and they usually been has to be in a laxative and as well as they have the it is very important cause dehydration itself is also a risk factor to develop people taking keine. So every symptoms are you see in the, analyzing, analyzing the gas symptoms is very important uh in chronic liver disease patients. Then we go to system systemic review and uh uh card pulmonary history is also an important cause. You will find it's important. It's pointing either to complications either to uh it's also pointing to uh causes. Um If patients you have to ask about chest pain, shortness of breath orthopnea, uh cough, syncope and no edema. Uh if heart failure, for example, is one of the causes of the liver cirrhosis right side, heart failure. So, cardio history is so important. And um also patients with chronic liver disease, they have uh one of their complications, HEPA two Pulmonary Syndrome. Um they present with fatigue, dizzy, uh peripheral edema, chest pain and syncope. Um This condition is uh diagnosed usually by echo and confirmed by right side heart heart catheterization. Um also patients with chronic liver disease, uh they could have a heart hepatic hydrothorax and it is the right side uh ballo effusion. So it associated uh with liver disease and it also may be present this uh symptoms uh like shortness of breath urinary system. This is very important to ask about urine amounts and uh urine color hematuria because of the bleeding risk of the patient. The patient's chronic liver disease dys urea if the patient had infections, infection is also one of the uh exacerbating factor of uh hepatic phal um patients with chronic liver disease and they also prone to develop hepatic renal syndrome is one of a complication of the chronic liver disease. And it usually happen in the late stage. Uh they develop renal failure. Secondly to arterial vasodilation inside this intra-abdominal circulation. And it is triggered by the water hypertension. And all this will lead to reduce sp perfusion and lead to renal failure. And this is one of the poor factor in the late state patients seeing a system. Also, it is very important to ask about uh with history of confusion, confusion or coma or alarming symptom in the presence of jaundice. Uh It is one of the manifestation of hepatic encephalopathy uh as well as history of ataxia and parkinsonism, especially in young age uh in the presence of chronic live disease and circo. Uh Then we have to think about possibility of wells some disease, this a genetic disorder. So that lead to co accumulation in brain, a liver and other organs, musculoskeletal system, itching. History of itching is very important. Post patient is post hepatic jaundice that patient is primary biliary sco and patient is primary a second uh primary bili primary sclerosing cho. So young patients, primary secondary biliary cirrosis, they present with jaundice and itching. Uh joint pain and joint swelling is very important and it most of the time uh pointing towards autoimmune disorders and autoimmune hepatitis. Any questions so far past medical history. Um Previous history of this uh I have to ask a patient about the uh in history of to in the past um is as a patient, has a history of blood transfusion, blood transfusion is a risk factor for Hepatitis B and C and HIV as well. History of diabetes is very important cause. It is associated with nonalcoholic fatty liver disease. History of dim high cholesterol and high triglycerides are also important or associated with the non alcohol fatty liver disease. History of ischemic heart disease or history of heart failure because of the, it's also related to the uh the of the cause of the cardiac uh cirrhosis endocrine disorders, uh hemochromatosis, pointing to hemochromatosis, especially if the patient has symptoms. Pointing to multiple endocrine systems, hemochromatosis also is an a genetic disorder associated with excessive iron uh deposition. It's um it, it cause uh diabetes. It could cause uh hypoadrenalism that cause liver cirrosis and it's also causing um arthrosis autoimmune disorders. If the patient had any history of immune to immune disorders like uh sle rheumatoid arthritis, then you think about the autoimmune hepatitis and other autoimmune causes like primary biliary cirrhosis. Any history of in respiratory bowel disease, inflammatory bowel disease are associated with primary uh sclerosing colitis, which, which one of the cause also of the uh liver cirrhosis drug history. As I mentioned before, that is one of the causes of the liver cirrhosis. You have to look uh in the patient medication, uh uh medical uh in the patient's drug history. I'm going to ask careful about the hepatotoxic medications, uh like methotrexate and history of using antituberculous medications, history of um using amiodarone and me dopa I supposed to, it's important in every patient to ask about the drug allergies. IV drug abuse cause it is associated with hepatitis C. That's one of the most common causes of uh current liver disease associated with other vi risk of other viral infection like hepatitis C and HIV. Hr V can cause um sclerosing cholangitis and it's also one of the causes of the conc heart disease, family history. Um uh any family history of this uh this will point uh toward the genetic disorders or some patients. They may have uh paternal uh transmission of viral uh uh hepatitis B or hepatitis C. Uh Liver is in history of family liver disease, in history of hemochromatosis. And w some disease is a genetic disorders that uh runs in family. Social history is a very important history to ask about alcohol history. Uh In details about duration amount. Alcohol is uh one of the most common cause of current liver disease. The smoking history is always important in every patient. Smoking, always uh related to many uh comorbidities, sexual activities. Uh and uh how many partners uh uh he has and it is protective uh sexual activities or not because of the risk of the patient for the risk of hepatitis B and C. Uh Always a patient has to ask about activity of their livings, how they are living at home, whether they need family support, whether they need carers whether, whether they need working aids, it is always important part uh in history and always you should show an embassy to your patience. Um We uh now um uh start in um the examination and we'll start from begin our examination. Um You have to go step by step uh systemically in every patients. And keep in mind that you are looking for a feature of chronic liver disease, feature of the causes of chronic liver disease and features of complication of chronic liver disease. Your examination, how is the patient generally look? Uh they look well, they look pale, they look edematous, they look emaciated. Um They even some patients, you could see how they be on these patients. You see their skin is is is is deeply BP and most of the patients with chronic liver disease will have low blood pressures. Uh pulse, you examine the pulse in details rate. Uh what is it is uh r what is as it, whether it is equal is it collapse pulse? Uh How is the preferred position? R? Um usually the patients with chronic liver disease, they have hypothalamic circulation, you will have bounding bones and you will have collapsing bones. Uh respiratory rate. How is your oxygen saturation? How is it to temperature and if it is high, keep sepsis in your mind and especially uh when you are facing patients with coronary liver disease and especially if they have asti you have to be careful while assessing them, you have to pick up if there is any signs of spontaneous bacterial perit. And uh it is the first things that will have to come to your mind when you are assessing uh those patients examination of the eye looks. So for the jaundice, we look for the type for the P we look for dens, dens Asma since he has respond to hyperlipidemia which is related to the uh not fail. Uh you have to look for the GVP this KVP. And if there is any evidence of uh right side heart failure, lymphadenopathy, um we go to the hands. Flan tumor is a very important uh sign in chronic liver disease to identify patients with hepatic encephalopathy. You have to ask the patient to stretch their arms, spread your fingers and fingers backward for a few minutes. You will see their fingers coming down. It is very important signs of a hepatic uh in uh patients with hepatic uh encephalopathy and is also in also patients with metabolic op like patients with zero keil, for example, um fingers, clubbing, heart is very important sign for chronic diseases and malignancies and cor uh cor liver disease, particularly leukonychia and it a whitening of the uh fingers and caused by hyperpnea that uh hypo that associated with chronic liver disease. Uh palmer Ermin, that is a sign of one of the signs of the hypothalamic circulation is very common in, in uh uh chronic liver disease. Patients PLO du between contractures, this fibrosis and contracture of the palmar fascia. And it's very common alcoholic and alcoholic uh liver patients. And it's pathognomic uh to alcoholic liver patients. It could happen also uh in trauma patients. But in the context of the colonic liver disease, uh it's pointing to alcoholic uh liver cirrhosis. At the end of this exam, I have to use a use slides for what each sign for the arms and just for wall to look for is uh signs of spider in the eye. It is small dilated arterial. It's most likely related to the uh excess estrogen in our body. In current liver disease. Uh the the body will uh elimination of uh hormones like that. Estrogen should be less for that. Uh This is lead to uh spider I and genu in male patients. Uh you have to get suppressed for the gynecomastia but it suppressed. Um then you have to look for the aha signs like AROS is ne cancer. It is very common patient. This signs in patients with uh uh metabolic disorders and uh you know, like a whole fatty liver disease. Uh it is a darkness of skin and skin folds at the sites of the cans is negative cause most likely the ax and the back of the neck. It's very important to look for the lower uh lim for uh mainly for the be uh edema. This is signs for the examination of flapping tremors. You ask the patient to stretch their hands, spread their fingers and you will see their uh fingers and uh their arms is, is down and moving. Uh These are very important signs of uh ga uh alcoholic, uh oh, sorry of uh hepatic encephalopathy, finger coughing. Uh, the dorsal aspect of two fingers side by side with the nail, touching each other. Normally you'll be s you'll see like a tight shaped gap. And if not this, confirm a flopping Liping could disease in many other disorders. Uh patients bronch disease, patient with se lung disease, lung abscess and patients with coric liver disease as well. This is also slides for uh examination of AIS or uh the flapping li uh tumors. Again, you will ask the patient to spread your arms, spread your fingers, few minutes, you see your hands flapping down. Leukonychia is one of the common signs in chronic liver disease related due to low albumin and low protein. Its white mails spider in the eye or a spider angiomata, spider ectasia is also the same uh other name for the spider nebi spa bit more clear in this patient makes in the abdomen, palmer erma. I can through this negative ones. One of the features of metabolic uh syndromes, patients with type two diabetes, patient with obesity, patients with dyslipidemia and um associated with non alcohol, fatty liver disease or non alcohol history of hepatitis. Then we go to uh systemic examination. You have to inspect your abdomen, uh looking for uh any evidence of ascites, abdomen distended, these 12 flanks and the umbilicus is everted in the main in the patients with massive ascites. We have to look for the signs of other signs of coral liver disease in the case for like the dilated vein. So I and patients uh sometimes you will see patients with um who who, who underwent multiple uh acetic uh paracentesis, you sign scarring signs or the paracentesis, signs superficial palpation and the palpation. You have the squat by the sides of the bed. So the patient abdomen at your eye level, as a patient, if they have any pain and examine the painful area in the last area as the last area superficial. But patient, while watching the patient face to illicit tenderness, elicit the bound tenderness and gardening. This is in every abdomen examination and you could elicit also ASIS sometimes if the patient has massive oitis de palpation is usually detects organs, liver spleen and kidneys, lymph nodes, liver, in most patients of chronic liver disease is not palpable except patients with um non fatty liver disease. Sometimes they may have hepatic moly uh so liver, maybe we need to check for the liver spine. While before the rec discuss, um spleen is usually in large a question of o um while while we're performing discussion, uh uh examination of liver disease, uh it's very important to perform uh shifting the less and also to be because for the liver spa shifting dullness, you have to be because surgery um too laterally until you feel appreciate the dullness. So keep your fingers at the dull spots and ask the patient to lean on to opposite side. If the dumbness was followed, this now will be moved by gravity. Uh The previous numbness area now is re this is uh one of the confirmatory uh signs of citi um as I mentioned before, you have to work as well for the liver span. Uh liver visualization can liver disease patients percussion site will be in the me clavicular line starting uh from lower uh chest wall and going up and identify the liver upper border under the image of uh the liver sizes, liver size is usually 7 to 10 centimeters normally. Um Don't forget to continue systemic examination, looking for signs of either signs of chronic liver disease or signs of complication of liver disease. Uh Don't forget also to perform rectal examination and to look for the testicular atrophy dissipation of arthritis is dilated veins probably spider nea as well. This is. Well, how to for me how to perform mada, she been the less Uber center, truly appreciate the dullness to the patient to lie up in the opposite side, then you will be gas again. And if this re results, this is a positive show skin dullness and most likely this patient has citi thank you very much for approaching the end of the uh election? Thank you very much doctor. Does anyone have any questions for the doctor? So there's a question a why is that testicular atrophy in CLD, as I mentioned before that uh the patients with chronic liver disease, uh they usually, they have a problem in i uh secretions of their uh hormones and ands which will make a lot of an uh disturbance. This main is the reason for the testicular atrophy. Um Thank you doctor. If anyone has any other questions, please put it in the chat. Raise your hand and meet yourself and then feel free to ask the doctor. In the meantime, can you fill out the feedback form, please? It's really appreciated. Um I think doctor um there's another que another question in the chat. Is there an increased circulation estrogen in cld to be deduce elimination of gens. There is the reason why uh they will have uh like uh gas region in their bodies and they will have signs like uh spider media and signs like GMA and testicular atrophy. Um There's another question, immuno chroma chromatosis is associated with hemochromatosis is a genetic disorder that are associated with excessive protein. I uh iron deposition in the bodies. Uh it, it deposits in the liver and cause a chronic liver disease. It also, it could cause uh multiple endocrine problems like diabetes like uh hypoadrenalism. And in some patients even Hypotears and they also have uh signs of arthropathy. Most likely like uh pseudogout arthropathy, a transient family is autosomal abdominal disorders as much as I know. But I think it's, it's more do on this whole life. Ok. I think there's no more questions left doctor. Thank you very much for the lecture. Um Really appreciate it. Thank you everyone for attending and I hope you have a lovely day, rest of the evening or morning where it can I have everyone to fill out? The form is, is very crucial for us to continue. And um thank you very much, doctor again. Thank you very much and thank you everyone. You too, have a lovely evening. You too. Good bye bye bye.