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Approach to the Patient with liver Disease (LIVER DISEASES (DIAGNOSIS OF…

- - - - symptoms of liver disease (nature, patterns of onset, and progression); constellation of symptoms and their patterns of onset rather than a specific symptom points to an etiology; manifestations:
        
        constitutional symptoms
        
        fatigue: most common + most characteristic symptom of liver disease; describ as lethargy, weakness, listlessness, malaise, incr need for sleep, lack of stamina, and poor energy; typically arises after activity or exercise + rarely present or severe after adequate rest; i.e., it is “afternoon” rather than “morning” fatigue; often intermittent and variable in severity from hour to hour and day to day.
        
        nausea: occurs w/ more severe liver disease + may accompany fatigue or be provoked by smelling food odors or eating fatty foods. Vomiting can occur but rarely persistent or prominent.
        
        poor appetite: w/ weight loss occurs frequently in acute liver disease but rare in chronic disease except when cirrhosis present and advanced.
        
        Diarrhea uncommon except w/ severe jaundice (lack of bile acids reaching intestine can lead to steatorrhea)
        
        malaise
        
        more liver-specific symptoms
        
        Jaundice, dark urine, light stools: Jaundice hallmark symptom of liver disease + most reliable marker of severity. Patients u. report darkening of urine before noticing scleral icterus; rarely detectable w/ a bilirubin level < 2.5 mg/dL; w/ severe cholestasis--> also lightening of stools colour and steatorrhea; Jaundice w/o dark urine u. indicates indirect (unconjugated) hyperbilirubinemia + typical of hemolytic anemia and genetic disorders of bilirubin conjugation (common and benign form= Gilbert’s syndrome (5% of general population; jaundice more noticeable after fasting + w/ stress) + rare and severe form= Crigler-Najjar syndrome)
        
        itching: occurs w/ acute liver disease, appearing early in obstructive jaundice (from biliary obstruction or drug-induced cholestasis) and somewhat later in hepatocellular disease (acute hepatitis); also occurs in chronic liver diseases—typically cholestatic forms such as PBC and sclerosing cholangitis, in which it is often presenting symptom, preceding onset of jaundice; can occur in any liver disease, particularly once cirrhosis develops.
        
        abdominal pain: RUQ discomfort or ache (“liver pain”): in many liver diseases and u. marked by tenderness over liver area; arises from stretching or irritation of Glisson’s capsule (surrounds liver and rich in nerve endings); Severe pain most typical of gallbladder disease, liver abscess, and severe veno-occlusive disease but also an occasional accompaniment of acute hepatitis.
        
        bloating
        
        suggestive of cirrhosis, end-stage liver disease, or complications of cirrhosis such as portal HTN
      - and on potential RFs for liver disease:
        Major RFs:
        alcohol use,
        medication use (including herbal compounds, birth control pills, and over-the-counter medications),
        personal habits,
        sexual activity,
        travel,
        exposure to jaundiced or other high-risk persons,
        injection drug use,
        recent surgery,
        remote or recent transfusion of blood or blood products,
        occupation,
        accidental exposure to blood or needlestick,
        and familial history of liver disease.
        
        assessing risk of viral hepatitis:
        careful history of sexual activity (#number of lifetime sexual partners and, for men, a history of having sex with men. Sexual exposure is a common mode of spread of hepatitis B but is rare for hepatitis C. A family history of hepatitis, liver disease, and liver cancer is also important. Maternal-infant transmission occurs with both hepatitis B and C. Vertical spread of hepatitis B can now be prevented by passive and active immunization of the infant at birth. Vertical spread of hepatitis C is uncommon, but there are no reliable means of prevention. Transmission is more common among HIV-coinfected mothers and is also linked to prolonged and difficult labor and delivery, early rupture of membranes, and internal fetal monitoring. A history of injection drug use, even in the remote past, is of great importance in assessing the risk for hepatitis B and C. Injection drug use is now the single most common risk factor for hepatitis C. Transfusion with blood or blood products is no longer an important risk factor for acute viral hepatitis. However, blood transfusions received before the introduction of sensitive enzyme immunoassays for antibody to hepatitis C virus in 1992 is an important risk factor for chronic hepatitis C. Blood transfusion before 1986, when screening for antibody to hepatitis B core antigen was introduced, is also a risk factor for hepatitis B. Travel to a developing area of the world, exposure to persons with jaundice, and exposure to young children in day-care centers are risk factors for hepatitis A. Tattooing and body piercing (for hepatitis B and C) and eating shellfish (for hepatitis A) are frequently mentioned but are actually types of exposure that quite rarely lead to the acquisition of hepatitis.