USMLE – Manifestations of Liver Disease
Liver disease produces a wide range of clinical manifestations. Acute liver disease is most common and jaundice is its main manifestation, usually in association with systemic features of an acute illness. Severe acute liver disease can give rise to neuropsychiatric symptoms (encephalopathy) which characterize the rare syndrome of fulminant or acute hepatic failure. Chronic liver disease causes manifestations resulting from damage to the liver itself and from portal hypertension. Fluid retention (ascites and edema) and hepatic encephalopathy are due mainly to a combination of these two processes and are features of chronic liver failure (or hepatic decompensation). The main manifestation of portal hypertension is bleeding from varices or gastropathy. In most countries the dominant cause of portal hypertension is hepatic cirrhosis, and though the underlying liver disease is always advanced, liver failure mayor may not be present.
Investigation of patients with abnormal liver function tests
The almost universal availability of automated biochemical analysis and the frequency of insurance, employment and health screening examinations have led increasingly to the identification of abnormal biochemical liver tests in asymptomatic people. While the finding of abnormal biochemical liver tests may be indicative of a severe underlying liver disease, it is important to note that chronic liver disease may be associated with normal liver function tests; hence approximately 10% of patients with cirrhosis are identified unexpectedly at laparotomy or autopsy.
Investigation of patients with abnormal liver function tests starts with a clinical history and physical examination. In particular, clinical features of jaundice, pruritus, ascites, gastrointestinal bleeding and hepatic encephalopathy are sought. Fatigue, tiredness and weakness are also common features in patients with chronic liver disease. The physical examination specifically addresses whether or not there are cutaneous manifestations of chronic liver disease such as palmar erythema, spider telangiectasia and other skin changes. Abdominal examination may reveal hepatosplenomegaly and ascites. Features of hepatic encephalopathy, such as flapping tremor (asterixis) and constructional apraxia, should be sought. In the absence of specific features in the history or physical examination, further investigation of abnormal liver function tests may suggest a cholestatic or hepatitic abnormality.