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Hey guys. Today I'll be discussing again about one of the most important organs in our body, which is the liver. However, this time I will be explaining about the possible clinical manifestations of chronic liver disease throughout this article. Liver has the largest size in comparison of all internal human organs. The skin is technically the largest “organ” though, due to its massive surface area coverage. Yes you’ve won, skin. I have mentioned about the variety functions of this amazing organ back in my first Gastro steemit blogpost. As a recap from that artice, the liver involves in many sorts of metabolisms, synthesis and storage of proteins, degradation of nitrogen products, hormone & drug deactivations, and immunological roles. All these important functions of liver goes southwards when it develops cirrhosis. Blub blub blub.

Cirrhosis represents the last stage of the liver disease, which is a chronic condition marked by cell degeneration, inflammation and fibrous thickening of the tissue. Cirrhosis means scarring. It is a pathological condition that causes the loss of normal microscopic lobular structure or architecture. It simply means that the liver has lost its normal integrity as a functioning organ. In advanced stages of this chronic illness, it is considered as irreversible. You can’t undo those nasty scars you’ve made. The only method of treatment is via liver transplant. Let’s hope that it won’t go to that stage and thus I’m creating this blogpost to create awareness of the possible physical findings. In comparison with the term chronic liver disease, cirrhosis is the end stage of the disease. Chronic liver disease refers to a disease of the liver which lasts over a period of six months.

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As far as my experience in three different hospitals in Malaysia for the internal medicine posting, I’ve came across many chronic liver disease cases. Most of them are caused by chronic infection by the hepatitis C virus. Some other common causes include alcohol ingestions, chronic hepatitis B infection and non-alcoholic fatty liver disease. I’ve been taught to remember the causes of liver cirrhosis via the mnemonic VITAMIN C. Well, this mnemonic can be applied to various sorts of conditions. Nuff said.

V – Vascular = Budd-Chiari Syndrome
I – Infection = Hepatitis B, C, Amoebic infestations
T – Trauma
A – Autoimmune = Autoimmune Hepatitis
M – Metabolic = Hemochromatosis, Wilson’s disease
I – Idiopathic
N – Neoplasm = Hepatoma, Hepatocellular Carcinoma
C – Congenital

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There are so many to talk about when it comes to chronic liver disease. However I’m going to shift the focus towards the physical examination findings of chronic liver disease and how does those interesting manifestations develop. Sure, there are a lot of signs that we can look at when someone is having the disease.

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Jaundice

Jaundice is defined as the yellowish discolouration of the skin and mucous membrane that results from high level of bilirubin in the blood. The bilirubin level should be higher than 2-3mg/dL in order for it to exhibit the yellow colour, which is twice its upper limit of normal. It is best observed in natural daylight and the type of jaundice in chronic liver disease is the intrahepatic type. Other causes of similar skin pigmentation are carotinaemia (excess consumption of carotene which are so abundant in carrots and mangoes), acriflavine and picric acid ingestion. So avoid ingesting so much carrots or else you’ll be subjected to so many unnecessary investigations. Hah!

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Generalized skin pigmentation

Bronzing of skin. This condition can result from hemochromatosis which is defined as the systemic iron deposition in the body. Hemochromatosis is a known cause of liver cirrhosis. The most common organs that these iron will reside are the liver, heart and endocrine glands. Hemochromatosis can be divided into primary and secondary causes. Primary hemochromatosis is usually hereditary and it is gene dependent. Secondary hemochromatosis is often as a result of severe chronic hemolysis (destruction of red blood cells), multiple blood transfusions as the transfused heme is also iron-based, excess iron supplementation or poisoning, and overload of iron from dietary intake. Becoming Tony Stark doesn’t sound that thrilling anymore eh?

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Porphyria cutanea tarda

This fancy condition which I’ve learnt from my supervisor during my internal medicine posting, who is the head of the Endocrine Unit in the hospital, is actually a cutaneous manifestation that is associated with alcoholism and hepatitis C. When our supervisor was explaning about the stigmata of alcoholic liver disease and mentioned this condition, we were like “what and what tarda?!” I swear he had to repeat the terminology three times for us to actually able to write it down. Full of typos still. Anyway, both conditions can result in chronic liver disease. This condition is caused by the deficiency in uroporphyrinogen decarboxylase or UROD. Both of the condition mentioned before can lead to the deficiency in this enzyme, which somehow causes buildups in porphyrin in the body. Fragile vesicles usually appear on sun-exposed areas of the skin and heal with scarring.

Note: I'm sorry I couldn't find a picture without copyrights for this skin manifestation. Try googling it if you're interested :)

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Leuconychia

This condition that affects the nails is known also as Terry’s nails. Chronic liver disease affects many of the liver function, including protein synthesis. Albumin, which is normally synthesized by the liver can be profoundly low in individuals with liver problems. Low albumin level, which is termed as hypoalbuminemia, causes the nail beds to opacify. This often leaves a rim of pink nail bed at the top of the nail. Free manicure!
Due to the compression caused by overload of extracellular fluid, the nail bed turns white in colour. Read up on starling’s law to understand how hypoalbuminemia causes buildups of extra-cellular fluid.

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Finger clubbing

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Patients with liver cirrhosis may have finger clubbing, which is as much as one out of three affected individuals. There are multiple theories regarding the pathophysiology of this condition and one of the accepted ones stated that this condition may be related to arteriovenous shunting in the lungs, which causes low arterial oxygen supply to the peripheries. The cause is poorly understood. Contrary to popular beliefs, you don’t dance better in the clubs if you have clubbed toenails.

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Palmar erythema

This condition is described as the reddening of the palms of the hands affecting the thenar and hypothenar eminences. The origin of this problem is still unknown but some suggested that it is attributed to the raised oestrogen levels. Other condition which can cause palmar erythema includes the thyrotoxicosis, rheumatoid arthritis, polycythemia (increase in red blood cells level), and pregnancy. Oh yeah you can get this sort of palms if you slap someone so hard, gazillion times.

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Palmar pallor

Pallor or pale is caused by anaemia. Anaemia is the medical term for low red blood cell or low hemoglobin level. The palmar creases are often inspected for pallor. How does chronic liver disease causes anemia? There are two established conditions in chronic liver disease which could result in anaemia. The first one is when there is an upper gastro-intestinal bleed caused by portal hypertension. Portal hypertension is a complication of chronic liver disease. The scarred liver (cirrhosis), causes the portal vein to have higher pressure than normal. The normal portal pressure is 5-10 mmHg. Anything higher than this value is defined as portal hypertension. When the portal vein becomes hypertensive, the surrounding veins develop collaterals as a compensation to reduce back the pressure. One of the most important location of the collateral development is the oesophagus and the stomach. The veins in these areas tend to bulge and prone to rupture, causing the bleeding events. Patients with upper-GI bleed often complains of melena, or black and tarry faeces. The second cause of anemia in chronic liver disease is the anemia of chronic disease. Lol. Okay, don’t laugh. I know that sentence sounds funny..
This type of anemia is caused by the high cytokines level, which is an inflammatory mediator. Chronic disease often results in inflammation, somehow. High cytokines level is postulated to suppress erythropoiesis (which is known as the process of red blood cell formation).

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Dupuytren’s contracture

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Finally an excuse to permanently express your middle finger to the world ? Okay. Kidding. The contractures that normally occurs in the palm are visible and palpable. This contracture results in permanent flexion, in which the ring finger is the most commonly affected one. It worsens over time until to the extent where the fingers can’t be normally extended. It is postulated that the abnormally high amount of xanthine causes this contracture as the palmar fascia of the affected individual contains a huge number of xanthine. Xanthine is related to alcohol ingestion. Oh yeah, even showing off your middle finger is now theoretically related to alcohol abuse.

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Bruising

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Large bruises, or known as ecchymoses, may develop because of clotting abnormalities. Like I’ve mentioned in my previous blog regarding the liver, this organ produces clotting factors. In chronic liver disease, the production of these essential factors are often impaired, resulting in easy bruising as the clotting process becomes poor. Exclude other causes of multiple bruises such as ongoing marital affairs.. okay kidding.

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Spider naevi

This is an interesting finding that usually appears in the arms and chest. It is consists of a central arteriole which radiates to numerous small vessels. The small vessels are spider’s legs. They range in size from simply visible to the naked eye to half a centimeter in diameter. To confirm the presence of this arachnid’s sign, pressure can be applied with a pointed object to the central arteriole. This will cause a blanching of the whole lesion. Upon releasing the pressure, there will be rapid refilling of blood from the center to the spider’s legs. High level of oestrogen, which is similar to palmar erythema, is often blamed for the appearance of this creature. In the endometrium, oestrogens are known to produce a dilating effects on the spiral arteries. An enormous amount of oestrogen flowing inside the black widow huh. Black widow, spider naevi.. get it?!

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Kayser-fleisher rings

This beautiful rings which are often seen in slit-lamp examination, are manifestation of Wilson’s disease. Take note that Wilson’s disease is a cause of chronic liver disease. The brownish-green rings in the peripheral part of the cornea are the depositions of excess copper, which is the hallmark of Wilson’s disease. Wilson has gorgeous eyes.

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Parotid enlargement

Parotid glands are located on both sides of the mouth, and in front of both ears. Alcoholism (or manboobs)is the culprit of parotid enlargement. Similar to Wilson’s disease, alcoholism is one of the cause of Chronic liver disease. Excess alcohol ingestion causes fatty infiltration to this gland, which results in the increase of size. Yeahh alcohol has a high amount of calories, expressing fats everywhere in the body.

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Gynaecomastia

Gynaecomastia (or manboobs)is the enlargement of male breasts. Such an unsightly scene. This may be a sign of chronic liver disease as changes in the sex hormones oestradiol to testosterone ratio can be affected in this disease. So don’t take this as an excuse to drink more beer as it is not a substitute for surgical breast enlargement for women, it doesn’t work that way. So just don’t think about it....
In patients with liver cirrhosis, spironolactone which is a type of diuretic, is often used to treat ascites (excessive fluid accumulation in the peritoneal cavity). Ascites is one of the complications of chronic liver disease. Spironolactone is a known cause of gynaecomastia, so try to substitute it with other classes of diuretics. Gynaecomastia may affect single or both breasts, and may be painful to touch. Ouch.

In a nutshell, chronic liver disease exhibits important signs that doctors should not miss. They maybe small and often overlooked but the diagnosis of chronic liver disease is important as there are many complications of the condition such as ascites (fluid accumulation in the peritoneum or the tummy), hepatic encephalopathy (a complication that affects the brain which often cause abnormal behaviours), coagulopathy (as I’ve mentioned in this blogpost, easy bruising), and even malignant changes in the liver structure (a cancer known as hepatocellular carcinoma). Hence, urgent treatment is required to avoid such nasty consequences. Just stop drinking will ya?
With that, thank you :)

References

1. Talley et al. Clinical examination. 7th edition. Australia. Churcill Livingstone. El Sevier, 2014. Print
2. Garden et al. Principles and Practice of Surgery. China. Churchill Livingstone. El Sevier, 2014. Print
3. Kumar P., Clark M., Kumar & Clark's Clinical Medicine. Ninth Edition. London: ElSevier, 2017. Print
4. Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis. Uptodate. Retrieved on June 2, 2018, from https://www.uptodate.com/contents/cirrhosis-in-adults-etiologies-clinical-manifestations-and-diagnosis
5. Liver. Wikipedia. Retrieved on June 2, 2018, from https://en.wikipedia.org/wiki/Liver
6. The Liver. Teachmeanatomy. Retrieved on June 2, 2018 from http://teachmeanatomy.info/abdomen/viscera/liver/