hepatology in the abdominal osce · osce-aid presents: hepatology in the abdominal osce. chronic...
TRANSCRIPT
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OSCE-Aid Presents:
Hepatology in the abdominal
OSCE
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Chronic liver disease
Ascites
Hepatomegaly
Splenomegaly
Hepato-splenomegaly
Renal – covered in another lecture today
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Chronic liver disease (CLD)
This is common and it is easy for the examiners to
bring a patient with CLD to your exam.
Once you have established the diagnosis (often a
‘spot’ diagnosis!) you need to consider what may be
the cause.
The peripheral signs will help you work this out.
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CLD - signs
From the end of the bed –
• Cachexia
• Abdominal distension
• Bruising
• Ascitic drain
• Jaundice
• Reduced body hair in males
• Tattoos
• Track marks
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CLD - signs
In the hands -
• Palmar erythema
• Dupuytren’s contracture
• Liver flap
• Bruising/petechiae
• Leuconychia
• Excoriation marks
• Clubbing
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CLD - signs
In the face -
• Jaundice – look at the sclera carefully
• Poor dentition
• Angular stomatitis
• Enlarged parotid glands bilaterally
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CLD - signs
In the chest –
• Gynaecomastia
• Reduced body hair (look in the axillae)
• Spider naevi (ensure you also examine the
upper back for these).
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CLD - signs
• A cirrhotic liver is usually small and
fibrosed, but can also sometimes be
enlarged.
• Assess for shifting dullness
• Scars from previous paracentesis or liver
biopsy
• Caput medusae
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Clues to aetiology of chronic
liver disease
• Alcohol – palmar erythema, Dupuytren’s, parotid enlargement,
angular stomatitis, cachexia, ascites, liver not palpable (fibrosed).
• Viral hepatitis (hepatitis B and C) – tattoos, needle track
marks.
• NAFLD – usually overweight or obese, may have needle marks on finger tips
from CBG testing if diabetic.
• Auto-immune conditions (PBC and PSC) – middle-aged women, evidence
of other auto-immune conditions such as ulcerative colitis or vitiligo.
• Metabolic conditions
– Haemochromotosis
– Wilson’s disease
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Decompensation of chronic liver
disease
• Ascites
• Jaundice
• Encephalopathy
• Hepato-renal syndrome
Possible causes -
• Sepsis eg. spontaneous bacterial peritonitis
• Upper GI bleed
• Drugs – opiates
• Constipation
• Hepatocellular carcinoma
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Presentation of CLD
‘These findings are consistent with a diagnosis of chronic
liver disease, and I suspect this is secondary to excess
alcohol due to the following signs…
In addition there is evidence of decompensation, with
ascites, jaundice and coagulopathy.
I would investigate further by …’
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How could you grade the severity of
chronic liver disease?
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How could you grade the severity of
chronic liver disease?
The Child-Pugh Score, a score based on presence
and extent of encephalopathy, ascites, INR,
bilirubin, and albumin. This gives a score which
categorises patients into one of three classes –
Class A – 1 year survival of 100%
Class B – 1 year survival of 80%
Class C – 1 year survival of 50%
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How would you like to investigate this patient?
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How would you like to investigate this patient?
‘I would like to do a full set of bedside
observations. I would do blood tests (FBC, U&E,
LFTs, coagulation, glucose and albumin), dip
the urine, and start a stool chart. If ascites was
present I would perform a diagnostic tap and
send the ascitic fluid for MCS, albumin, and
cytology.’
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How would you like to investigate this patient?
‘I would perform a liver screen to help establish
the aetiology –
• Hepatitis B and C serology
• Haematinics – Ferritin and iron
• Copper + Caeruloplasmin
• Autoimmune profile – ANA, Anti Sm, AMA, Anti
LKM, ANCA
• AFP
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How would you like to investigate this patient?
‘I would consider imaging…
• USS abdomen
• CT CAP if malignancy
• ERCP to diagnose PSC (beading
strictures)
…and a liver biopsy.’
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How would you manage a patient with
chronic liver disease?
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How would you manage a patient with
chronic liver disease?
Conservative management:
• Education about the disease.
• Encourage healthy lifestyle.
• MDT approach: hepatologist, GP, dietician, alcohol
liaison nurse, family.
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Medical management:
• HCV is curable, HBV is treatable – treatment in a viral
hepatology specialist clinic with anti-viral
medications, such as ribavirin and an interferon.
• Venesection for haemochromatosis
• Ursodeoxycholic acid for PBC
• Penicillamine in Wilson’s
• Immunosuppressive drugs for autoimmune disease
Surgical management:
• Liver transplantation
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Causes of ascites
Cirrhosis (80%)
Cancer
Congestive cardiac failure
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Hepatomegaly - causes
Cirrhosis
Cancer
Congestive cardiac failure
Immunological conditions – PBS, PSC.
Infection – hepatitis
Infiltrative conditions – amyloid
“There is a palpable mass in the RUQ which moves down with
respiration, is dull to percussion, and I am unable to get above.”
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Splenomegaly
‘There is a smooth palpable mass in the LUQ which is dull
to percussion and moves towards the RLQ on inspiration. It
is not ballotable.’
What are the possible causes?
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Splenomegaly - causes
• Infection – EBV / infective endocarditis / malaria
• Haematological - CML / myelofibrosis / lymphoma
• Portal hypertension – commonly secondary to CLD
• Rheumatological - Felty’s syndrome
• Other rarer causes (probably best not mentioned…)
– sarcoid / amyloid
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Splenomegaly - causes
• Elderly gentleman with conjunctival pallor and
lymphadenopathy?
• Patient who has recently returned from holiday in
Tanzania?
• Patient with signs of chronic liver disease?
• Middle aged lady with a symmetrical, deforming,
poly-arthropathy of the hands?
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Splenomegaly - causes
• Elderly gentleman with conjunctival pallor and
lymphadenopathy? CML
• Patient who has recently returned from holiday in
Tanzania? Malaria
• Patient with signs of chronic liver disease? Portal
hypertension
• Middle aged lady with a symmetrical, deforming,
poly-arthropathy of the hands? Splenomegaly
associated with rheumatoid arthritis.
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Presentation of splenomegaly
‘This gentleman has a large mass palpable in the
LUQ, which extends towards the RLQ, consistent with
massive splenomegaly. In addition he is cachectic,
there is conjunctival pallor, and significant
lymphadenopathy in the cervical and supra-clavicular
regions. Taking all this into account, I think the most
likely diagnosis is chronic myeloid leukaemia, but my
differential includes…’
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How would you like to investigate this
patient?
Investigations to diagnose splenomegaly would include:
• USS spleen
• CT abdomen
Investigations to diagnose underlying cause of splenomegaly:
• FBC, LFTs + blood film (thick and thin)
• Viral serology
• Bone marrow biopsy
• Lymph node biopsy
• Genetic analysis (Ph. Chromosome, JAK2 mutations).
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Hepato-splenomegaly - causes
• Infection
• Myelo- and lympho-proliferative
disorders
• Cirrhosis with portal hypertension.
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Chronic liver disease
Ascites
Hepatomegaly
Splenomegaly
Hepato-splenomegaly
Renal – covered in another lecture today
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Written by: Dr Clare Price
Edited by: Dr Celine Lakra
Hosted by: OSCE-Aid