Acute liver failure physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Acute liver failure}} | {{Acute liver failure}} | ||
{{CMG}} {{AE}} | {{CMG}} {{AE}} {{HS}} | ||
==Overview== | ==Overview== | ||
Patients with acute liver failure may appear [[lethargic]], [[Anorexia|anorexic]] and [[fatigue]]. In the initial stages of acute liver failure, the patient may have mild mental status changes such as altered sleep pattern but may become confused or develop [[coma]] in the later stages as the disease progresses. Physical examination of acute liver failure is remarkable for [[hepatomegaly]], right upper quadrant [[abdominal tenderness]], [[ascites]] and [[encephalopathy]]. | |||
==Physical Examination== | ==Physical Examination== | ||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
* Patient with acute liver failure may be appearing | * Patient with acute liver failure may be appearing ill and [[Lethargic|lethargic.]]<ref name="pmid18462374">{{cite journal| author=Mochida S, Nakayama N, Matsui A, Nagoshi S, Fujiwara K| title=Re-evaluation of the Guideline published by the Acute Liver Failure Study Group of Japan in 1996 to determine the indications of liver transplantation in patients with fulminant hepatitis. | journal=Hepatol Res | year= 2008 | volume= 38 | issue= 10 | pages= 970-9 | pmid=18462374 | doi=10.1111/j.1872-034X.2008.00368.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462374 }} </ref><ref name="pmid23013075">{{cite journal| author=Hoofnagle JH, Nelson KE, Purcell RH| title=Hepatitis E. | journal=N Engl J Med | year= 2012 | volume= 367 | issue= 13 | pages= 1237-44 | pmid=23013075 | doi=10.1056/NEJMra1204512 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23013075 }} </ref> | ||
* The patients with acute liver failure with mild mental status changes such as altered sleep pattern at initial stages may become confused or develop a comatose condition in the later stage. | * The patients with acute liver failure with mild mental status changes such as altered sleep pattern at initial stages may become confused or develop a [[comatose]] condition in the later stage. | ||
===Vital Signs=== | ===Vital Signs=== | ||
*Low-grade fever if the acute liver is due to viral infection. | *[[Low-grade fever]] if the acute liver failure is due to [[viral infection]]. | ||
*[[Hypothermia]] / hyperthermia may be present | *[[Hypothermia]] / [[hyperthermia]] may be present. | ||
*[[Tachycardia]] may be present in shock liver | *[[Tachycardia]] may be present in shock [[liver]]. | ||
*Low blood pressure may be present in shock liver. | *[[Low blood pressure]] may be present in shock [[liver]]. | ||
===Skin=== | ===Skin=== | ||
*[[Jaundice]] | *[[Jaundice]] | ||
* Vesicular skin lesions can be seen if the acute liver failure is due to herpes simplex infection. | * Vesicular skin lesions can be seen if the acute liver failure is due to [[herpes simplex infection]]. | ||
* Signs of [[easy bruising]]. | |||
===HEENT=== | ===HEENT=== | ||
* Icteric sclera | * [[Sclera|Icteric sclera]] | ||
* If the acute liver failure causes cerebral edema, the ophthalmoscopic exam may reveal papilloedema. | * If the acute liver failure causes [[cerebral edema]], the ophthalmoscopic exam may reveal [[papilloedema]]. | ||
* Pupillary changes can also be seen with increased intracranial pressure. In grade I encephalopathy, the | * Pupillary changes can also be seen with increased [[intracranial pressure]]. In grade I [[encephalopathy]], the [[pupil]] may have a normal response. In grade II to III [[encephalopathy]], the [[pupil]] can be hyperresponsive. In grade III to IV [[encephalopathy]], the pupil begin to respond slowly. | ||
===Neck=== | ===Neck=== | ||
Not significant | Not significant | ||
===Lungs=== | ===Lungs=== | ||
Not significant | |||
===Heart=== | ===Heart=== | ||
Not significant | |||
===Abdomen=== | ===Abdomen=== | ||
*[[Abdominal distention]] due to ascites | *[[Abdominal distention]] due to ascites | ||
* Diffuse abdominal tenderness. | * Diffuse [[Abdominal tenderness|abdominal tenderness.]] | ||
*[[Abdominal tenderness]] in the right upper abdominal quadrant. | *[[Abdominal tenderness]] in the right upper abdominal quadrant. | ||
*[[Hepatomegaly]] | *[[Hepatomegaly]] | ||
===Back=== | ===Back=== | ||
Not significant | |||
===Genitourinary=== | ===Genitourinary=== | ||
Not significant | |||
===Extremities=== | ===Extremities=== | ||
The extremities may have signs of easy bleeding due to [[coagulopathy]]. | |||
===Neuromuscular=== | ===Neuromuscular=== | ||
*[[Hepatic encephalopathy]] is included in the diagnostic criteria of acute liver failure. The findings in [[hepatic encephalopathy]] varies from subtle mental status changes to [[coma]]. | |||
*The presence of [[hepatic encephalopathy]] is one of the defining characteristics of acute liver failure. Findings in patients with [[hepatic encephalopathy]] are variable, ranging from changes in behavior to [[coma]]. | |||
====Grades of Hepatic Encephalopathy==== | |||
Based on their clinical manifestation, different grades of [[hepatic encephalopathy]] are defined as:<ref name="Conn-1977">{{Cite journal | last1 = Conn | first1 = HO. | last2 = Leevy | first2 = CM. | last3 = Vlahcevic | first3 = ZR. | last4 = Rodgers | first4 = JB. | last5 = Maddrey | first5 = WC. | last6 = Seeff | first6 = L. | last7 = Levy | first7 = LL. | title = Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. | journal = Gastroenterology | volume = 72 | issue = 4 Pt 1 | pages = 573-83 | year = 1977 | doi = | PMID = 14049 }}</ref> | |||
*'''Grade I''' | |||
::Grade I [[encephalopathy]] manifests with changes in behavior and minimal changes in the level of [[consciousness]]. | |||
*'''Grade II''' | |||
Based on their clinical manifestation, different grades of [[hepatic encephalopathy]] are defined as:<ref name="Conn-1977">{{Cite journal | last1 = Conn | first1 = HO. | last2 = Leevy | first2 = CM. | last3 = Vlahcevic | first3 = ZR. | last4 = Rodgers | first4 = JB. | last5 = Maddrey | first5 = WC. | last6 = Seeff | first6 = L. | last7 = Levy | first7 = LL. | title = Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. | journal = Gastroenterology | volume = 72 | issue = 4 Pt 1 | pages = 573-83 | ::Grade II [[encephalopathy]] manifests with inappropriate behavior, gross disorientation, [[drowsiness]], and possibly [[asterixis]]. | ||
'''Grade I''' | *'''Grade III''' | ||
Grade I encephalopathy manifests with changes in behavior and minimal changes in the level of consciousness. | ::Grade III [[encephalopathy]] manifests with marked [[confusion]], incoherent speech, and mostly sleeping but arousable to vocal stimuli. | ||
'''Grade II''' | *'''Grade IV''' | ||
Grade II encephalopathy manifests with inappropriate behavior, gross disorientation, drowsiness, and possibly asterixis. | ::Grade III [[encephalopathy]] manifests with [[comatose]], unresponsive to pain, and [[Decorticate posturing|decorticate]] or [[decerebrate]] posturing. | ||
'''Grade III''' | |||
Grade III encephalopathy manifests with marked confusion, incoherent speech, and mostly sleeping but arousable to vocal stimuli. | |||
'''Grade IV''' | |||
Grade III encephalopathy manifests with comatose, unresponsive to pain, and decorticate or decerebrate posturing. | |||
==References== | ==References== | ||
Latest revision as of 21:00, 18 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]
Overview
Patients with acute liver failure may appear lethargic, anorexic and fatigue. In the initial stages of acute liver failure, the patient may have mild mental status changes such as altered sleep pattern but may become confused or develop coma in the later stages as the disease progresses. Physical examination of acute liver failure is remarkable for hepatomegaly, right upper quadrant abdominal tenderness, ascites and encephalopathy.
Physical Examination
Appearance of the Patient
- Patient with acute liver failure may be appearing ill and lethargic.[1][2]
- The patients with acute liver failure with mild mental status changes such as altered sleep pattern at initial stages may become confused or develop a comatose condition in the later stage.
Vital Signs
- Low-grade fever if the acute liver failure is due to viral infection.
- Hypothermia / hyperthermia may be present.
- Tachycardia may be present in shock liver.
- Low blood pressure may be present in shock liver.
Skin
- Jaundice
- Vesicular skin lesions can be seen if the acute liver failure is due to herpes simplex infection.
- Signs of easy bruising.
HEENT
- Icteric sclera
- If the acute liver failure causes cerebral edema, the ophthalmoscopic exam may reveal papilloedema.
- Pupillary changes can also be seen with increased intracranial pressure. In grade I encephalopathy, the pupil may have a normal response. In grade II to III encephalopathy, the pupil can be hyperresponsive. In grade III to IV encephalopathy, the pupil begin to respond slowly.
Neck
Not significant
Lungs
Not significant
Heart
Not significant
Abdomen
- Abdominal distention due to ascites
- Diffuse abdominal tenderness.
- Abdominal tenderness in the right upper abdominal quadrant.
- Hepatomegaly
Back
Not significant
Genitourinary
Not significant
Extremities
The extremities may have signs of easy bleeding due to coagulopathy.
Neuromuscular
- Hepatic encephalopathy is included in the diagnostic criteria of acute liver failure. The findings in hepatic encephalopathy varies from subtle mental status changes to coma.
- The presence of hepatic encephalopathy is one of the defining characteristics of acute liver failure. Findings in patients with hepatic encephalopathy are variable, ranging from changes in behavior to coma.
Grades of Hepatic Encephalopathy
Based on their clinical manifestation, different grades of hepatic encephalopathy are defined as:[3]
- Grade I
- Grade I encephalopathy manifests with changes in behavior and minimal changes in the level of consciousness.
- Grade II
- Grade II encephalopathy manifests with inappropriate behavior, gross disorientation, drowsiness, and possibly asterixis.
- Grade III
- Grade III encephalopathy manifests with marked confusion, incoherent speech, and mostly sleeping but arousable to vocal stimuli.
- Grade IV
- Grade III encephalopathy manifests with comatose, unresponsive to pain, and decorticate or decerebrate posturing.
References
- ↑ Mochida S, Nakayama N, Matsui A, Nagoshi S, Fujiwara K (2008). "Re-evaluation of the Guideline published by the Acute Liver Failure Study Group of Japan in 1996 to determine the indications of liver transplantation in patients with fulminant hepatitis". Hepatol Res. 38 (10): 970–9. doi:10.1111/j.1872-034X.2008.00368.x. PMID 18462374.
- ↑ Hoofnagle JH, Nelson KE, Purcell RH (2012). "Hepatitis E." N Engl J Med. 367 (13): 1237–44. doi:10.1056/NEJMra1204512. PMID 23013075.
- ↑ Conn, HO.; Leevy, CM.; Vlahcevic, ZR.; Rodgers, JB.; Maddrey, WC.; Seeff, L.; Levy, LL. (1977). "Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial". Gastroenterology. 72 (4 Pt 1): 573–83. PMID 14049.