Approach to the patient with Liver Disease - for Medical Students.

1. Approach to the
Patient with Liver
Disease
Dr.Rajkumar M.D
(General Medicine)

2. For Diagnosis of Liver disease
 History
 Physical examination
 Lab tests
 Radiological Examinations
 Invasive Procedures

3. History
 Fatigue – daytime
 Nausea & Vomitting
 Anorexia
 Wt loss/Wt gain
 Abdominal pain/distention
 Icterus
 Dark urine
 Abnormal stool- Clay

4. History
 Pruritus
 Easy bruisability
 Sleep disturbance
 Change in mental status

5. Predisposing factors
 Alcohol abuse
 Iv drug abuse, Multiple sex partners,Blood transfusion
 Drug History, Native Treatment
 Family History

6. Physical Examination
 Jaundice-(Sclera)
 Anemia
 Skin- Bruises,Spider angioma,Palmar erythema.
 Parotid Enlargement
 Gynacomastia
 Distended Veins

9. Abdominal Examination
 Bulky Flanks-earliest sign of Ascites.
 Caput medusae
 Enlarged Veins
 Hepatomegaly/Splenomegaly
 Gall bladder palpable- Carcinoma of GB,Pancreatic
head.

11. LAB TESTS
 Serum Bilirubin= 0.3-1mg/dl.
 Total And Conjugated Bilirubin Measured In Blood.
(Unconj:conj=4:1)=(0.8:0.2)
 ALT,AST,ALP
 Albumin
 Prothrombin Time
 Coagulation Factor Levels
 Plasma Lipids And Lipoproteins

12. ENZYMES REFLECT DAMAGE TO
HEPATOCYTES
1)Aminotransferases = ALT,AST (10-40 IU).
2)Aminotransferases >1000 IU seen in Viral
Hepatitis,Ischemic liver injury,Drug induced
Hepatitis.
3)AST:ALT>2 Suggestive Of Alcoholic Liver Disease.

13. ENZYMES REFLECT CHOLESTASIS
 Alkaline Phosphatase
 5’ Nucleotidase
 γ- Glutamyl Transpeptidase (GGT)

14. BIOSYNTHETIC FUNCTION OF LIVER
 Serum Albumin
 Serum Globulin
 Coagulation Factors –All Expt VIII(Endothelium)

15. HEPATIC IMAGING
 USG & CT
 MRCP
 ERCP TO VISUALISE BILIARY TREE.

16. APPROACH TO JAUNDICE
 Symptom Not Disease
 Normal Bilirubin= 0.3-1.0 Mg/dl
 Clinically Obvious If > 2.5 Mg/dl.

18. Types of Jaundice
 Pre-hepatic(Hemolysis)
 Hepatic
 Post-hepatic(Cholestatic)

20. PRE-HEPATIC HEPATIC POST-HEPATIC
SYMPTOMS DARK URINE (HB),
ANEMIA, ICTERUS
SPLENOMEGALY
DARK URINE(CONJ.BIL+
UROBILIN))
DARK STOOLS
ICTERUS
DARK URINE(CONJ.BIL)
PALE STOOLS
PRURITUS
LAB UNCONJ.HYPER (TB<6)
W/O BILIRUBINURIA
LDH-INCREASED
RETICULOCYTOSIS
URINE BILE PIGMENTS+
1)BOTH UNCONJ+ CONJ
BILIRUBIN .
2)ALT (VIRAL),
3)AST(ALCOHOL)
4)ALP-N/MILD
5)URINE BILE
PIGMENTS+
1)CONJ.HYPER
2)ALP- INCREASED
3)ABSENT
UROBILINOGEN/
STERCOBILINOGEN.
CAUSES HEREDITARY
SPHEROCYTOSIS
BLOOD TRANSFUSION
CRIGLER-NAJJAR
GILBERT
DUBIN –JOHNSON
ROTOR SYNDROME
ALCOHOL
VIRAL,DRUGS,
TOXINS
INTRAHEPATIC
HEATITIS
PRIMARY BILIARY
CIRRHOSIS
EXTRAHEPATIC
GALL STONES
CANCER
STRICTURES

21. PRE-HEPATIC HEPATIC POST-HEPATIC
Total Bilirubin Slightly Increased
(Direct < 15%)
Increased Increased
Conj. Bilirubin Normal Increased Increased
Unconj.Bilirubin Increased Increased Normal
Urobilinogen Normal/Increased Increased Negative
Urine Colour Dark(hemoglobinuria) Dark(uro+ Conj.Bil) Dark(conj.Bil)
Aminotransferases Normal Increased Increased
Splenomegaly Present Present Absent

22. EXERCISE 1
 A 45 YRS OLD MALE PRESENTED WITH JAUNDICE
AND FEVER FOR 10 DAYS
LAB:
TOTAL Sr.Bil=12mg, Direct= 5mg
ALT-1000 IU(<40), AST- 400IU (<40),ALP-300IU(20-40)
Diagnosis ?

23. EXERCISE 2
 A 20 yr old patient presented with
jaundice,anemia,splenomegaly
Lab:
TSB-4mg,Direct-0.8
Hb-7
Diagnosis?

24. EXERCISE 3
 65 YRS OLD MALE PATIENT CAME WITH
COMPLAINTS OF GENERALISED
ITCHING,ABDOMINAL PAIN,CLAY COLORED
STOOLS.
LAB
STB- 16mg, Direct-9mg/dl,ALP-600 IU
Urine urobilinogen- Negative.
Diagnosis?