Cirrhosis physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
Overview
Many signs and symptoms may occur in the presence of cirrhosis or as a result of the complications or causes 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.
Physical Examination
Skin
- Spider angiomata, or spider nevi, may be present. Vascular lesions consisting of central arterioles surrounded by many smaller vessels due to an increase in estradiol may also be present. These occur in about 33% of cases.[1]
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- Telangiectasia, or spider veins, may be present. Small dilated blood vessels near the surface of the skin.
- Palmar erythema may be present. There are exaggerations of normal speckled mottling of the palm, due to altered sex hormone metabolism.
- Dupuytren's contracture may be present. There is thickening and shortening of palmar fascia that leads to flexion deformities of the fingers. It is thought to be due to fibroblastic proliferation and disorderly collagen deposition. It is relatively common (33% of patients).
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Eyes
- Jaundice. It presents as a 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.
- Kayser-Fleischer rings may be present. They are dark rings that appear to encircle the iris of the eye.
Abdomen
- Liver size. It can be enlarged, normal, or shrunken.
- Splenomegaly. It is due to congestion of the red pulp as a result of portal hypertension.
- Ascites. It is an accumulation of fluid in the peritoneal cavity giving rise to flank dullness (needs about 1500 mL to detect flank dullness).
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- 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.
- Cruveilhier-Baumgarten murmur. It is a venous hum heard in the epigastric region due to collateral connections between the portal system and the remnant of the umbilical vein in portal hypertension.
Extremities
- Hypertrophic osteoarthropathy may be present. It consistis of chronic proliferative periostitis of the long bones that can cause considerable pain.
- Nail changes may be present.
- Muehrcke's nails. They are paired horizontal bands separated by normal color due to hypoalbuminemia (low production of albumin).
- Terry's nails. When the proximal two thirds of the nail plate appears white and the distal one-third red, they are referred to as Terry's nails. They are also due to hypoalbuminemia
- Clubbing. This is when the angle between the nail plate and proximal nail fold > 180 degrees
Neurologic
- Asterixis may be present. It presents as bilateral asynchronous flapping of outstretched, dorsiflexed hands seen in patients with hepatic encephalopathy.
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- Coma may be present in cases of encephalopathy.
Other
- Gynecomastia may be present. Fhis is a benign proliferation of glandular tissue of the 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.
- Fetor hepaticus may be present. There is a sweet pungent smell in the breath due to increased dimethyl sulfide. This is due to severe portal-systemic shunting.
- Testicular atrophy may be present. The male reproductive organs diminish in size and may also stop functioning.
- Hemorrhoids may be present. There would be swelling and inflammation of the veins in the rectum and anus.
- Hematemesis may be present. This consists of vomiting of blood.
- Melena may be present. Black, "tarry" feces that are associated with gastrointestinal hemorrhage are referred to as melena.
References