PHYSICAL FINDINGS SUGGESTIVE OF CIRRHOSIS
Cirrhosis represents the final common histologic pathway for a wide variety of chronic liver diseases. The term cirrhosis was first introduced by Laennec in 1826.
In patients with chronic diseases of the liver, fibrosis (scarring) of the liver often occurs. When the scarring becomes advanced, the condition is called cirrhosis of the liver. There are many causes of cirrhosis. Disease, drug use, infection, heavy alcoholic drinking, exposure to certain toxins, and blocked bile ducts can cause damage to the liver and lead to cirrhosis. Among the known causes of this condition, chronic alcoholism and Hepatitis C are the most common in the United States .
A person can have cirrhosis without immediately exhibiting symptoms of the condition. Over time, however, healthy cells are replaced with scar tissue and liver function is reduced. As liver function begins to fail, symptoms of exhaustion, loss of appetite, nausea, and weight loss may become evident. The affected individual may also experience weakness, abdominal pain, gynecomastia (enlarged breasts), and shrinkage of the testicles (testicular atrophy) and spider-like blood vessels on the skin.
As cirrhosis progresses, complications may develop. These complications may include edema, ascites, bruising, bleeding, jaundice, itching, and gallstones. Other complications can include toxins in the blood or brain, medication sensitivity, portal hypertension, varices, insulin resistance, type 2 diabetes, and liver cancer. Additionally, a person with cirrhosis may develop problems with other organs. .
What Tests Are Used To Diagnose Cirrhosis ?
. . Laboratory tests
Your blood is checked for certain enzymes and excess bilirubin, a substance that may indicate liver damage.
Magnetic resonance elastography (MRE).
. This noninvasive advanced imaging test, detects hardening of the liver.
*A Mayo study found MRE to be more accurate than liver biopsy for diagnosing cirrhosis
CT, MRI, Ultrasound .
A tissue sample (biopsy) may be taken to identify the severity and extent of liver damage. .
Are there actually some physical clues that suggest that you have cirrhosis? .
The answer to this question is yes.
The following is a list of clues that indicate that you may already have cirrhosis. These are listed alphabetically by their common medical name. It is important to remember that, although helpful, each of these physical manifestations do not indicate the actual cause of one's liver disease, and, in fact, are not specific only to liver disease. They can be due to other disorders as well.
Extend the arms, spread the fingers, dorsiflex the wrist and observe for the abnormal “flapping” tremor at the wrist. If not immediately apparent, this tremor may be accentuated by asking the patient to keep the arms straight while the examiner gently hyperextends the patient’s wrist with a sweeping motion
"Bilateral Asterixis": Metabolic encephalopathies, especially hepatic and renal, are the most common causes of bilateral asterixis. Those caused specifically by hepatic failure are known as “liver (or hepatic) flap”.
Other causes of asterixis include cardiac and respiratory disease, electrolyte abnormalities and drug intoxication. Electrolyte abnormalities known to cause asterixis include hypoglycaemia, hypokalaemia and hypomagnesaemia. Drug intoxications include barbiturate intoxication, alcoholism, phenytoin intoxication (“phenytoin flap”) and primidone intoxication. Wilson’s disease and focal brain lesions in the rostral midbrain tegmentum may also cause asterixis.
.Enlarged blood vessels that snake out from the belly button in a patient with ascites. The term Caput Medusae describes the appearance of distended and engorged umbilical veins which are seen radiating from the umbilicus across the abdomen to join systemic veins. It is a sign of severe portal hypertension with portal-systemic shunting through the umbilical veins. The name originates from the apparent similarity to Medusa's hair once Minerva had turned it into snakes.
Edema is caused by either systemic diseases, that is, diseases that affect the various organ systems of the body, or by local conditions involving just the affected extremities. The most common systemic diseases associated with edema involve the heart, liver, and kidneys. In these diseases, edema occurs primarily because of the body's retention of too much salt (sodium chloride). The excess salt causes the body to retain water. This water then leaks into the interstitial tissue spaces, where it appears as edema.
Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema. Any form of pressure, such as from the elastic in socks, can induce pitting with this type of edema.
Peripheral edema, which is usually seen as pitting edema of the legs and feet, also occurs in cirrhosis. The edema is a consequence of the hypoalbuminemia and activation of the renin-angiotensin- aldosterone hormonal system, which prompt the kidneys to retain salt and water. The presence or absence of edema in patients with cirrhosis and ascites is an important consideration in the treatment of the ascites.
In patients with ascites without edema, diuretics must be given with extra caution. The reason for this is that a diuresis (induced increased volume of urine) that is too depleting or rapid in these patients can lead to a low blood volume (hypovolemia), which can possibly be followed by kidney and liver failure. .
In contrast, when patients who have both edema and ascites undergo diuresis, the edema fluid in the interstitial space serves as somewhat of a buffer against the development of low blood volume. The excess interstitial fluid moves into the blood vessel saces to rapidly replenish the depleted blood volume
.ENCEPHALOPATHY An altered mental status leading to coma. Can be treated with animal protein restriction and a poorly absorbed sugar called Lactulose.
Hepatic encephalopathy is caused by disorders that affect the liver. These include disorders that reduce liver function (such as cirrhosis or hepatitis) and conditions in which blood circulation does not enter the liver. The exact cause of hepatic encephalopathy is unknown. An important job of the liver is to change toxic substances that are either made by the body or taken into the body (such as medicines) and make them harmless. However, when the liver is damaged, these "poisons" may build up in the bloodstream.
. Ammonia, which is produced by the body when proteins are digested, is one of the harmful substances that is normally made harmless by the liver. Many other substances may also build up in the body if the liver is not working well. They can cause damage to the nervous system.
. Patients with mild and moderate hepatic encephalopathy show decreased short-term memory and concentration with testing of mental state. They may also have a flapping tremor, fetor hepaticus (a sweet musty aroma of the breath), hyperventilation and hypothermia.
.First Principles of Gastroenterology GI Textbook Hepatic Encephalopathy
.Hepatic encephalopathy (HE) is a complex, potentially reversible neuropsychiatric condition that occurs as a consequence of acute or chronic liver disease. It is characterized by changes of personality, consciousness, behavior and neuromuscular function
. . . SPIDER ANGIOMATA
Also See :Nails and Health:What Your Nails Can Tell You .
Definition Thrombocytopenia is an abnormal drop in the number of blood cells involved in forming blood clots. These cells are called platelets. ..
The normal amount of platelets is usually between 150,000 and 450,000 cells per microliter of blood. A microliter is an amount equal to one one-millionth of a liter (a liter is almost equal to a quart). Platelet numbers are counted by having a blood sample collected and placing a measured amount of blood in a machine called a cell counter. When the platelet number drops below 150,000 cells per microliter of blood, this person is said to be thrombocytopenic. Causes & symptoms Abnormal reductions in the number of platelets are caused when abnormalities occur in any of the following three processes: decreased platelet production by the bone marrow; increased trapping of platelets by the spleen; or a more rapid than normal destruction of platelets. Persons with this condition easily bruise and can have episodes of excess bleeding (a hemorrhage).
... Platelets come from megakaryocytes, which are produced in the material located within the center cavity of the bones (bone marrow). When abnormalities develop in the marrow, the marrow cells can lose their ability to produce platelets in correct amounts. The result is a lower than normal level of platelets in the blood. Drugs used in cancer chemotherapy can cause the marrow to malfunction in this way, as can the presence of tumor cells in the marrow itself. Normally, the spleen holds about one-third of the body's platelets as part of this organ's function to recycle aging or damaged red blood cells (the cells that carry oxygen in the blood). When liver disease or cancer of the spleen is present, the spleen can enlarge, resulting in a greater number of platelets staying in the organ. This condition results in abnormally low numbers of platelets in the blood.
. Platelets can breakdown in unusually high amounts in persons with abnormalities in their blood vessel walls, with blood clots, or with man-made replacement heart valves. Devices placed inside blood vessels to keep them from closing (stents) due to weakened walls or fat build-up can also cause platelets to breakdown. In addition, infections and other changes in the immune system can speed up the removal of platelets from the circulation.
. Diagnosis Thrombocytopenia is diagnosed by having a blood sample taken and counting the platelets present in the sample. However, accurately determining the medical reason for this conditions is complex.
.. Once a low platelet count is verified, a careful evaluation of the function of the bone marrow and spleen are necessary. Improper functioning of either or both of these organs can cause thrombocytopenia. In addition, the causes for the abnormal spleen or marrow function must be investigated since different cancers, blood disorders, or liver disease can be the true cause for the drop in platelets found in the blood.
. Treatment If low platelet counts are caused by an enlarged spleen, removal of the spleen can help raise the platelet level, since the spleen is no longer there to capture the platelets. However, proper treatment for what causes the enlarged spleen is necessary as well. Low platelet counts can indicate more serious conditions. If a dysfunctional immune system is found to be the cause for this condition, drugs like steroids or gamma globulin can be used to help maintain platelet levels in certain cases. If low platelet levels are due to an abnormally low level of platelet production, transfusions of platelets can be given as well.
. Prognosis Thrombocytopenia can result in fatal bleeding, but it also can indicate various other, more serious, cancers and disorders that affect the blood cells. This condition requires thorough medical evaluation.
Prevention There is no known way to prevent thrombocytopenia. ,
Key Terms to know: Gamma globulin: One of a group of proteins found in the blood that is involved in helping the body fight infections. Stent: A man-made surgical device, usually tube-shaped, that is placed into a blood vessel to keep it from closing. Transfusion: The transfer of blood from one person to another. Transfusions can be direct, in which blood is transferred from the donor to the recipient; or indirect, in which the blood is taken from the donor, stored in a container, and then given to the recipient.
.. Patients with massive ascites may experience abdominal discomfort, depressed appetite, and decreased oral intake. Diaphragmatic elevation may lead to symptoms of dyspnea. Pleural effusions may result from the passage of ascitic fluid across channels in the diaphragm. Umbilical and inguinal hernias are common in patients with moderate and massive ascites. The use of an elastic abdominal binder may protect the skin overlying a protruding umbilical hernia from maceration and may help prevent rupture and subsequent infection. Timely large-volume paracentesis also may help to prevent this disastrous complication.
.Umbilical hernias should not undergo elective repair unless patients are significantly symptomatic or their hernias are irreducible. As with all other surgeries in patients with cirrhosis, herniorrhaphy carries multiple potential risks such as intraoperative bleeding, postoperative infection, and liver failure because of anesthesia-induced reductions in hepatic blood flow. However, these risks become acceptable in patients with severe symptoms from their hernia. Urgent surgery is necessary in the patient whose hernia has been complicated by bowel incarceration.
.Esophageal varices are swollen veins in the lining of the lower esophagus near the stomach. Gastric varices are swollen veins in the lining of the stomach. The swelling of these veins is caused by liver disease. Swollen veins in the esophagus or stomach resemble the varicose veins that some people have in their legs. Because the veins in the esophagus are so close to the surface of the esophagus, swollen veins in this location can rupture and cause dangerous bleeding.
. Esophageal varices almost always occur in people who have cirrhosis of the liver. Cirrhosis causes scarring of the liver, which slows the flow of blood through the liver. Scarring causes blood to back up in the portal vein, the main vein that delivers blood from the stomach and intestines to the liver. This "back up" causes high blood pressure in the portal vein and other nearby veins, and this is called portal hypertension. The backup of blood forces veins to enlarge in the vicinity of the stomach and esophagus. Esophageal varices usually have enlarged, irregularly shaped bulbous regions (varicosities) that are interrupted by narrower regions. Because the blood pressure inside the varices is higher than inside normal blood vessels, and the walls of the vessels (and esophagus) are thin, the veins rupture easily and can bleed profusely.
. Symptoms Portal hypertension often does not cause any symptoms, and sometimes is discovered only when the varices bleed. When significant bleeding occurs, a person will vomit blood, often in large amounts. People with massive bleeding feel dizzy and may lose consciousness. Some people bleed in smaller amounts over a longer period, and they swallow the blood rather than vomit. Their stools may contain red or tarry-black blood. People with bleeding from the esophagus usually also have symptoms of cirrhosis of the liver.
.Diagnosis To diagnose esophageal varices, a doctor will use an instrument called an endoscope, a thin, flexible tube with a camera at its tip that is inserted through the mouth so the doctor can see the walls of the esophagus and search for the source of bleeding. If bleeding is occurring in the esophagus, this procedure will be done as an emergency. Tiny instruments may be attached to the endoscope to provide treatment at the same time. .
Expected Duration Bleeding from esophageal varices can stop on its own or with treatment. However, bleeding esophageal varices can be fatal, particularly in people with severe liver disease. Half or more of people who survive episodes of bleeding from esophageal varices will have the problem return during the first one to two years. The risk of recurrence can be reduced with treatment.