Extrahepatic Manifestations of Liver Disease (OSCE)

NEUROLOGICAL

• LOC, delirium, coma
• asterixis (arms out, dorsiflexed hands, eyes closed → hepatic encephalopathy)

BREATHING

• Cheyne-Stokes (encephalopathy)
• Kussmaul (metabolic acidosis)
• fetor hepaticus (musty liver breath)

EYES

• scleral icterus

MOUTH

• sublingual jaundice
• parotid gland enlargement, tenderness

NECK

• spider angiomata
  • blanching, necklace distribution, can be in the back
  • up to 2 in men and 5 in women is normal

HANDS

• nails (clubbing, leukonychia, Lindsay’s, Terry’s nails)
• palmar erythema (ulnar)
• Dupuytren’s contracture
• thenar muscle wasting

TRUNK

• jaundice
• clotting
  • ecchymosis (prothrombin deficiency)
  • purpura/petechiae (platelet deficiency)
• ↑ estrogen (gynecomastia, testicular atrophy, loss of axillary and pubic hair)

ABDOMEN

• caput medusa
• ascites
  • bulging flanks
  • shifting dullness
  • fluid wave
• hepatomegaly (initially large and firm, liver later shrinks)
• splenomegaly

LOWER LEGS

• lower extremity edema
  • be reluctant to diagnose ascites without seeing swollen legs