Initial assessment & workup for a case of
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This presentation contains slides explaining how to take history and identify clinical signs and symptoms of liver disease, followed by a preliminary laboratory and radiological examination appropriate for a patient with suspected liver disease prior to treatment
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Initial assessment & workup for a case of
- 1. Initial Assessment & Workup for a case of Liver Cirrhosis
- 2. Asymptomatic (detected on USG) Non-specific symptoms Symptoms of complications Presenting complaints
- 3. Asymptomatic (detected on USG) Non-specific symptoms* Symptoms of complications Presenting complaints *Non- specific symptoms: Muscle wasting Cramps Weight loss Abdominal discomfort
- 4. Ascites Jaundice UGI bleeding Hepatic Encephalopathy Symptoms of Complication
- 5. Ascites Jaundice UGI bleeding Hepatic Encephalopathy Symptoms of Complication Malena Hemetemesis
- 6. Ask for: Past History: Known alcoholic Type 2 diabetes mellitus Systemic Hypertension Obesity Dyslipidemia Hepatitis C or B H/O Blood transfusion
- 7. Personal History Alcohol intake Altered sleep pattern H/o Infertility H/o Amenorrhoea Intravenous drug abuse Tattoos Ask for:
- 8. Variceal bleeding Caput medusa AscitesSplenomegaly Look for: Haemarrhoids
- 9. Signs of Portal hypertension Variceal bleeding Splenomegaly Look for: Haemarrhoids
- 10. Asterixis or Flapping tremor Ataxic gait Signs of Hepatic Encephalopathy Look for: Nystagmus
- 11. Stage Intellectual impairment Neuromuscular impairment I Irritability, depression, anxiety Tremor Incordination II Altered sleep pattern, behavioural changes Asterixis, ataxic gait, slurred speech III Somnolence, confusion, drowsiness Muscular rigidity, Nystagmus, clonus, Babinskis sign IV Coma Unresponsive to pain West- Haven Criteria for grading Hepatic Encephalopathy Look for:
- 12. Spider naevi Palmar erythema Aloepecia Gynaecomastia Aloepecia Palmar erythema Spider naevi Men: Gynaecomastia testicular atrophy, impotence Women: Amenorrhoea, Breast atrophy Look for: Signs of Endocrine changes
- 13. Petechiae Dupuytrens contracture Other signs Parotidomegaly Dupuytrens contracture Clubbing/ cyanosis Leuconychia Fetor hepaticus Purpura/ Petechiae Epistaxis Bruises Leuconychia KF Ring Xanthelasma Clubbing Signs of Coagulopathy
- 14. Diagnostic Workup Liver function tests Hemogram Blood grouping & typing Prothrombin time Serological markers for HCV and HBV USG Ascitic fluid tap Liver Biopsy (gold standard)
- 15. Liver Function Tests ALT/ AST: Elevated ALP: Elevated Hyperbilirubinemia Reversal of Albumin: Globulin ratio
Editor's Notes
- #15: If a patient has a persistently increased ALT level, viral hepatitis serologies should be assayed. If these are negative, the remaining serologic work-up should include an antinuclear antibodies test or antismooth muscle antibody test, or both, to evaluate for autoimmune hepatitis; and a fasting transferrin saturation level or unsaturated iron-binding capacity and ferritin level18to evaluate for hereditary hemochromatosis.15In patients younger than 40 years in whom Wilsons disease is suspected, serum ceruloplasmin and copper levels should be measured,19but screening all patients with chronic hepatic injury for Wilsons disease is not indicated.15Primary biliary cirrhosis or primary sclerosing cholangitis should be suspected in patients with chronic cholestasis. Testing for 留1-antitrypsin (A1AT) deficiency may be of benefit in patients with chronic hepatic injury and no other apparent cause. Although the role of A1AT deficiency in liver disease in adults is not clearly defined, testing is especially important in neonates with evidence of hepatic injury.15Ultrasonography or biopsy is necessary to establish the diagnosis of NAFLD.