PBL 15 – Another hard day at the office
Rick Allen
Systemic effects of alcohol
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Dupuytren’s contracture – NOT liver disease
Fine resting tremor
Spider naevi – via cirrhosis
Nervous system
o temporary anterograde amnesia.
o Sleep disturbance: ↓ REM, dreams
o Snoring: relaxed pharynx muscles, exacerbate sleep apnoea.
o Impaired judgement, risk taking behaviour, ↓ coordination
o Headache, thirst, nausea, vomiting
o Peripheral neuropathy: bilateral limb numbness, tingling, parasthesia
o Cerebellar degeneration and atrophy: gait and stance, nystagmus
o Wernicke Korsakoff
o Cerebral degeneration and atrophy: ↓ cognition. Reversible
o LOTS of psych syndromes
GIT
o Bilateral parotidomegaly – fatty infiltration
o Glossitis – malnutrition?
o Oesophagitis, gastritis  bleeding.
o Vomiting  Mallory Weiss tear.
o Pancreas – pancreatitis.
o Liver – impairs gluconeogenesis  ↓glucose from glycogen, ↑ lactate, ↓fatty
acid oxidation  fat accumulation in liver
o Leukoplakia – white thickening of the tounge, premalignant
Cancer
o ↑ risk for breast, oral, oesophageal, rectal and others.
Haematopoietic
o ↑ MCV, ↓ WBC (chronic), suppress marrow  thrombocytopeniaPetechiae
CVS
o ↓contractility, ↑ peripheral vasodilation  ↓BP and ↑ CO
o Chronic  dose related ↑ in BP  HTN
o Cardiomyopathy (dilatation) mural thrombi and arrhythmia
Genitals
o Testicular atrophy
o Erectile dysfunction
o Gynaecomastia – damage to Leydig cells in testis, alcoholic cirrohosis 
estrogen : testosterone shift.
o Amenorrhea, ↓ovarian size, ↑abortion risk, fetal alcohol syndrome.
MSK
o Alcoholic proximal myopathy: skeletal muscle weakness. Cachexia: malnutrition?
o Ca metabolism changes, ↓bone density, ↓growth  ↑ fracture risk & necrosis
Endocrine
o ↑ cortisol
o ↓vasopressin initially then ↑ once alcohol levels fall
o ↓serum thyroxine (T3) and T4.
PBL 15 – Another hard day at the office
Rick Allen
Systemic effects of liver disease
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Acute liver disease can be asymptomatic. Can be general (fever, malaise, anorexia).
Jaundice as the disease progresses. Signs = jaundice and enlarged liver. Cholestatic –
pale stools and dark urine. Spider naevi and palmar erythema.
CHRONIC – examination may be normal!!!
Nails
o Leuconychia – white nail bed, due to hypoalbuminaemia. Unknown mechanism.
o Muehrcke’s lines – transvers white lines, due to hypoalbuminaemia
o Blue lunulae – Wilson’s disease (hepatolenticular degeneration)
o Clubbing – 1/3 pt.s w. cirrhosis.
o Cyanosis – severe long standing liver disease
Palms
o Palmar erythema – can affect soles, unknown aeitiology, chronic liver disease
and many other causes. Estrogen related?
o Asterixis (hepatic flap) - hepatic encephalopathy, interruption of proprioception
to brainstem reticular formation. Absent at rest, bilateral, not synchronus.
EARLY sign of liver failure.
o Apparent tremor – Wilson’s disease
Arms
o Bruising – ecchymoses may be due to clotting abnormalities. Petechiae – due to
DIC in severe liver disease (or acute hepatic necrosis) OR hypersplenism from
portal HTN.
o Pruritis – obstructive/ cholestatic jaundice. Presenting feature of primary biliary
cirrhosis. Retention of a bile substance? Cholestasis
o Spider naevi – areas of drainage of the SVC. Arms, neck, chest. Thought to be
estrogen related (cirrhosis/viral hep/ chronic liver failure can’t inactivate E 
excess  dilate the arteries of blushing?)
Eyes
o Jaundice in sclera
o Kayser-Fleischer rings – Wilson’s disease -> inappropriate copper metabolism
o Xanthelasma/Xanthamata – increased serum cholesterol, possibly due to
cholestasis  lipoprotein X. Common in primary biliary cirrhosis
Mouth
o Fetor hepaticus – sweet smelling breath due to failure to demethylate
methionine in the diseased liver (severe hepatocellular disease).
o Haematemesis – bleeding oesophageal varices
Chest
o Gynaecomastia – chronic liver disease, cirrhosis, chronic autoimmune hepatitis
 estrogen : testosterone shift. (Spironolactone trying to treat ascites in portal
HTN.
o Loss of libido, testicular atrophy and amenorrhea for same reasons.
Abdomen
o Distension/ascites – Portal HTN
o Caput Medusae – Portal HTN  shunt to systemic flow via umbilical veins. Flow
away from umbilicus.
o Hepatomegaly- If only left lobe felt, cirrhosis.
 Large – metastases, steatosis/steatohepatitis, RHF, HCC
PBL 15 – Another hard day at the office
Rick Allen
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Mod – the above + haemochromotosis, haematological cancer, fatty
liver secondary to obesity DM or toxins, infiltration
 Small – above + hepatitis, biliary obstruction, hydatid cyst, HIV
 Firm/irregular – HCC, metastases, cirrhosis, hydatid, granuloma….
 Tender – hepatitis, rapid enlargement (RHF, hepatic vein thrombosis),
HCC, hepatic abcess, biliary obstruction
 Pulsatile – HCC, vascular abnormalities, tricuspid regurg.
Hepatosplenomegaly – chronic liver disease  portal HTN
Loss of liver dullness on percussion – massive hepatic necrosis
Friction rub auscultated – inflam. of liver, HCC/metastases, abscess, recent
biopsy, liver infarct  parietal and visceral peritoneum.
Venous hum – Shunt/patent umbilical vein due to portal HTN (cirrhosis)
Acute abdomen – bleed in hepatic tumour
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Legs
o Peripheral oedema – portal HTN
o Cachexia and bruising
Poop and pee
o Steatorrhea, pale stools, dark urine. Malena from bleeding varices.
Systemic
o Fever (1/3 pt.s w. advanced cirrhosis) or infected ascites.
o Hepatic encephalopathy (stuperous  coma) Cirrhosis or Fulminant hep. Failure
to remove toxins (organ failure and shunt)
o Pigmentation (chronic liver disease/haemochromatosis  haemosiderin
stimulate melanocytes)
o Porphyria cutanea tarda (fragile vesicle on skin  scar. Chronic poor metabolism
of porphyrin due to alcoholism, liver disease, Hep C) pg 158
o Jaundice(conjunctival or skin)
o Lethargy (acute/chronic liver disease, unknown mechanism)
o Cachexia and weight loss (liver adenoma and HCC)
PBL 15 – Another hard day at the office
Rick Allen
Cirrhosis = 2 or more of spider naevi, palmar erythema, splenomegaly/ascites, abnormal collateral
veins on the abdomen.
Portal HTN Signs = Splenomegaly, collateral veins  haematemesis, ascites
Causes= Cirrhosis, presinusoidal (portal vein compression eg cancer, intravascular
clotting eg polycythemia, umbilical vein phlebitis), intrahepatic (sarcoid/lymphoma/leukaemic
infiltrates, congential hepatic fibrosis), postsinusoidal (hepatic vein outflow obstruction: idiopathic,
pregnancy, the pill, cancer, paroxysmal nocturnal haemoglobinuria, trauma, schistosomiasis. Venoocclusive disease, constrictive pericarditis, chronic cardiac failure)
Hepatic Encephalopathy =
Grade 0 = normal
Grade 1 = changes (↓ awareness, anxiety, euphoria, ↓ attention span, ↓ math ability)
Grade 2 = lethargy, disorientation (time), personality changes, inappropriate behaviour
Grade 3 = stupor, confusion
Grade 4 = coma
Causes = acute liver failure, cirrhosis, chronic portosystemic encephalopathy (shunt)
Precipitated by = diarrhoea, vomiting or diuretics (hypokalaemia  ↑ ammonia production)
GI bleed or ↑ protein diet (nitrogenous bowel contents)
Infection
Acute liver cell decompensation (alcohol binge or hepatoma)
sedatives
Metabolic disturbances eg hypoglycaemia