Cirrhosis physical examination: Difference between revisions

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{{Cirrhosis}}
{{Cirrhosis}}
{{CMG}} ; {{AE}} {{ADI}}
{{CMG}} {{AE}} {{Cherry}}


==Overview==
==Overview==


Many signs and symptoms may occur in the presence of cirrhosis or as a result of the complications of cirrhosis. Many are nonspecific and may occur in other diseases and do not necessarily point to cirrhosis. Likewise, the absence of any sign or symptom does not rule out the possibility of cirrhosis.
Patients with [[cirrhosis]] usually present with signs of [[jaundice]], [[palmar erythema]], [[Spider angioma|spider angiomata]], [[Gynecomastia|gynaecomastia]] and alteration of [[Mental status examination|mental status]] arising due to complications of [[cirrhosis]]. Abdominal examination may show signs of [[abdominal distension]], [[caput medusae]], [[splenomegaly]] and flank dullness on [[percussion]]. Other findings on examination include nail changes, presence of [[Clubbing]], [[Dupuytrens contracture|dupuytren's contracture]](flexion deformities of the fingers) and [[Asterixis]] in cases with [[hepatic encephalopathy]].


==Physical Examination==
==Physical Examination==
===Skin===
* '''[[Spider angioma]]ta''', or '''spider nevi''', may be present. Vascular lesions consisting of central arteriole surrounded by many smaller vessels due to an increase in [[estradiol]]. These occur in about 33% of cases.<ref name="pmid10423070">{{cite journal |author=Li CP, Lee FY, Hwang SJ, ''et al'' |title=Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function|journal=Scand. J. Gastroenterol. |volume=34 |issue=5 |pages=520-3 |year=1999 |pmid=10423070 |doi=}}</ref>
{|
| {{#ev:youtube|RT-8OzD9j00}}
| {{#ev:youtube|-fTGzcsygBI}}
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* '''[[Telangiectasia]]''', or '''spider veins''', may be present. Small dilated [[blood vessel]]s near the surface of the skin.


[[Image:Telangectasia.jpg|thumb|center|300px|Telangectasia]]
*Physical examination of [[Patient|patients]] with [[cirrhosis]] is usually remarkable for: [[jaundice]], [[Spider angioma|spider angiomata]], [[ascites]], [[asterixis]], [[Splenomegaly|spleenomegaly]] and [[palmar erythema]].


* '''[[Palmar erythema]]''' may be present. Exaggerations of normal speckled mottling of the palm, due to altered sex hormone metabolism.
===Appearance of the patient===
*[[Patient|Patients]] with [[cirrhosis]] usually appear weak due to constitutional [[Symptom|symptoms]] such as [[weight loss]], [[anorexia]] and [[muscle atrophy]]. Yellowish discoloration of [[skin]] and [[abdominal distension]] may also be present due to [[ascites]].  


[[Image:Palmar erythema.jpg|thumb|300px|center|Palmar erythema]]
*Normal/low [[blood pressure]] with normal [[pulse pressure]].


* '''[[Dupuytren's contracture]]''' may be present. Thickening and shortening of palmar fascia that leads to flexion deformities of the fingers. Thought to be due to fibroblastic proliferation and disorderly collagen deposition. It is relatively common (33% of patients).
===Skin===
 
*[[Jaundice]] : yellow discoloration of the skin, eyes, and mucus membranes due to increased [[bilirubin]] (at least 2-3 mg/dL or 30 mmol/L). [[Urine]] may also appear dark.
[[Image:Morbus dupuytren fcm.jpg|thumb|300px|center|Dupuytren's contracture]]
*[[Pallor]]
*[[Bruise|Bruises]]
*[[Palmar erythema]] on the [[Thenar eminence|thenar]] and [[Hypothenar eminence|hypothenar eminences]], due to altered sex hormone metabolism.
*[[Spider angioma|Spider angiomata]]: Increased estradiol levels lead to the formation of vascular lesions consisting of central arterioles surrounded by smaller vessels <ref name="pmid10423070">{{cite journal |author=Li CP, Lee FY, Hwang SJ, ''et al'' |title=Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function|journal=Scand. J. Gastroenterol. |volume=34 |issue=5 |pages=520-3 |year=1999 |pmid=10423070 |doi=}}</ref> 
*'''[[Telangiectasia|Telangiectasias]]''' or '''spider veins:''' small dilated [[blood vessel]]s near the surface of the [[skin]].
<gallery widths="250px">


[[Image:Dupuytren's2010.JPG|thumb|300px|center|Dupuytren's contracture]]
Telingectasia1.jpg||thumb|200px|Telingectasias <br> Source: Wikimedia commons
Image:Palmar erythema 1.jpg|thumb|Palmar erythema <br> Source: Wikimedia commons<ref name="urlFile:Kawasaki symptoms D.jpg - Wikimedia Commons">{{cite web |url=https://commons.wikimedia.org/wiki/File:Kawasaki_symptoms_D.jpg |title=File:Kawasaki symptoms D.jpg - Wikimedia Commons |format= |work= |accessdate=}}</ref>


===Eyes===
</gallery>
* '''[[Jaundice]]'''. Yellow discoloring of the skin, eye, and mucus membranes due to increased [[bilirubin]] (at least 2-3 mg/dL or 30 mmol/L). Urine may also appear dark.
{{#ev:youtube|RT-8OzD9j00}}
* '''[[Kayser-Fleischer ring]]s''' may be present.  Dark rings that appear to encircle the [[iris (anatomy)|iris]] of the [[eye]].


[[Image:Kayser-Fleischer ring.jpg|thumb|center|300px|A Kayser-Fleischer ring in a 32-year-old patient who had longstanding speech difficulties and [[tremor]].]]
===HEENT===
* Abnormalities of the head/hair may include thinning of hair on the scalp due to [[hyperestrogenism]]
* '''[[Kayser-Fleischer ring]]s:''' dark rings that appear to encircle the [[iris (anatomy)|iris]] of the [[eye]] in [[Patient|patients]] with [[Wilson's disease]]<ref name="pmid28573989">{{cite journal |vauthors=Sridhar MS, Rangaraju A, Anbarasu K, Reddy SP, Daga S, Jayalakshmi S, Shaik B |title=Evaluation of Kayser-Fleischer ring in Wilson disease by anterior segment optical coherence tomography |journal=Indian J Ophthalmol |volume=65 |issue=5 |pages=354–357 |year=2017 |pmid=28573989 |pmc=5565897 |doi=10.4103/ijo.IJO_400_16 |url=}}</ref>
* [[Parotid gland]] enlargement
* [[Fetor hepaticus]]: severe portal-systemic shunting leads to increased levels of [[dimethyl sulfide]] leads to a sweet pungent smell in the breath
[[File:Output WVsMqP (1).gif|500px|center|thumb|Liver Cirhhosis <br> Source: Wikimedia commons]]


===Abdomen===
===Abdomen===
* Inspection:
** [[Abdominal distension]]
** [[Caput medusae]]<ref name="KimKeum2014">{{cite journal|last1=Kim|first1=SH|last2=Keum|first2=B|last3=Kim|first3=ES|last4=Jeen|first4=YT|last5=Chun|first5=HJ|title=Hepatobiliary and Pancreatic: Caput medusae|journal=Journal of Gastroenterology and Hepatology|volume=29|issue=12|year=2014|pages=1952–1952|issn=08159319|doi=10.1111/jgh.12802}}</ref><ref name="pmid24818343">{{cite journal |vauthors=Chandail VS, Jamwal V |title=Caput medusae |journal=J Assoc Physicians India |volume=61 |issue=8 |pages=564 |year=2013 |pmid=24818343 |doi= |url=}}</ref>


* '''Liver size'''. Can be [[hepatomegaly|enlarged]], normal, or shrunken.
* Palpation:
* '''[[Splenomegaly]]'''. Due to congestion of the red pulp as a result of portal hypertension.
** Fluid wave
* '''[[Ascites]]'''. Accumulation of fluid in the peritoneal cavity giving rise to flank dullness (needs about 1500 mL to detect flank dullness).
** [[Hepatomegaly]] may be present in initial stages. The liver may also be normal or shrunken.
* '''[[Caput medusae|Caput medusa]]'''. In portal hypertension, the umbilical vein may open. Blood from the portal venous system may be shunted through the periumbilical veins into the umbilical vein and ultimately to the abdominal wall veins, manifesting as caput medusa.
** [[Splenomegaly|Spleenomegaly]] may be present in patients with [[cirrhosis]] from nonalcoholic etiologies, due to portal hypertension
* '''[[Cruveilhier-Baumgarten murmur]]'''. Venous hum heard in epigastric region due to collateral connections between portal system and the remnant of the umbilical vein in portal hypertension.


===Extremities===
* Percussion:
* '''[[Hypertrophic osteopathy|Hypertrophic osteoarthropathy]]''' may be present. Chronic proliferative periostitis of the long bones that can cause considerable pain.
**  Flank dullness may be present due to [[ascites]] (needs approximately 1500ml for detection)
* '''[[Nail changes]]''' may be present.
** '''[[Muehrcke's lines|Muehrcke's nails]]'''.  Paired horizontal bands separated by normal color due to [[hypoalbuminemia]] (low production of [[human serum albumin|albumin]]).
** '''[[Terry's nails]]'''.  Proximal two thirds of the nail plate appears white with distal one-third red, also due to hypoalbuminemia
** '''[[Clubbing]]'''.  Angle between the nail plate and proximal nail fold > 180 degrees


===Neurologic===
* Auscultation:
* '''[[Asterixis]]''' may be present. Bilateral asynchronous flapping of outstretched, dorsiflexed hands seen in patients with hepatic [[encephalopathy]].
** [[Cruveilhier-Baumgarten murmur]]: venous hum that may be present in patients with [[portal hypertension]].
{{#ev:youtube|Or65nOrcz1A}}
*** Mechanism: due to collateral connections between remnant of the [[umbilical vein]] and the [[Portal venous system|portal system]]
*** Location: [[Epigastrium]]
*** Exacerbating factors:  [[Valsalva maneuver]]
*** Diminished by: application of [[pressure]] on the [[skin]] above the [[Navel|umbilicus]]
<gallery widths="250px">


* '''[[Coma]]''' can be noticed in cases of encephalopathy.
image:Hepaticfailure.jpg|thumb|300px|Abdominal distention, ascites-By James Heilman, MD (Own work) <ref name="https://creativecommons.org/licenses/by-sa/3.0", CC BY-SA 3.0>, <"https://commons.wikimedia.org/wiki/File%3AHepaticfailure.jpg">via Wikimedia Commons</ref>
</gallery>
{{#ev:youtube|8LDUtAAUJBc}}
{{#ev:youtube|CHUBTgrU3Oc}}


===Other===
===Genitourinary===
* '''[[Gynecomastia]]''' may be present. Benign proliferation of glandular tissue of male breasts presenting with a rubbery or firm mass extending concentrically from the nipples. This is due to increased estradiol and can occur up to 66% of patients.
*[[Testicular atrophy]] 
* '''[[Fetor hepaticus]]''' may be present. Sweet pungent smell in breath due to increased [[dimethyl sulfide]] due to severe portal-systemic shunting.
*Inversion of the normal male [[pubic hair]] pattern
* '''Constitutional symptoms''' may be present.  These symptoms include [[anorexia]], [[fatigue]], [[weakness]], and [[weight loss]].
===Neuromuscular===
* '''[[Testicular atrophy]]''' may be present.  [[Testes|Male reproductive organs]] diminish in size and may be accompanied by ceasing to function.
* [[Hepatic encephalopathy]] may have signs of:
* '''[[Hemorrhoids]]''' may be present.
** Alteration of [[Mental status examination|mental status]]
* '''[[Hematemesis]]''' may be present.
** [[Confusion]]
* '''[[Melena]]''' may be present.
** [[Coma]]
* [[Asterixis]] (bilateral but asynchronous flapping motions of outstretched, dorsiflexed hands) is seen in patients with [[hepatic encephalopathy]].
{{#ev:youtube|Or65nOrcz1A}}


==References==
===Extremities===
*[[Edema]] of the lower extremities
*[[Muscle atrophy]]
*Nail changes:<ref name="pmid13316143">{{cite journal |vauthors=MUEHRCKE RC |title=The finger-nails in chronic hypoalbuminaemia; a new physical sign |journal=Br Med J |volume=1 |issue=4979 |pages=1327–8 |year=1956 |pmid=13316143 |pmc=1980060 |doi= |url=}}</ref>
**Muehrcke nails: paired horizontal white bands separated by normal color due to [[hypoalbuminemia]] <ref name="pmid27104368">{{cite journal |vauthors=Callemeyn J, Van Haecke P, Peetermans WE, Blockmans D |title=Clubbing and hypertrophic osteoarthropathy: insights in diagnosis, pathophysiology, and clinical significance |journal=Acta Clin Belg |volume=71 |issue=3 |pages=123–30 |year=2016 |pmid=27104368 |doi=10.1080/17843286.2016.1152672 |url=}}</ref><ref name="pmid24350360">{{cite journal |vauthors=Gibb C, Smith PJ, Miller R |title=Clubbing |journal=Br J Hosp Med (Lond) |volume=74 |issue=11 |pages=C170–2 |year=2013 |pmid=24350360 |doi= |url=}}</ref><ref name="pmid23099284">{{cite journal |vauthors=Morán LM, Ariza A |title=Hypertrophic osteoarthropathy associated to liver cirrhosis |journal=Reumatol Clin |volume=9 |issue=4 |pages=248–9 |year=2013 |pmid=23099284 |doi=10.1016/j.reuma.2012.06.010 |url=}}</ref><ref name="pmid22534387">{{cite journal |vauthors=Tully AS, Trayes KP, Studdiford JS |title=Evaluation of nail abnormalities |journal=Am Fam Physician |volume=85 |issue=8 |pages=779–87 |year=2012 |pmid=22534387 |doi= |url=}}</ref><ref name="pmid19888943">{{cite journal |vauthors=Salem A, Gamil H, Hamed M, Galal S |title=Nail changes in patients with liver disease |journal=J Eur Acad Dermatol Venereol |volume=24 |issue=6 |pages=649–54 |year=2010 |pmid=19888943 |doi=10.1111/j.1468-3083.2009.03476.x |url=}}</ref>
**Terry nails: the proximal two-thirds of the nail plate appears white, whereas the distal one-third is red due to [[hypoalbuminemia]]
** [[Clubbing]]:  the angle between the nail plate and proximal nail fold is greater than 180 degrees
**Severe [[clubbing]]:
***"Drum stick" appearance of distal fingers 
***[[Hypertrophic pulmonary osteoarthropathy|Hypertrophic osteoarthropathy]]: chronic proliferative [[periostitis]] of the [[long bones]] <ref name="pmid27935768">{{cite journal |vauthors=Yap FY, Skalski MR, Patel DB, Schein AJ, White EA, Tomasian A, Masih S, Matcuk GR |title=Hypertrophic Osteoarthropathy: Clinical and Imaging Features |journal=Radiographics |volume=37 |issue=1 |pages=157–195 |year=2017 |pmid=27935768 |doi=10.1148/rg.2017160052 |url=}}</ref><ref name="pmid8017989">{{cite journal |vauthors=Pitt P, Mowat A, Williams R, Hamilton E |title=Hepatic hypertrophic osteoarthropathy and liver transplantation |journal=Ann. Rheum. Dis. |volume=53 |issue=5 |pages=338–40 |year=1994 |pmid=8017989 |pmc=1005335 |doi= |url=}}</ref> 
*[[Dupuytrens contracture|Dupuytren's contracture]] may cause flexion deformities of the fingers: This occurs due to shortening and thickening of the palmar fascia, due to collagen deposition and fibroblastic proliferation.<ref name="pmid28505213">{{cite journal |vauthors=Auld T, Werntz JR |title=Dupuytren's disease: How to recognize its early signs |journal=J Fam Pract |volume=66 |issue=3 |pages=E5–E10 |year=2017 |pmid=28505213 |doi= |url=}}</ref> 
*[[Asterixis]] in cases with [[hepatic encephalopathy]]<ref name="pmid24372275">{{cite journal |vauthors=Butz M, Timmermann L, Gross J, Pollok B, Südmeyer M, Kircheis G, Häussinger D, Schnitzler A |title=Cortical activation associated with asterixis in manifest hepatic encephalopathy |journal=Acta Neurol. Scand. |volume=130 |issue=4 |pages=260–7 |year=2014 |pmid=24372275 |doi=10.1111/ane.12217 |url=}}</ref><ref name="pmid20842766">{{cite journal |vauthors=Mendizabal M, Silva MO |title=Images in clinical medicine. Asterixis |journal=N. Engl. J. Med. |volume=363 |issue=9 |pages=e14 |year=2010 |pmid=20842766 |doi=10.1056/NEJMicm0911157 |url=}}</ref><ref name="pmid20412035">{{cite journal |vauthors=Schiano TD |title=Clinical management of hepatic encephalopathy |journal=Pharmacotherapy |volume=30 |issue=5 Pt 2 |pages=10S–5S |year=2010 |pmid=20412035 |doi=10.1592/phco.30.pt2.10S |url=}}</ref>
<gallery widths="250px">


{{reflist|2}}
256px-Dupuytren's2010.JPG|left|thumb|Dupuytren's contracture  <br> Source: Wikimedia commons
Dupuytren´s Contracture on the ring finger.jpg|thumb|300px|Dupuytren´s Contracture on the ring finger <ref name="https://creativecommons.org/licenses/by-sa/4.0", CC BY-SA 4.0>, <"https://commons.wikimedia.org/wiki/File%3ADupuytren%C2%B4s_Contracture_on_the_ring_finger.jpg">via Wikimedia Commons</ref>
Phy exam.jpg|thumb|Clubbing: angle between the nail plate and proximal nail fold is greater than 180 degrees  <br> Source: Wikimedia commons
File:Nail.gif|thumb|center|300px|Muehrcke's nails: paired horizontal white bands separated by normal color  <br> Source:Wikimedia commons <ref name="urlFile:Muehrckes lines.JPG - Wikimedia Commons">{{cite web |url=https://commons.wikimedia.org/wiki/File:Muehrcke%27s_lines.JPG |title=File:Muehrcke's lines.JPG - Wikimedia Commons |format= |work= |accessdate=}}</ref>


</gallery>


=== Chest findings ===
* [[Gynecomastia]]: due to increased estradiol levels
* Loss of chest or [[Underarm hair|axillary hair]]
===Other findings===
* [[Hemorrhoids]]
* [[Hematemesis]]
* [[Melena]]


==References==
{{reflist|2}}


{{WH}}
[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Disease]]


{{WS}}
{{WS}}
{{WH}}

Latest revision as of 19:41, 19 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Patients with cirrhosis usually present with signs of jaundice, palmar erythema, spider angiomata, gynaecomastia and alteration of mental status arising due to complications of cirrhosis. Abdominal examination may show signs of abdominal distension, caput medusae, splenomegaly and flank dullness on percussion. Other findings on examination include nail changes, presence of Clubbing, dupuytren's contracture(flexion deformities of the fingers) and Asterixis in cases with hepatic encephalopathy.

Physical Examination

Appearance of the patient

Skin

  • Telingectasias Source: Wikimedia commons

    Telingectasias
    Source: Wikimedia commons

  • Palmar erythema Source: Wikimedia commons[2]

    Palmar erythema
    Source: Wikimedia commons[2]

{{#ev:youtube|RT-8OzD9j00}}

HEENT

Liver Cirhhosis
Source: Wikimedia commons

Abdomen

  • Palpation:
    • Fluid wave
    • Hepatomegaly may be present in initial stages. The liver may also be normal or shrunken.
    • Spleenomegaly may be present in patients with cirrhosis from nonalcoholic etiologies, due to portal hypertension
  • Percussion:
    •  Flank dullness may be present due to ascites (needs approximately 1500ml for detection)
  • Abdominal distention, ascites-By James Heilman, MD (Own work)

    Abdominal distention, ascites-By James Heilman, MD (Own work)

{{#ev:youtube|8LDUtAAUJBc}} {{#ev:youtube|CHUBTgrU3Oc}}

Genitourinary

Neuromuscular

{{#ev:youtube|Or65nOrcz1A}}

Extremities

  • Dupuytren's contracture Source: Wikimedia commons

    Dupuytren's contracture
    Source: Wikimedia commons

  • Dupuytren´s Contracture on the ring finger

    Dupuytren´s Contracture on the ring finger

  • Clubbing: angle between the nail plate and proximal nail fold is greater than 180 degrees Source: Wikimedia commons

    Clubbing: angle between the nail plate and proximal nail fold is greater than 180 degrees
    Source: Wikimedia commons

  • Muehrcke's nails: paired horizontal white bands separated by normal color Source:Wikimedia commons [18]

    Muehrcke's nails: paired horizontal white bands separated by normal color
    Source:Wikimedia commons [18]

Chest findings 

Other findings

References

  1. ↑ Li CP, Lee FY, Hwang SJ; et al. (1999). "Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function". Scand. J. Gastroenterol. 34 (5): 520–3. PMID 10423070.
  2. ↑ "File:Kawasaki symptoms D.jpg - Wikimedia Commons".
  3. ↑ Sridhar MS, Rangaraju A, Anbarasu K, Reddy SP, Daga S, Jayalakshmi S, Shaik B (2017). "Evaluation of Kayser-Fleischer ring in Wilson disease by anterior segment optical coherence tomography". Indian J Ophthalmol. 65 (5): 354–357. doi:10.4103/ijo.IJO_400_16. PMC 5565897. PMID 28573989.
  4. ↑ Kim, SH; Keum, B; Kim, ES; Jeen, YT; Chun, HJ (2014). "Hepatobiliary and Pancreatic: Caput medusae". Journal of Gastroenterology and Hepatology. 29 (12): 1952–1952. doi:10.1111/jgh.12802. ISSN 0815-9319.
  5. ↑ Chandail VS, Jamwal V (2013). "Caput medusae". J Assoc Physicians India. 61 (8): 564. PMID 24818343.
  6. ↑ MUEHRCKE RC (1956). "The finger-nails in chronic hypoalbuminaemia; a new physical sign". Br Med J. 1 (4979): 1327–8. PMC 1980060. PMID 13316143.
  7. ↑ Callemeyn J, Van Haecke P, Peetermans WE, Blockmans D (2016). "Clubbing and hypertrophic osteoarthropathy: insights in diagnosis, pathophysiology, and clinical significance". Acta Clin Belg. 71 (3): 123–30. doi:10.1080/17843286.2016.1152672. PMID 27104368.
  8. ↑ Gibb C, Smith PJ, Miller R (2013). "Clubbing". Br J Hosp Med (Lond). 74 (11): C170–2. PMID 24350360.
  9. ↑ Morán LM, Ariza A (2013). "Hypertrophic osteoarthropathy associated to liver cirrhosis". Reumatol Clin. 9 (4): 248–9. doi:10.1016/j.reuma.2012.06.010. PMID 23099284.
  10. ↑ Tully AS, Trayes KP, Studdiford JS (2012). "Evaluation of nail abnormalities". Am Fam Physician. 85 (8): 779–87. PMID 22534387.
  11. ↑ Salem A, Gamil H, Hamed M, Galal S (2010). "Nail changes in patients with liver disease". J Eur Acad Dermatol Venereol. 24 (6): 649–54. doi:10.1111/j.1468-3083.2009.03476.x. PMID 19888943.
  12. ↑ Yap FY, Skalski MR, Patel DB, Schein AJ, White EA, Tomasian A, Masih S, Matcuk GR (2017). "Hypertrophic Osteoarthropathy: Clinical and Imaging Features". Radiographics. 37 (1): 157–195. doi:10.1148/rg.2017160052. PMID 27935768.
  13. ↑ Pitt P, Mowat A, Williams R, Hamilton E (1994). "Hepatic hypertrophic osteoarthropathy and liver transplantation". Ann. Rheum. Dis. 53 (5): 338–40. PMC 1005335. PMID 8017989.
  14. ↑ Auld T, Werntz JR (2017). "Dupuytren's disease: How to recognize its early signs". J Fam Pract. 66 (3): E5–E10. PMID 28505213.
  15. ↑ Butz M, Timmermann L, Gross J, Pollok B, Südmeyer M, Kircheis G, Häussinger D, Schnitzler A (2014). "Cortical activation associated with asterixis in manifest hepatic encephalopathy". Acta Neurol. Scand. 130 (4): 260–7. doi:10.1111/ane.12217. PMID 24372275.
  16. ↑ Mendizabal M, Silva MO (2010). "Images in clinical medicine. Asterixis". N. Engl. J. Med. 363 (9): e14. doi:10.1056/NEJMicm0911157. PMID 20842766.
  17. ↑ Schiano TD (2010). "Clinical management of hepatic encephalopathy". Pharmacotherapy. 30 (5 Pt 2): 10S–5S. doi:10.1592/phco.30.pt2.10S. PMID 20412035.
  18. ↑ "File:Muehrcke's lines.JPG - Wikimedia Commons".

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