Gastroenterology and Hepatology — Short Cases

b} Gastroenterology and Hepatology—Short Cases Man-Fung Yuen, Wai-Keung Leung, and Ching-Lung Lai Overview Usual patients for abdominal examination: cirrhosis, hepatocel- lular carcinoma, haematological conditions with hepatomegaly and/or splenomegaly, polycystic diseases of the kidneys and the liver (see Chapters 9 and 10), transplanted kidney General examination may not be necessary unless specified because the range of diseases is wide and the time for short case examination is limited. General If relevant, look for stigmata of chronic liver disease: jaundice, pallor, spider angioma/telangiectasia, clubbing of fingers (see below), palmar erythema, Dupuytren’s contracture, leukonykia, flapping tremor and/or fetor hepaticus (unlikely to be present in patients stable enough for the examination), loss of secondary sexual characteristics (hair), testicular atrophy (examine only after asking the patient), shin pigmentation, ankle oedema. Note: rectal, genital, and pelvic examinations are usually not expected in the context of an examination. Clubbing of fingers, early stages: floating sensation, and loss of angle between nail and nail bed. Floating sensation requires TWO hands to elicit; the sensation is best felt near the junction of nail and the nail bed.

Gastroenterology and Hepatology 67 Late stages: increased longitudinal curvature of nails; drum- stick formation (almost never seen in liver diseases). Inspection Note shape, umbilicus (normal, flattened or everted), scars (especially important for transplanted kidneys), dilated veins. Hernial examination should be a special examination. Patient should not be exposed beyond the public area “routinely”. Examination of the genital area should only be carried out after special request to the patient. The breasts need not be exposed for abdominal examination, except for percussion of the upper border of the liver. Ask for the patient’s permission. Palpation General palpation serves the purpose of getting the patient to relax as well as detecting areas of tenderness and obvious abnormal masses/organomegaly. Palpation of liver, spleen, and kidneys may be followed by per- cussion immediately after each organ has been palpated. The palpating hand should remain still while the patient is asked to take deep breaths in order to bring the respective abdominal organ down to meet the palpating hand(s). This caveat also applies to palpation of the kidneys. If the liver is not palpable, remember that it can be small (post- viral cirrhosis), so continue percussing for the lower border of the liver above the costal margin. A shrunken cirrhotic liver may result in almost no liver dullness. For hepatomegaly, determine: — The lower border of the liver expressed as cm below right costal margin and/or below xiphisternum; the upper border, and the span at the right mid-clavicular line. Occasionally, there may be isolated enlargement of the left lobe, e.g., due to localized carcinoma. In describing the liver size, always mention the upper and lower borders in addition to the span.

68 Problem-Based Medical Case Management The span is often erroneously determined when hastily measured; giving the upper and lower borders will ensure no mistakes are made as to whether it is normal or enlarged. (Note: the normal liver span in Asians at the right mid- clavicular line is 10-12 cm; an enlarged liver cannot have a span less than 10 cm.) — The character of the liver edge (sharp, rounded, irregular), surface consistency (soft, firm, hard, nodular), presence or absence of tenderness; presence of bruit need not be determined routinely unless hepatocellular carcinoma or alcoholic hepatitis is suspected. For splenomegaly, determine size below the costal margin by measurement along the longest axis. Also note consistency and tenderness. Palpation of the spleen should be with the finger-tips along a line joining the umbilicus and the left anterior axillary fold (Gardner’s line). There is a general tendency to move the hand lateral to this imaginary line as one moves one’s hand upwards. This is a major reason for missing a spleen tip. In the presence of ascites, if the spleen is not palpable along Gardner’s line, try: — Palpating more laterally in case it has floated laterally. — “Dipping” (ballottement), i.e., using finger-tips to “push” a possibly enlarged spleen downwards through the abdominal wall and wait for it to rebound and hit the finger-tips. A spleen differs from the left kidney: being more anterior, dull on percussion (percuss above the costal margin), having no sub- costal gap and possibly having a notch or notches on the medial border (but only if it is enlarged to > 10 cm below the costal margin). Note: both the spleen and kidney move up and down with respiration due to diaphragmatic movement. Percussion Other than to confirm the size or presence of respective organs, percuss for presence or absence of ascites. In performing shift- ing dullness, after percussing the line of dullness with the

Case 5.1 Gastroenterology and Hepatology ~ 69 patient supine, remember to percuss upwards after turning the patient to the side, to prove that the previously dull area is now resonant. Auscultation Bowel sounds are not very useful in the assessment of medical patients but are obviously relevant in adynamic ileus or intesti- nal obstruction. Vascular bruit over an enlarged liver may be due to hepatoma or alcoholic hepatitis. Renal bruit (see Chapters 9 and 10). 5.1 Alcoholic liver disease Classical signs Parotid swelling Signs of chronic liver disease Hepatomegaly (firm, tender, may have a bruit) Splenomegaly (less common than in chronic viral hepatitis B and C disease) Ascites: usually minimal except in late stage disease Differential diagnosis Cirrhosis with an enlarged liver: ~ Alcoholism ~ Primary biliary cirrhosis — Wilson’s disease - Autoimmune hepatitis - Cardiac cirrhosis - Primary haemachromatosis and primary sclerosing cholan- gitis are exceedingly rare in Asians. ~ Hepatocellular carcinoma superimposed on underlying post- viral cirrhosis

70 Problem-Based Medical Case Management Case 5.2 Important investigations ¢ Blood tests: liver function tests, anti-mitochondrial antibody, copper and caeruloplasmin, anti-nuclear antibody, alpha fetoprotein. o Ultrasonography to exclude associated hepatocellular carcinoma Pitfalls and tips ¢ When uncertain of the abdominal findings, ask the patient to take deeper, slower breaths. ¢ Liver edges are sometimes confused with abdominal wall fat. 5.2 Ascites and splenomegaly Classical signs » Distended abdomen with flattened or everted umbilicus » Dilated veins usually only seen indistinctly * Hernias: ask for the examiner and patient’s permission. + Liver is often not palpable. Percuss for its lower border from below upwards, continuing above the costal margin until the dullness is detected. Find the upper border of liver by down- ward percussion. In postviral cirrhosis, the liver span is often markedly reduced to only one or two intercostal spaces. ¢ Splenomegaly may be more difficult to detect in the presence of ascites. If palpation along Gardner’s line does not reveal the organ, try to palpate more laterally since it may “float” laterally with ascites. “Dipping” (ballottement) should also be performed both along Gardner’s line and more laterally. Try turning the patient onto the right side. Palpate for the spleen with the left hand “hooking” the spleen forward at the renal angle, i.e., angle between the lowermost palpable rib and the lateral border of the erector spinalis muscle (dipping may also be tried in this position). Finally, with patient supine again, percuss along the

Case 5.2 Gastroenterology and Hepatology 71 Gardner’s line from above the umbilicus to one or two spaces above the left costal margin; the whole of Gardner’s line should be resonant in normal subjects. Causes e Cirrhosis of the liver due to chronic hepatitis B or C infection Important investigations * Blood tests: liver function tests, prothrombin time, complete blood picture for hypersplenism * Aectiology tests: hepatitis B serology: HBsAg, HBeAg/anti- HBe, HBV DNA; hepatic C serology: anti-HCV, HCV RNA * Diagnostic abdominal tap for white cell count to exclude spontaneous bacterial peritonitis (ascitic fluid for malignant cytology has < 10% positive rate). Discussion ° Management of ascites should include fluid restriction to 1 litre/day; low (2 g) salt diet; potassium-sparing diuretics, e.g., amiloride, spirolactone (for females); loop diuretics; therapeu- tic paracentesis with adequate albumin replacement. Pitfalls and tips ° Spleens are often missed by palpating too laterally.

72 Problem-Based Medical Case Management Examination case Examination case scenarios i. Undertake a general examination and exainine the abdomen. Important signs e Jaundice e Liver palms « Epigastrium distended « Firm, enlarged liver with an irregular surface e Ascites ¢ No spleen Diagnosis Alcoholic cirrhosis Question What are the causes for cirrhosis with a large liver? « Alcohol, Wilson’s disease or a hepatocellular carcinoma complicating post-viral cirrhosis. ii. Examine this patient’s abdomen. Important signs o Ascites ¢ Hard, slightly enlarged liver with irregular edge, together with associated tenderness and a bruit ° 4 cm spleen Diagnosis Hepatocellular carcinoma Question What are the common aetiological agents for hepatocellular carcinoma? e Hepatitis (B and C), alcohol.