Professional Documents
Culture Documents
Chronic Liver Disease
Chronic Liver Disease
Prensentation
Sir, this patient has decompensated chronic liver disease with portal hypertension,
splenomegaly and ascites.
My findings include:
Presence of an enlarged spleen that is palpable 3cm from the left costal margin. It is
non-tender, firm in consistency, smooth surface, regular edge, notch border with no
splenic rub. I am unable to get above this mass. The liver is not enlarged with a span
of 12 cm in the right mid-clavicular line. The kidneys are not ballotable. There is
presence of ascites with shifting dullness and this is not associated with tenderness.
He is deeply jaundice and bruising noted on the ULs and LLs with presence of
stigmata of CLD including leukonychia, clubbing, palmar erythema, spider naevi and
gynaecomastia with loss of axillary hair. There is also presence of bilateral edema.
Complications:
He is cooperative with the examination with no flapping tremor to suggest hepatic
encephalopathy.
There are no enlarged Cx LNs and patient is not cachexic looking. There is also no
conjunctival pallor noted.
Aetiology:
I did not find any parotidomegaly, dupytren’s contracture, tattoos, surgical scars or
thrombosed veins.
Treatment:
I did not notice any abdominal tap marks but patient has sinus bradycardia, indicating
use of beta-blockers.
In summary, this patient has decompensated chronic liver disease with portal
hypertension, splenomegaly and ascites. There is presence of bruising, leukonychia,
jaundice with no evidence of hepatic encephalopathy.
B. In the local context, the most likely underlying etiology is chronic ethanol
ingestion, chronic hepatitis B and C.
C. The most likely aetiology is chronic ethanol ingestion as I notice that this patient
has presence of parotidomegaly. In view that there is also a hard irregular liver that is
palpable, it raises the possibility of an underlying mitotic lesion of the liver.
D. The most likely aetiology is
1. Primary biliary cirrhosis as she is a middle-aged lady with evidence of CLD with
pruritus, xanthelasma and generalised pigmentation.
2. Hemochromatosis as he is a middle-aged gentleman with slate-grey appearance
with presence of diabetic dermopathy. I would like to complete the examination by
examining the CVS for CMP, urine dipstick for glycosuria and for small testes
secondary to pituitary dysfunction.
3. Wilson’s disease as the patient has a short stature associated with Kayser Fleisher
rings of the eyes and tremor and chorea of the affecting the left upper limb.
4. Haemolytic anaemia (Thalassemia major/intermedius, Hereditary spherocytosis) as
the patient has a short stature associated with hyperpigmentation and thalassemic
facies with frontal bossing, flat nasal bridge and maxillary hyperplasia. I would like to
complete the examination by examining the CVS for CMP, urine dipstick for
glycosuria and for small testes secondary to pituitary dysfunction.
Questions
What is cirrhosis of the liver?
Defined pathologically
Diffuse liver abnormality
Fibrosis and abnormal regenerating nodules
When should an abdominal paracentesis be done for a patient with cirrhosis and
ascites?
Newly diagnosed to r/o SBP
Symptomatic – fever, abdominal pain, encephalopathy, GI bleed
When examining a patient with signs of chronic liver disease, think of:
Primary biliary cirrhosis
Clinical
Female middle age
CLD with pruritus, xanthelesma, generalised pigmentation,
hepatosplenomegaly
Stages
Asymmptomtic with normal LFTs (positive Abs)
Asymptomatic with abnormal LFTs
Symptomatic – lethary and pruritus
Decompensated
Commonly associated with sicca syndrome, arthralgia, Raynauds,
Sclerodactyly and Thyroid disease
Ix
Raised ALP, Anti-Mitochondrial Ab – M2 Ab, IgM
Lipids
Other tests for CLD
Histology – Granulomatous cholangitis
Mx
Symptomatic
Urosdeoxycholic acid
Cholestyramine
Fat soluble vitamins
Immunosuppression – Cyclosporin, steroids, AZA, MTX, tacrolimus,
colchicines
Liver transplant
Hemochromatosis
Clinical
Male
Slate-grey appearance, hepatomegaly
Affects
Liver – cirrhosis and cancer
Pancrease – DM
Heart failure (CMP)
Pituitary dysfunction
Pseudogout
Therefore requests
Urine dipstick, CVS examination and testicular examination
Autosomal recessive, HLA-A3, Ch 6 – HFE gene, increased Fe absorption
with tissue deposition,
Ix
Raised ferrritin, transferrin saturation and liver Bx
Mx
Non-pharmological
Avoid alcohol
Avoid shellfish as they are susceptible to Vibrio vulnificus
Venesection
Dy/Dx of generalised pigmentation
Liver – hemochromatosis in males and PBC in females
Addison’s
Uremia
Chronic debilitating conditions eg malignancy
Chronic haemolytic anaemia
Wilson’s disease
Clinical
Short stature
Eyes
KF rings - greenish yellow to golden brown pigmentation of the limbus of
the cornea due to deposition of Cu in Descemet’s membrane at 12 and 6
o’clock position. Also occurs in PBC and cryptogenic cirrhosis
Sunflower cataract
Extrapyrimidal
Tremor and chorea
Presents as difficulty writing and speaking in school
Pseudogout
Penicillamine complications
Myasthenic – ptosis
Lupus – malar rash, small hand arthritis
Urinalysis for glycosuria from proximal RTA
Autosomal recessive, Ch 13, increased Cu absorption and tissue deposition
Ix
Low serum ceruloplasmin, increased 24H urinary Cu
Liver Bx – increased Cu deposition
Mx
Penicillamine
Ulcerative Colitis
Clinical
o Skin – erythema nodosum, pyoderma gangrenosum
o Joint arthropathy – LL arthritis, AS, sacroilitis
o Aphthous ulcers
o Ocular – iritis, uveitis and episcleritis
o CLD – Cirrhosis, chronic active hepatitis, fatty liver PSC,
Cholangiocarcinoma, metastatic colorectal cancer, amyloid