Introduce yourself and ask permission to perform the examination.

End of the Bed

Hands

Signs in Chronic Liver Disease	Comments
Clubbing	Cirrhosis of any cause also: rarely :GI lymphoma/ coeliac disease / inflammatory bowel disease
Dupuytren’s	Ring& little finger. ½ are bilateral Fibrous thickening of skin and soft tissue causing contractureà Other causes: Diabetes/ Alcohol/ hereditary
Jaundice	Pre/ Intra /Post hepatic causes
Asterixis (Liver Flap)	Asymmetrical. Thought to be due to ammonia accumulation(Liver not metabolising properly) Key sign of hepatic encephalopathy
Pruritis and scratch marks
Xanthoma/ tendon Xanthomata	Also associated with Hypercholesterolemia
Spider Naevi	Fill from the centre, >5 in the draining of the SVC is significant
Pigmentation /palmar erythema	Bronze diabetes: Haemochromatosis
Tattoo’s	Hep B&C risk
Tremor	ETOH related/ withdrawal
Needle Tracks	Hep B&C
Muscle Wasting
Splinter Haemorrhages	(think also SBE/ Vasculitis)
Leuconychia	white nails=low protein state

Kolionychia= Iron def anaemia

Look for finger prick marks of diabetes self checking (helpful for renal)

LN (cancer/ lymphoma) esp Virchows node (gastric cancer – palpable left supraclavicular fossa)
JVP
Chest – Gynaecomastia (also marijuana/ oestrogen/ spironolactone: used to treat ascites)

Kneel at the bedside
Always inspect first including the renal angles on both sides to check for scars
Look at the patients face when you palpate
Divide the abdomen into a 3×3 grid and palpate through each quadrant superficially
If you find a mass attempt to describe it in terms of its
Size
Surface
Fixed to the skin
Shape
Mobility
Tenderness
Firmness
Resonant
Movement with respiration
Bruit

Following this in the next few pages of the guide we describe Hepatomegaly and Splenomegaly on their own or together…

Size of spleen	Causes
Massive	CML Myelofibrosis Malaria Kala-Azar Some Lymphomas Gaucher’s Disease
Large >6cm below costal margin (remembering it goes towards the RIF)	Myeloproliferative states (As above CML/ myelofibrosis) Lymphoma& Leukaemia’s (e.g. CLL)
Smaller but palpable	Loads(!) including Blood related Lymphoma Leukaemia Idiopathic thrombocytopenic purpura (ITP: bruising, treat with steroids/ rituximab/ splenectomy) Congestive Portal Hypertension from liver disease of any sort/ hepatic vein thrombosis/CCF etc Infection EBV (glandular fever) CMV,TB, Hepatitis,HIV Inflammatory Diseases Felty’s: [triad of Neutropaenia/ Rheumatoid arthritis& Splenomegaly] Amyloid (chronic disease) Lupus Sarcoidosis

A big liver and a big spleen usually represents either a

1) Lymphoproliferative disorder (Lymphoma/Leukaemia)

2) Cirrhosis and Portal Hypertension

Big Liver in Cirrhosis? I thought it shrank…

It does! But…there are some things that can make it large again e.g.

A hepatoma (advocates for screening all CLD with USS every 6 months/ Raised AFP is a common finding)
PBC
Alcoholic liver disease can still give you an enlarged (attempting to regenerate) cirrhotic liver
Secondary amyloidosis

Group	Example	Comments
Cancer	Colorectal	Only met from the liver that can be resected which can be a curative procedure: the famous Mercedes Benz scar of the 3 flap approach like the Mercedes symbol. (this scar usually signifies a liver transplant)
	Lung & others	Any Mets to LN/ other organs means the condition is inoperable
	Hepatoma	Check AFP. Occurs in cirrhotic livers due to any cause of cirrhosis. In an exam think about this if a cirrhotic liver “starts to enlarge”
Autoimmune	Primary Biliary Cirrhosis	Females: 25% have a big liver Anti mitochondrial Antibody 98ish % specific Diagnosis: Liver Biopsy
Inflammatory	Sarcoidosis	Granuloma on Biopsy
	Amyloid	“Congo red” stain
Congestive	CCF Portal Vein thrombosis	Usually give a big spleen too…
Normal	COPD	Pushed down by hyperinflation
	Reidel’s lobe	Physiological variant and this can push all the way down to the iliac crest