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Approach

• Expose patient
• Begin at the hands

1. Inspect
   • Peripheral stigmata of chronic liver disease
   • Hands
     1. Digital clubbing - Cirrhosis, IBD
     2. Leukonychia - liver disease, fungal infection, hypoalbuminaemia
     3. Terry's lines - white nails with pink tips seen in cirrhosis
     4. Palmar erythema - vasodilation due to non-metabolised oestrogens
     5. Duputyren's contrature
     6. Live flap
   • Arms / trunk
     1. Spider naevi
     2. Tattoos - risk factor for HBV, HCV
     3. Scratch marks - icterus, post hepatic jaundice
     4. Gynaecomastia
   • Face / neck
     1. Pale conjunctivae
     2. Yellow sclera
     3. Hepatic fetor
     4. Palpate supraclavicular fossa
   • Abdomen
     1. Swelling due to ascities
     2. Fullness inRUQ
     3. Distended abdominal veins - occur in portal hypertension (caput medusae)
2. Palpate
   • Palpate in RIF, ask patient to breathe in and out to detect the liver edge coming down on inspiration
   • Define distance in fingerbreadths from costal margin at which liver edge appears
   • Palpate edge of liver again noting presence of nodules / firm or smooth
3. Percuss
   • Percuss edge of liver beginning at top of right hemithorax; usually at level of 5th rib
4. Auscultate
   • Bruit heard in HCC / alcoholic hepatitis / carcinoma
   • Venous hum: associated with portal hypertension
5. Check spleen
6. Check for ascities

Causes of hepatomegaly

1. Physiological
   • Reidel's lobe
   • Hyperexpanded chest
2. Infections
   • Bacterial - TB, liver abscess
   • Viral - EBV, CMV
   • Protozoal - malaria, histoplasmosis, amoebiasis, hydatid, schistosomiasis
3. ALD
   • Fatty liver
   • Cirrhosis
4. Metabolic
   • Wilson's disease
   • Haemochromatosis
   • Infiltration - amyloid
5. Malignant
   • Primary / secondary solid tumours
   • Lymphoma
   • Leukaemia
6. Congestive cardiac
   • Right heart failure
   • Tricuspid regurgitation (pulsatile liver)
   • Budd-Chiari syndrome

Completion

• Complete abdominal examination
• Check peripheral and sacral oedema

Investigations

1. Blood tests
   • FBC - raised WCC in infection
   • LFTs - albumin, evidence of hepatic dysfunction
   • Clotting - functional hepatic impairment
   • CRP - increased in infection
2. Radiological investigations
   • USS: define liver architecture, idea/size of liver
   • Contrast-enhanced CT

Portal hypertension

1. Portal pressure > 10mmHg (normal is 5-10mmHg)
2. Portal blood flow through liver greatly reduced or even reversed in most severe cases
3. Causes:
   • Extrahepatic - increased resistance to flow: portal / splenic vein thrombosis
   • Intrahepatic - cirrhosis, RH failure, sarcoid, schistosomiasis - ova of parasite colonise and obstruct portal venules