Cirrhosis physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Patients with cirrhosis usually present with signs of jaundice, palmar erythema, spider angiomata, gynaecomastia and alteration of mental status arising due to complications of cirrhosis. Abdominal examination may show signs of abdominal distension, caput medusae, splenomegaly and flank dullness on percussion. Other findings on examination include nail changes, presence of Clubbing, dupuytren’s contracture(flexion deformities of the fingers) and Asterixis in cases with hepatic encephalopathy.

• Physical examination of patients with cirrhosis is usually remarkable for: jaundice, spider angiomata, ascites, asterixis, spleenomegaly and palmar erythema.

• Patients with cirrhosis usually appear weak due to constitutional symptoms such as weight loss, anorexia and muscle atrophy. Yellowish discoloration of skin and abdominal distension may also be present due to ascites.

• Normal/low blood pressure with normal pulse pressure.

• Jaundice : yellow discoloration of the skin, eyes, and mucus membranes due to increased bilirubin (at least 2-3 mg/dL or 30 mmol/L). Urine may also appear dark.
• Pallor
• Bruises
• Palmar erythema on the thenar and hypothenar eminences, due to altered sex hormone metabolism.
• Spider angiomata: Increased estradiol levels lead to the formation of vascular lesions consisting of central arterioles surrounded by smaller vessels ^[1] 
• Telangiectasias or spider veins: small dilated blood vessels near the surface of the skin.

• 
  Telingectasias
  Source: Wikimedia commons
• 
  Palmar erythema
  Source: Wikimedia commons^[2]

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• Abnormalities of the head/hair may include thinning of hair on the scalp due to hyperestrogenism
• Kayser-Fleischer rings: dark rings that appear to encircle the iris of the eye in patients with Wilson’s disease^[3]
• Parotid gland enlargement
• Fetor hepaticus: severe portal-systemic shunting leads to increased levels of dimethyl sulfide leads to a sweet pungent smell in the breath

• Inspection:
  • Abdominal distension
  • Caput medusae^[4][5]

• Palpation:
  • Fluid wave
  • Hepatomegaly may be present in initial stages. The liver may also be normal or shrunken.
  • Spleenomegaly may be present in patients with cirrhosis from nonalcoholic etiologies, due to portal hypertension

• Percussion:
  •  Flank dullness may be present due to ascites (needs approximately 1500ml for detection)

• Auscultation:
  • Cruveilhier-Baumgarten murmur: venous hum that may be present in patients with portal hypertension.
    • Mechanism: due to collateral connections between remnant of the umbilical vein and the portal system
    • Location: Epigastrium
    • Exacerbating factors: Valsalva maneuver
    • Diminished by: application of pressure on the skin above the umbilicus

• 
  Abdominal distention, ascites-By James Heilman, MD (Own work) ^[6]

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• Testicular atrophy 
• Inversion of the normal male pubic hair pattern

• Hepatic encephalopathy may have signs of:
  • Alteration of mental status
  • Confusion
  • Coma
• Asterixis (bilateral but asynchronous flapping motions of outstretched, dorsiflexed hands) is seen in patients with hepatic encephalopathy.

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• Edema of the lower extremities
• Muscle atrophy
• Nail changes:^[7]
  • Muehrcke nails: paired horizontal white bands separated by normal color due to hypoalbuminemia ^{[8][9][10][11][12]}
  • Terry nails: the proximal two-thirds of the nail plate appears white, whereas the distal one-third is red due to hypoalbuminemia
  •  Clubbing:  the angle between the nail plate and proximal nail fold is greater than 180 degrees
  • Severe clubbing:
    • “Drum stick” appearance of distal fingers
    • Hypertrophic osteoarthropathy: chronic proliferative periostitis of the long bones ^[13][14]
• Dupuytren’s contracture may cause flexion deformities of the fingers: This occurs due to shortening and thickening of the palmar fascia, due to collagen deposition and fibroblastic proliferation.^[15]
• Asterixis in cases with hepatic encephalopathy^[16][17][18]

• 
  Dupuytren’s contracture
  Source: Wikimedia commons
• 
  Dupuytren´s Contracture on the ring finger ^[19]
• 
  Clubbing: angle between the nail plate and proximal nail fold is greater than 180 degrees
  Source: Wikimedia commons
• 
  Muehrcke’s nails: paired horizontal white bands separated by normal color
  Source:Wikimedia commons ^[20]

• Gynecomastia: due to increased estradiol levels
• Loss of chest or axillary hair

• Hemorrhoids
• Hematemesis
• Melena

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