Physical methods of liver examination

During a general examination of a patient with liver disease, a number of signs are found that allow one to suspect not only liver damage, but also to make a tentative statement about its etiology. It is important to keep in mind that these signs can be identified by examining a variety of organs and systems: skin, face, eyes, salivary glands, palms and feet, mammary glands, testicles. Minor and major liver signs are distinguished.

Signs of liver damage revealed during a general examination of the patient

Chronic hepatitis and liver cirrhosis of any etiology.	Clubbing of the fingers; liver palms and feet; spider veins; jaundice, ascites, edema.
Alcoholic hepatitis and liver cirrhosis.	Facies alcoholica; spider veins; intense palmar erythema; Dupuytren's contracture; gynecomastia; testicular atrophy; enlarged parotid glands.
Primary biliary cirrhosis.	Xanthelasma, xanthomas, skin hyperpigmentation.
Bile duct obstruction, primary sclerosing cholangitis (cholestasis).	Scratching; hyperpigmentation of the skin.
Liver cirrhosis with portal hypertension.	Dilation of the veins of the abdominal wall; ascites.
Liver cirrhosis with hepatocellular insufficiency.	Intense jaundice; edematous-ascitic syndrome; hemorrhagic syndrome (bruises, purpura); "liver" odor (factor hepaticus); tremor of the hands, tongue.
Wilson-Konovalov disease.	Kayser-Fleischer ring (during an ophthalmologist examination).

Minor liver signs include, first of all, skin changes: spider veins ( telangiectasias ) - from single to scattered in large numbers (fields of spider veins), a peculiar enhancement of the skin vascular pattern (areas of skin resembling a paper banknote), as well as the so-called liver palms (palmar erythema) and feet, caused by hyperestrogenemia and, possibly, the functioning of arteriovenous anastomoses, which indicates primarily cirrhosis of the liver of viral and alcoholic etiology, less often - acute hepatitis. Vascular changes in the skin can also have the appearance of classic hemorrhagic vasculitis ( Schonlein-Henoch purpura ), often very widespread, and usually reflect the activity of chronic hepatitis or cirrhosis of the liver, sometimes ulcers form in places of vascular changes.

In liver diseases, the skin may also show manifestations of hemorrhagic syndrome (from small petechiae to bruises), often found due to low prothrombin levels or thrombocytopenia. Cholesterol depots - xanthomas with typical localization in the eyelid area (xanthelasma) - give the skin a peculiar appearance, which may indicate primary biliary cirrhosis of the liver. Increased levels of estrogens, poorly metabolized by the affected liver, cause the development of gynecomastia - a common symptom of alcoholic liver cirrhosis. Alcoholic liver cirrhosis is indicated by enlarged parotid salivary glands; sometimes very pronounced (giant mumps), as well as peculiar cicatricial fibrous compactions of the palmar aponeurosis - Dupuytren's contractures. In alcoholic liver disease, testicular atrophy is sometimes detected. Often, with long-term liver cirrhosis of various etiologies, clubbing-type changes in the terminal phalanges of the fingers are detected.

Finally, it is necessary to specifically name another sign, detected during a general examination, - the presence of the Kayser-Fleischer ring, easily detected by an ophthalmologist in the form of a peculiar change in the cornea. This sign with a high degree of reliability allows us to state a long-term (genetically determined) disorder of copper metabolism, leading to the development of liver cirrhosis in Wilson-Konovalov disease.

During a general examination, attention is paid to the degree of exhaustion, especially pronounced in advanced cirrhosis or liver cancer, while general weight loss is often combined with large abdominal dimensions due to ascites. Of no small importance for understanding the genesis of isolated ascites is the detection of dilated veins of the abdominal wall (the so-called head of Medusa), which with a high probability allows us to discuss the presence of portal hypertension.

Finally, it should be noted that some liver diseases, especially those that are actively progressing (the so-called chronic active hepatitis and active liver cirrhosis), may be accompanied by a number of general (systemic) non-specific syndromes - non-infectious fever (naturally, with cholecystitis, cholangitis, liver abscess, the fever is typically infectious, often hectic, with chills and profuse sweating), arthritis, vascular changes with Raynaud's syndrome (dead fingers syndrome), the so-called dry syndrome ( Sjogren's syndrome - lack of saliva formation - xerostomia, tears - keratoconjunctivitis, widespread dental caries). Sometimes liver disease manifests itself with these very signs, resembling or repeating another disease, for example, scleroderma, systemic lupus erythematosus, rheumatoid arthritis, and only a thorough study of the anamnesis and the results of liver examination, including biopsy, allow us to diagnose primary liver disease.

The so-called major liver signs are signs of syndromes characteristic of liver diseases ( jaundice, portal hypertension, etc.).

The main method of physical examination of the liver, as well as other abdominal organs, including the spleen, is palpation, but it is preceded by inspection and percussion, which allow for an approximate assessment of the size of these organs. Usually, the spleen is examined after the liver is examined.

When examining the liver area, one can only note a significant enlargement of the liver ( hepatomegaly ), which is better detected with a thin abdominal wall, due to volumetric formations (tumor nodes, echinococcal cysts, large abscess), sometimes with cirrhosis, congestive liver with heart failure. In all these cases, attention is drawn to the asymmetry of the abdomen due to bulging and lagging behind in the movement of the abdominal wall in the right hypochondrium and epigastrium. One can also see the pulsation of the enlarged liver due to the wave of blood regurgitation with tricuspid valve insufficiency.

An enlarged gallbladder (dropsy, empyema of the gallbladder) can cause a visible protrusion and is easily palpated with a large accumulation of bile in it (absence of adhesions, excluding recurrent chronic cholecystitis ), the outflow of which is hampered by compression of the common bile duct by a tumor of the head of the pancreas or in the area of the large papilla of the duodenum (the papilla of Vater is the place where the common bile duct enters the duodenum), known as Courvoisier's symptom.