OSCE-Aid Presents:

Hepatology in the abdominal

OSCE

Chronic liver disease

Ascites

Hepatomegaly

Splenomegaly

Hepato-splenomegaly

Renal – covered in another lecture today

Chronic liver disease (CLD)

This is common and it is easy for the examiners to

bring a patient with CLD to your exam.

Once you have established the diagnosis (often a

‘spot’ diagnosis!) you need to consider what may be

the cause.

The peripheral signs will help you work this out.

CLD - signs

From the end of the bed –

• Cachexia

• Abdominal distension

• Bruising

• Ascitic drain

• Jaundice

• Reduced body hair in males

• Tattoos

• Track marks

CLD - signs

In the hands -

• Palmar erythema

• Dupuytren’s contracture

• Liver flap

• Bruising/petechiae

• Leuconychia

• Excoriation marks

• Clubbing

CLD - signs

In the face -

• Jaundice – look at the sclera carefully

• Poor dentition

• Angular stomatitis

• Enlarged parotid glands bilaterally

CLD - signs

In the chest –

• Gynaecomastia

• Reduced body hair (look in the axillae)

• Spider naevi (ensure you also examine the

upper back for these).

CLD - signs

• A cirrhotic liver is usually small and

fibrosed, but can also sometimes be

enlarged.

• Assess for shifting dullness

• Scars from previous paracentesis or liver

biopsy

• Caput medusae

Clues to aetiology of chronic

liver disease

• Alcohol – palmar erythema, Dupuytren’s, parotid enlargement,

angular stomatitis, cachexia, ascites, liver not palpable (fibrosed).

• Viral hepatitis (hepatitis B and C) – tattoos, needle track

marks.

• NAFLD – usually overweight or obese, may have needle marks on finger tips

from CBG testing if diabetic.

• Auto-immune conditions (PBC and PSC) – middle-aged women, evidence

of other auto-immune conditions such as ulcerative colitis or vitiligo.

• Metabolic conditions

– Haemochromotosis

– Wilson’s disease

Decompensation of chronic liver

disease

• Ascites

• Jaundice

• Encephalopathy

• Hepato-renal syndrome

Possible causes -

• Sepsis eg. spontaneous bacterial peritonitis

• Upper GI bleed

• Drugs – opiates

• Constipation

• Hepatocellular carcinoma

Presentation of CLD

‘These findings are consistent with a diagnosis of chronic

liver disease, and I suspect this is secondary to excess

alcohol due to the following signs…

In addition there is evidence of decompensation, with

ascites, jaundice and coagulopathy.

I would investigate further by …’

How could you grade the severity of

chronic liver disease?

How could you grade the severity of

chronic liver disease?

The Child-Pugh Score, a score based on presence

and extent of encephalopathy, ascites, INR,

bilirubin, and albumin. This gives a score which

categorises patients into one of three classes –

Class A – 1 year survival of 100%

Class B – 1 year survival of 80%

Class C – 1 year survival of 50%

How would you like to investigate this patient?

How would you like to investigate this patient?

‘I would like to do a full set of bedside

observations. I would do blood tests (FBC, U&E,

LFTs, coagulation, glucose and albumin), dip

the urine, and start a stool chart. If ascites was

present I would perform a diagnostic tap and

send the ascitic fluid for MCS, albumin, and

cytology.’

How would you like to investigate this patient?

‘I would perform a liver screen to help establish

the aetiology –

• Hepatitis B and C serology

• Haematinics – Ferritin and iron

• Copper + Caeruloplasmin

• Autoimmune profile – ANA, Anti Sm, AMA, Anti

LKM, ANCA

• AFP

How would you like to investigate this patient?

‘I would consider imaging…

• USS abdomen

• CT CAP if malignancy

• ERCP to diagnose PSC (beading

strictures)

…and a liver biopsy.’

How would you manage a patient with

chronic liver disease?

How would you manage a patient with

chronic liver disease?

Conservative management:

• Education about the disease.

• Encourage healthy lifestyle.

• MDT approach: hepatologist, GP, dietician, alcohol

liaison nurse, family.

Medical management:

• HCV is curable, HBV is treatable – treatment in a viral

hepatology specialist clinic with anti-viral

medications, such as ribavirin and an interferon.

• Venesection for haemochromatosis

• Ursodeoxycholic acid for PBC

• Penicillamine in Wilson’s

• Immunosuppressive drugs for autoimmune disease

Surgical management:

• Liver transplantation

Causes of ascites

Cirrhosis (80%)

Cancer

Congestive cardiac failure

Hepatomegaly - causes

Cirrhosis

Cancer

Congestive cardiac failure

Immunological conditions – PBS, PSC.

Infection – hepatitis

Infiltrative conditions – amyloid

“There is a palpable mass in the RUQ which moves down with

respiration, is dull to percussion, and I am unable to get above.”

Splenomegaly

‘There is a smooth palpable mass in the LUQ which is dull

to percussion and moves towards the RLQ on inspiration. It

is not ballotable.’

What are the possible causes?

Splenomegaly - causes

• Infection – EBV / infective endocarditis / malaria

• Haematological - CML / myelofibrosis / lymphoma

• Portal hypertension – commonly secondary to CLD

• Rheumatological - Felty’s syndrome

• Other rarer causes (probably best not mentioned…)

– sarcoid / amyloid

Splenomegaly - causes

• Elderly gentleman with conjunctival pallor and

lymphadenopathy?

• Patient who has recently returned from holiday in

Tanzania?

• Patient with signs of chronic liver disease?

• Middle aged lady with a symmetrical, deforming,

poly-arthropathy of the hands?

Splenomegaly - causes

• Elderly gentleman with conjunctival pallor and

lymphadenopathy? CML

• Patient who has recently returned from holiday in

Tanzania? Malaria

• Patient with signs of chronic liver disease? Portal

hypertension

• Middle aged lady with a symmetrical, deforming,

poly-arthropathy of the hands? Splenomegaly

associated with rheumatoid arthritis.

Presentation of splenomegaly

‘This gentleman has a large mass palpable in the

LUQ, which extends towards the RLQ, consistent with

massive splenomegaly. In addition he is cachectic,

there is conjunctival pallor, and significant

lymphadenopathy in the cervical and supra-clavicular

regions. Taking all this into account, I think the most

likely diagnosis is chronic myeloid leukaemia, but my

differential includes…’

How would you like to investigate this

patient?

Investigations to diagnose splenomegaly would include:

• USS spleen

• CT abdomen

Investigations to diagnose underlying cause of splenomegaly:

• FBC, LFTs + blood film (thick and thin)

• Viral serology

• Bone marrow biopsy

• Lymph node biopsy

• Genetic analysis (Ph. Chromosome, JAK2 mutations).

Hepato-splenomegaly - causes

• Infection

• Myelo- and lympho-proliferative

disorders

• Cirrhosis with portal hypertension.

Chronic liver disease

Ascites

Hepatomegaly

Splenomegaly

Hepato-splenomegaly

Renal – covered in another lecture today

Written by: Dr Clare Price

Edited by: Dr Celine Lakra

Hosted by: OSCE-Aid