COMMENTARY

Evaluating the Patient With Abnormal Liver Tests

Rowen K. Zetterman, MD

Disclosures

October 08, 2009

In This Article

History and Physical Examination

The symptoms of liver disease are nonspecific. Anorexia, nausea and vomiting, fever and chills, right-upper-quadrant pain, dark urine and light-colored stools, or alteration of taste for cigarettes (suggesting acute hepatitis) may be present. Dry mouth and dry eyes are associated with autoimmune disorders such as primary biliary cirrhosis, and pruritus develops with intrahepatic cholestasis or extrahepatic biliary blockage. In advanced liver disease, symptoms of confusion and disorientation may indicate hepatic encephalopathy. A history of illicit or prescribed medications, ethanol use, tattoos (especially self-administered), multiple sexual partners, and travel to endemic areas can raise questions of drug-induced or chronic viral hepatitis. The presence of type 2 diabetes mellitus, hypertension, or hyperlipidemia can suggest NAFLD.[12]

Table 1 summarizes signs that may suggest underlying liver disease and associated conditions.

Table 1. Signs of Liver Disease and Related Conditions

Physical Sign Possible Condition
Jaundice, spider angiomata Cirrhosis
Pregnancy
Hyperthyroidism
Hyperpigmentation Primary biliary cirrhosis
Cutaneous excoriations Cholestasis
Dupuytren's contractures Alcoholism
White nails, clubbing Cirrhosis
Xanthomata, xanthelasma Primary biliary cirrhosis
Obesity, increased waist circumference[13] Nonalcoholic fatty liver disease
Kayser-Fleischer corneal rings Wilson's disease
Parotid enlargement Alcoholic liver disease
Signs of congestive heart failure: jugular venous distention, right pleural effusion, S3 gallop Cardiac cirrhosis
Gynecomastia, testicular atrophy Cirrhosis
Peripheral edema, signs of ascites, hepatosplenomegaly, caput medusa Cirrhosis
Arterial bruit heard over the liver Hepatocellular carcinoma, alcoholic hepatitis, arteriovenous malformation (rare)


Age and Chronic Liver Disorders in Adults

Chronic liver disorders tend to group within specific age ranges. In the teenage years, Wilson's disease and autoimmune hepatitis are the most prevalent chronic liver diseases. During the twenties, Wilson's disease continues to present as liver disease up to the age of 25 years, and autoimmune hepatitis and chronic viral hepatitis also occur. In the 30-year age group, chronic viral hepatitis and primary biliary cirrhosis (90% are women) are likely. During the forties and fifties, primary biliary cirrhosis remains prevalent in women and alcoholic hepatitis, chronic viral hepatitis, and hemochromatosis occur in men.

After age 60 years, hemochromatosis will also be found in women and alpha-1 antitrypsin deficiency and cryptogenic cirrhosis become more common in both sexes. Drug-induced liver disease can be found at any age, although it is more common in older adults. Primary sclerosing cholangitis may also occur at any age, although it tends to occur in men in their twenties and thirties. NAFLD coupled with metabolic syndrome and occasionally alpha-1 antitrypsin deficiency occurs at any age.

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