Liver Examination.pptxnnnnnmnnnnnnnnnbbb

Ggghh

1. Presenter :- D r. Trapti Singh Moderator :- D r. Pratiksha Gogia No. of slides - 30 APROACH TO EXAMINATION OF LIVER PATIENT

2. HISTORY Arthralgia , myalgia & headache Fatigue & malaise , flatulent dyspepsia,low grade fever. (Day time fatigue) Anorexia, nausea & vomiting Drowisiness, inversion sleep rhythm Weight loss & weight gain Abdomen pain melaena , haemetemesis

3. Past history - Jaundice (viral hepatitis). Drugs (rifampicin, INH, anabolic steroids, OC pills; NSAID for melaena) or any herbal remedies taken. Blood transfusion or transfusion of any blood products (viral hepatitis B or C; recent tattooing or acupuncture; drug abuse. Alcohol consumption. Tuberculosis (ascites due to tuberculous peritonitis). Haematemesis or melaena (peptic ulcer, ruptured oesophageal varix, gastric malignancy). Fever (tuberculosis, hepato-cellular failure etc). Haematochezia (lower G. I. malignancy, haemorrhoids)

4. Personal history 1.alcohol intake. Dose of alcohol consumption, type of drink, daily/weekly pattern duration. 2. The patient takes mixed Indian diet Family 3. History may be positive in Wilson’s disease.

5. Family history Similar illness in the family—acute diarrhoea, food poisoning and viral hepatitis. Genetic hepatic disorders—Wilson’s disease, haemochromatosis and alpha-antitrypsin deficiency. Familial polyposis coli, inflammatory bowel disease and carciroma of colon

6. Physical Examination A.General examination Malnutrition Anemia Jaundice Hepatic facies Oedema feet Obvious swelling abdomen K-F ring Flapping tremor Gynecomastia

7. MALNUTRITION JAUNDICE PALLOR JAUNDICE GYANECOMASTIA PALMAR ERYTHEMA

8. B. SKIN CHANGES Spider naevi Palmar erythema Diffuse pigmentation of skin White nails/leuconychia Scanty axillary & pubic hair

9. Do not confuse the diffuse yellow sclerae of jaundice with small, yellowish fat pads (pingueculae) sometimes seen at the periphery of the sclerae. Certain signs (stigmata ) suggest chronic liver disease Palmar erythema and spider naevi are caused by excess oestrogen associated with reduced hepatic breakdown of sex steroids. Spider naevi are isolated telangiectasias that characteristically fill from a central vessel and are found in the distribution of the superior vena cava (upper trunk, arms and face). Women may have up to five spider naevi in health; palmar erythema and numerous spider naevi are normal during pregnancy. In men, these signs suggest chronic liver disease. Gynaecomastia (breast enlargement in males), with loss of body hair and testicular atrophy, may occur due to reduced breakdown of oestrogens. Leuconychia , caused by hypoalbuminaemia, may also occur in protein calorie malnutrition (kwashiorkor), occur in protein calorie malnutrition (kwashiorkor),malabsorption due to protein-losing enteropathy, as in coeliac disease, or heavy and prolonged proteinuria(nephrotic syndrome).

10. Finger clubbing is found in liver cirrhosis, inflammatory bowel disease and malabsorption syndromes. Other signs : Dupuytren’s contracture of palmar fascia with alcohol-related chronic liver disease bilateral parotid swelling due to sialoadenosis: chronic alcohol abuse. asterixis : hepatic encephalopathy fetor hepaticus :with or without encephalopathy altered mental state, varying from drowsiness with the day/night pattern reversed, through confusion and disorientation, to unresponsive coma

11. C. ABDOMEN EXAMINATION Caput medusa - dilatation of centrally located veins; s/o Portal HTN Enlarged veins run longitudinally along the side of the abdomen s/o of IVC obstruction Bulging flanks may be the earliest indicator of ascites (shifting dullness). Hepatomegaly and/or splenomegaly Palpable gallbladder : caused by carcinoma of bile duct and pancreatic head cancer

12. Caput medusa Ascites

13. Anterior view and regions of Abodmen

14. Regional division of abdomen

15. Inspection Skin Shape and movements Distension Prominent Veins Straie Brusies Pigmenation

16. Palpation Edge should be soft , sharp and reqular with asmooth surface. Normal liver may be slightly tender On inspiration, liver palpable about 3cm below right costal margin in midclavicular line HOOKING METHOD

17. tenderness hepatomegaly ascitis

18. Ascitis Shifting dullness fluid th rill

19. Percussion Upper border of liver is percussed in right,midclavicular line starting at midline Resonance becomes dull as upper border of liver is reached & becomes resonant again as lower level of liver is reached total span shouldn’t be >10cm Normal liver span

20. Auscultation

21. Features of cirrohsis

22. Portal Hypertension

23. Hepatic Encephalopathy

24. Thank you..