History and physical examination often suggest a cause of potential liver disorders and narrow the scope of testing for hepatic and biliary disorders.
History
Various symptoms may develop, but few are specific for liver disorders:
Common nonspecific symptoms include fatigue, anorexia, nausea, and occasionally, vomiting, particularly in severe disorders.
Loose, fatty stools (steatorrhea) can occur when cholestasis prevents sufficient bile from reaching the intestines. Patients with steatorrhea are at risk of deficiencies of fat-soluble vitamins (A, D, E, K). Common clinical consequences may include osteoporosis and bleeding.
Fever can develop in viral or alcoholic hepatitis.
Jaundice, occurring in both hepatocellular dysfunction and cholestatic disorders, is the most specific symptom. It is often accompanied by dark urine and light-colored stools.
Right upper quadrant pain due to liver disorders usually results from distention (eg, by passive venous congestion or tumor) or inflammation of the liver capsule.
Erectile dysfunction and feminization develop, usually due to imbalances in the normal estrogen/testosterone ratio, with more estrogen being present than is typical.
(See also Liver Structure and Function.)
Risk Factors for Liver Disorders
Category | Risk Factors |
|---|---|
Acquired | Alcohol use Blood transfusions (particularly before 1992)* Body piercing* Drug (prescription and nonprescription) and herbal product use Exposure to other liver toxins Exposure to hepatitis* High-risk sexual practices* Needlesticks* Parenteral or intranasal drug use* Tattoos* |
Familial | Family history of disorders such as primary biliary cholangitis, hemochromatosis, Wilson disease, alpha-1 antitrypsin deficiency, and hepatitis B (which can be vertically transmitted) |
* These factors increase risk of hepatitis in particular, as well as risk of liver disorders in general | |
Family history, social history, and drug and substance use history should note risk factors for liver disorders (see table Risk Factors for Liver Disorders ).
Physical examination
Abnormalities detectable during a physical examination usually do not develop until late in the course of liver disease. Some common findings suggest a cause (see table Interpretation of Some Physical Findings ).
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Interpretation of Some Physical Findings
Finding | Possible Causes | Comments |
|---|---|---|
Hepatic abnormalities | ||
Hepatomegaly | Passive venous congestion Liver hemorrhage (into a cyst or the parenchyma) | — |
Palpable mass | Cancer | — |
Liver firmness, irregular shape, blunt edges, and few if any individual nodules | — | |
Tenderness | Passive congestion Liver hemorrhage | Because of patient anxiety, often overdiagnosed True liver tenderness (a deep-seated ache) best elicited by percussion or compression of the rib cage Occasionally, if severe, mimics peritonitis |
Friction rubs or bruits (rare) | Tumor Hereditary hemorrhagic telangiectasia (Osler Webber Rendu) | — |
Extrahepatic abnormalities | ||
Alcoholic hepatitis if chronic or severe Peritoneal carcinomatosis Generalized fluid retention (eg, heart failure, nephrotic syndrome, hypoalbuminemia) | Typically abdominal distention, shifting dullness, and fluid wave May not be detectable if volume is < 1500 mL | |
Visibly dilated abdominal veins (caput medusae) | Inferior vena cava obstruction | — |
Splenomegaly | Nonalcoholic cirrhosis | — |
Asterixis | Uremia Heart failure if severe | Bilateral, asynchronous flapping of dorsiflexed hands with the arms outstretched |
Fetor hepaticus | Sweet, pungent smell | |
Drowsiness and confusion | Drugs Brain or systemic disorders | Nonspecific |
Wasted extremities plus protuberant abdomen with ascites (cirrhotic habitus) | Cirrhosis if advanced Cancers with peritoneal metastases if advanced | — |
Drugs Pituitary, genetic, systemic, and endocrine disorders | Testicular atrophy, erectile dysfunction, infertility, and loss of libido | |
In men, gynecomastia, loss of axillary or chest hair, and female pattern of pubic hair | Alcohol use disorder if chronic Drugs Endocrine disorders | Gynecomastia differentiated from pseudogynecomastia (in overweight men) by examination |
Gynecomastia plus testicular atrophy | Alcohol use disorder if chronic Pituitary or other endocrine disorders | — |
Pregnancy Undernutrition if severe Alcohol use disorder if chronic (possibly) | After compression, blanching with peripherally directed blood flow (to the outside of the lesion) Possibly increased risk of severe cirrhosis and variceal hemorrhage as number of angiomas increases May occur as a normal variant (usually < 3) | |
Palmar erythema | Feminization (in men) Pregnancy Hematologic cancers Alcohol use disorder if chronic (possibly) | Often most obvious on thenar and hypothenar eminences |
In patients with cirrhosis, clubbing | Possibly advanced portosystemic shunting or biliary cirrhosis Lung disorders if chronic Cyanotic heart disease Infection (eg, infective endocarditis) if chronic | — |
Hyperbilirubinemia caused by conditions such as hepatic or biliary disorders, hemolysis, use of certain drugs, or inborn errors of metabolism | Visible when bilirubin level is > 2 to 2.5 mg/dL (> 34 to 43 micromol/L) Affects sclerae (unlike carotenemia) | |
Muddy skin pigmentation, excoriations caused by constant pruritus, and xanthelasmas or xanthomas (cutaneous lipid deposits) | Cholestasis (including primary biliary cholangitis) if chronic | — |
Parotid gland enlargement | Alcohol use if chronic (often present with alcohol-associated cirrhosis) | — |
Slate gray or bronze skin | Hemochromatosis with deposition of iron and melanin | — |
Alcohol use if chronic Cigarette use Complex regional pain syndrome Repetitive motion or vibration | — | |
Testing
Testing for hepatic and biliary disorders, including blood tests, imaging, and sometimes liver biopsy, plays a prominent role in the diagnosis of liver disorders. Individual tests, particularly those of liver biochemistry and excretion, often have limited sensitivity and specificity. A combination of tests often best defines the cause and severity of disease.
