Some random things about Chronic Liver Disease

Q1 : What to look for in chronic liver disease during PE ?

Signs of hepatic failure
- Jaundice ( skin + sclera + mucous membrane, conjugated + unconjugated bilirubin ) + scratch marks
- Hepatomegaly ( due to extramedullary haemopoiesis)
- Anaemia
- Purpura (coagulopathy - factor II, VII, IX & X)
- hypoalbuminaemia -> Ankle edema, +\- ascites, nail changes (Leukonychia, Muehrcke's Line), oedema
- Finger clubbing

Signs of hyperestrinism (Hyper-estrogen-ism) - because liver cannot breakdown estrogen and cannot synthesize estrogen binding protein
- Spider Naevi
- Pectoral alopecia
- Female : Breast atrophy (dun ask me, tak tahu kenapa. xD)
- Male : Gynecomastia, Altered Pubic hair distribution, testicular atrophy
- Loss of axillary hair
- Palmar Erythema

Signs of decompensated liver disease (Portal Hypertension)
- Hypersplenism -> splenomegaly, Pancytopenia -> Pallor conjunctiva
- Caput medusae (blood flow towards the legs, must differentiate from visible veins due to IVC/SVC obstruction)
- Ascites
- Venous Hum
- Esophageal varices -> Pallor conjunctiva

Causes of Chronic Liver disease
- Hepatitis -> tattoo, IVDU needle injection scar, tender liver
- Alcoholism -> Dupuytren's contracture, parotid swelling
- Haemochromatosis -> Hyperpigmentation of the skin
- Thalassemia -> Desferrioxamine infusion pump, thalassemia facies, laparotomy scar, slate-gray hyperpigmentation of skin, stunted growth (Chronic liver failure is a sign of iron overload in Thalassemia)
- Wilson's disease -> Kayser-Fleischer Ring
- Hepatocellular Carcinoma -> Liver bruit/rub, firm and irregular liver on palpation

Complications of chronic liver disease
- Hepatic encephalopathy -> drowsiness, confusion, asterixis, constructional apraxia (Ask patient to draw a 5 point star, see picture)
- Spontaneous Bacterial Peritonitis -> reduced bowel sound

Q2 : Why anemia happens in Chronic Liver disease ?
- Hypersplenism
- Anemia of chronic liver disease
- Poor nutrition due to chronic illness
- Oesophageal Varices

Q3 : Why Spironolactone is the diuretic of choice in decompensated chronic liver disease with portal hypertension & ascites ?
- Because spironolactone has aldosterone antagonist activity
- In chronic liver disease, liver cannot metabolize aldosterone -> Hyperaldosteronism
- Might further precipitate oedema & ascite -> very bahaya

Q4 : Which electrolytes imbalance can cause confusion ?
- ONLY Sodium, Urea & calcium !!!

Q5 : How to quantify alcohol intake per week ?
- Male should consume less than 21 unit
- Female less than 14 unit
- 1 can of beer = 1 unit
- 1 shot of whiskey = 1 unit
- 1 serving of wine (half glass) = 1 unit

Q6 : List out clinical signs of alcoholism
- Peripheral neuropathy
- Proximal myopathy
- Beri-beri heart (CCF) - due to thiamine deficiency
- Cerebellar signs (ataxia)
- Wernicke's encephalopathy -> CNVI palsy (lateral rectus)
- Korsarkoff's psychosis -> Amnesia, confabulation

Q7 : Patient has G6PD, how can you see from investigations/signs that patient is having haemolysis of RBC right now ?
- Serum haptoglobulin decrease
- LDH high
- Reticulocyte high
- Normocytic initially, might be macrocytic later (MCV high)
- Dark Urine

Sources :
-Ward rounds and teaching with Dr. Paras. Thank you Dr Paras, we love you and we will miss you. >.<
- Prof Izham's Short case & you
- Oxford Handbook
- Burton Aids
- Netter's clinical anatomy

by Alvis
Please correct me if I am wrong, or if there are any uncertainties, thanks.