Hepatic encephalopathy physical examination: Difference between revisions

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__NOTOC__
__NOTOC__
{{Hepatic encephalopathy}}
{{Hepatic encephalopathy}}
{{CMG}}<nowiki>;{{AE}</nowiki>{{MMJ}}
{{CMG}};{{AE}}{{MMJ}}
==Overview==
==Overview==
In addition to changed level of consciousness, the hallmark of hepatic encephalopathy on the physical examination is the presence of [[asterixis]]. This is detected by having the patient hold out his outstretched arms and hands and cock his wrists back. In the presence of asterixis, there is a non-synchronized, intermittent flapping motion at the wrists. Asterixis is not specific to hepatic encephalopathy. It may also be seen in states such as [[renal failure]] and [[carbon dioxide]] retention.
In addition to changed level of consciousness, the hallmark of hepatic encephalopathy on the physical examination is the presence of [[asterixis]]. This is detected by having the patient hold out his outstretched arms and cocking his [[Wrist|wrists]] back. In the presence of [[asterixis]], there is a non-synchronized, intermittent flapping motion at the [[Wrist|wrists]]. Asterixis is not specific to hepatic encephalopathy. It may also be seen in states such as [[renal failure]] and [[carbon dioxide]] retention.
 
==Physical Examination==
 
===Skin===
*
 
*
 
===Abdomen===
*Signs of liver disease, such fluid collection in the abdomen ([[ascites]]), and occasionally a musty odor urine.
 
===Neurologic===
Nervous system signs may change. Signs include:
*Coarse, "flapping" shaking of the hands when attempting to hold the arms out in front of the body and lift the hands.
*Abnormal mental status, particularly cognitive (thinking) tasks such as connecting numbers with lines.
 
==References==
{{Reflist|2}}
 
[[Category:Disease]]
[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
 
{{WH}}
{{WS}}
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
==Physical Examination==
==Physical Examination==
*Physical examination of patients with hepatic encephalopathy is usually remarkable for: signs of [[personality changes]], signs of altered level of [[consciousness]], observing [[Jerking|jerking movement]] of the limbs([[asterixis]]), [[slurred speech]], writing disturbances, voice monotonous and [[Impaired memory]].<ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref><ref name="pmid4340155">{{cite journal| author=al-Arif A, Sporn MB| title=2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1716-9 | pmid=4340155 | doi= | pmc=426785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4340155  }} </ref><ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
*[[Physical examination]] of patients with hepatic encephalopathy is usually remarkable for signs of [[personality changes]], signs of altered level of [[consciousness]], [[Jerking|jerking movement]] of the [[limbs]] ([[asterixis]]), [[slurred speech]], writing disturbances, monotonous voice and [[impaired memory]]<ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref><ref name="pmid4340155">{{cite journal| author=al-Arif A, Sporn MB| title=2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1716-9 | pmid=4340155 | doi= | pmc=426785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4340155  }} </ref><ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
*The presence of [[asterixis]] on physical examination is highly suggestive of hepatic encephalopathy.<ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111 }} </ref>
===Appearance of the patient===
===Appearance of the Patient===
*Patients with hepatic encephalopathy usually appear [[Confusion|confused]], [[Drowsiness|drowsy]] and sometimes [[irritable]]<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457 }} </ref><ref name="pmid22348593">{{cite journal| author=Salam M, Matherly S, Farooq IS, Stravitz RT, Sterling RK, Sanyal AJ et al.| title=Modified-orientation log to assess hepatic encephalopathy. | journal=Aliment Pharmacol Ther | year= 2012 | volume= 35 | issue= 8 | pages= 913-20 | pmid=22348593 | doi=10.1111/j.1365-2036.2012.05038.x | pmc=3616137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22348593 }} </ref>
*Patients with hepatic encephalopathy usually appear confused, drowsy and sometimes [[irritable]].<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457 }} </ref>


===Vital Signs===
===Vital signs===
In patients with hepatic encephalopathy [[vital signs]] include:<ref name="pmid28835821">{{cite journal| author=Wannhoff A, Nusshag C, Stremmel W, Merle U| title=Slow ventricular tachycardia presenting with acute liver failure. | journal=SAGE Open Med Case Rep | year= 2017 | volume= 5 | issue=  | pages= 2050313X17718100 | pmid=28835821 | doi=10.1177/2050313X17718100 | pmc=5528920 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28835821  }} </ref>
In patients with hepatic encephalopathy [[vital signs]] include:<ref name="pmid28835821">{{cite journal| author=Wannhoff A, Nusshag C, Stremmel W, Merle U| title=Slow ventricular tachycardia presenting with acute liver failure. | journal=SAGE Open Med Case Rep | year= 2017 | volume= 5 | issue=  | pages= 2050313X17718100 | pmid=28835821 | doi=10.1177/2050313X17718100 | pmc=5528920 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28835821  }} </ref>
*[[Blood pressure]] may be normal or low or high.
*[[Blood pressure]] may be normal, low or high.
*[[Hypothermia]] or [[hyperthermia]] may be present
*[[Hypothermia]] or [[hyperthermia]] may be present
*[[Tachycardia]] with regular pulse may be present
*[[Tachycardia]] with regular [[pulse]] may be present


===Skin===
===Skin===
Signs of [[Liver diseases|liver disease]], may be seen such as:<ref name="pmid25755383">{{cite journal| author=Dogra S, Jindal R| title=Cutaneous manifestations of common liver diseases. | journal=J Clin Exp Hepatol | year= 2011 | volume= 1 | issue= 3 | pages= 177-84 | pmid=25755383 | doi=10.1016/S0973-6883(11)60235-1 | pmc=3940632 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25755383  }} </ref>
Signs of [[Liver diseases|liver disease]] may be seen, such as:<ref name="pmid25755383">{{cite journal| author=Dogra S, Jindal R| title=Cutaneous manifestations of common liver diseases. | journal=J Clin Exp Hepatol | year= 2011 | volume= 1 | issue= 3 | pages= 177-84 | pmid=25755383 | doi=10.1016/S0973-6883(11)60235-1 | pmc=3940632 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25755383  }} </ref>
*[[Yellow skin]]
*[[Yellow skin]]
*Protracted and disabling [[pruritus]]
*Protracted and disabling [[pruritus]]
*[[Spider angioma|Spider angiomas]]
*[[Spider angioma|Spider angiomas]]
*[[Palmar erythema]] <gallery widths="150px">
*[[Palmar erythema]]
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>
===HEENT===
===HEENT===
*Icteric [[sclera]]<ref name="pmid25755383" />
*[[Icterus (medicine)|Icteric]] [[sclera]]<ref name="pmid25755383" />
*[[Mydriasis|Dilated pupils]], sluggishly responsive to light<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
*[[Mydriasis|Dilated pupils]], sluggishly responsive to light<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
*Ophthalmoscopic exam may be abnormal with findings of papilledema<ref name="pmid1615943">{{cite journal| author=Crippin JS, Gross JB, Lindor KD| title=Increased intracranial pressure and hepatic encephalopathy in chronic liver disease. | journal=Am J Gastroenterol | year= 1992 | volume= 87 | issue= 7 | pages= 879-82 | pmid=1615943 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1615943  }} </ref>
*[[Ophthalmoscopy|Ophthalmoscopic]] exam may be abnormal with findings of [[papilledema]]<ref name="pmid1615943">{{cite journal| author=Crippin JS, Gross JB, Lindor KD| title=Increased intracranial pressure and hepatic encephalopathy in chronic liver disease. | journal=Am J Gastroenterol | year= 1992 | volume= 87 | issue= 7 | pages= 879-82 | pmid=1615943 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1615943  }} </ref>


===Neck===
===Neck===
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===Lungs===
===Lungs===
[[Physical examination]] of lungs is usually normal.
[[Physical examination]] of [[lungs]] is usually normal


===Heart===
===Heart===
[[Physical examination]] of heart is usually normal.
[[Physical examination]] of [[heart]] is usually normal


===Abdomen===
===Abdomen===
Signs of liver disease may be seen such as:
Signs of liver disease may be seen such as:
* Fluid collection in the abdomen ([[ascites]])<ref name="pmid4579401">{{cite journal| author=Losowsky MS, Scott BB| title=Ascites and oedema in liver disease. | journal=Br Med J | year= 1973 | volume= 3 | issue= 5875 | pages= 336-8 | pmid=4579401 | doi= | pmc=1586440 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4579401  }} </ref>
* Fluid collection in the [[abdomen]] ([[ascites]])<ref name="pmid4579401">{{cite journal| author=Losowsky MS, Scott BB| title=Ascites and oedema in liver disease. | journal=Br Med J | year= 1973 | volume= 3 | issue= 5875 | pages= 336-8 | pmid=4579401 | doi= | pmc=1586440 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4579401  }} </ref>
* [[abdominal tenderness]]<ref name="pmid14627332">{{cite journal| author=Riley TR, Koch K| title=Characteristics of upper abdominal pain in those with chronic liver disease. | journal=Dig Dis Sci | year= 2003 | volume= 48 | issue= 10 | pages= 1914-8 | pmid=14627332 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14627332  }} </ref>
* [[Abdominal tenderness]]<ref name="pmid14627332">{{cite journal| author=Riley TR, Koch K| title=Characteristics of upper abdominal pain in those with chronic liver disease. | journal=Dig Dis Sci | year= 2003 | volume= 48 | issue= 10 | pages= 1914-8 | pmid=14627332 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14627332  }} </ref>
*A palpable liver in the [[epigastrium]]([[hepatomegaly]])<ref name="pmid15618841">{{cite journal| author=McCormick PA, Nolan N| title=Palpable epigastric liver as a physical sign of cirrhosis: a prospective study. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 12 | pages= 1331-4 | pmid=15618841 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15618841  }} </ref>
*A palpable [[liver]] in the [[epigastrium]] ([[hepatomegaly]]- feel with [[inspiration]], relocate during [[expiration]])<ref name="pmid15618841">{{cite journal| author=McCormick PA, Nolan N| title=Palpable epigastric liver as a physical sign of cirrhosis: a prospective study. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 12 | pages= 1331-4 | pmid=15618841 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15618841  }} </ref>


===Back===
===Back===
[[Physical examination]] of back is usually normal.
[[Physical examination]] of back is usually normal


===Genitourinary===
===Genitourinary===
[[Physical examination]] of [[genitourinary system]] is usually normal.
[[Physical examination]] of [[genitourinary system]] is usually normal


===Neuromuscular===
===Neuromuscular===
*Patient may be unoriented to persons, place, and time<ref name="pmid22348593">{{cite journal| author=Salam M, Matherly S, Farooq IS, Stravitz RT, Sterling RK, Sanyal AJ et al.| title=Modified-orientation log to assess hepatic encephalopathy. | journal=Aliment Pharmacol Ther | year= 2012 | volume= 35 | issue= 8 | pages= 913-20 | pmid=22348593 | doi=10.1111/j.1365-2036.2012.05038.x | pmc=3616137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22348593 }} </ref>
*J[[Jerking|erking movement]] of the [[limbs]] ([[asterixis]]) is highly suggestive of hepatic encephalopathy<ref name="pmid27089111" />
*Altered mental status may be seen<ref name="pmid23474970">{{cite journal| author=Rahimi RS, Elliott AC, Rockey DC| title=Altered mental status in cirrhosis: etiologies and outcomes. | journal=J Investig Med | year= 2013 | volume= 61 | issue= 4 | pages= 695-700 | pmid=23474970 | doi=10.2310/JIM.0b013e318289e254 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23474970  }} </ref>
*[[Attention deficit]] and slow information processing<ref name="pmid24357348">{{cite journal| author=Nabi E, Bajaj JS| title=Useful tests for hepatic encephalopathy in clinical practice. | journal=Curr Gastroenterol Rep | year= 2014 | volume= 16 | issue= 1 | pages= 362 | pmid=24357348 | doi=10.1007/s11894-013-0362-0 | pmc=3918211 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24357348  }} </ref>
*[[Glasgow coma scale]] can be reduced
*Abnormal paper and pencil tests<ref name="pmid24357348">{{cite journal| author=Nabi E, Bajaj JS| title=Useful tests for hepatic encephalopathy in clinical practice. | journal=Curr Gastroenterol Rep | year= 2014 | volume= 16 | issue= 1 | pages= 362 | pmid=24357348 | doi=10.1007/s11894-013-0362-0 | pmc=3918211 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24357348 }} </ref>
*[[Altered mental status]] may be seen<ref name="pmid23474970">{{cite journal| author=Rahimi RS, Elliott AC, Rockey DC| title=Altered mental status in cirrhosis: etiologies and outcomes. | journal=J Investig Med | year= 2013 | volume= 61 | issue= 4 | pages= 695-700 | pmid=23474970 | doi=10.2310/JIM.0b013e318289e254 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23474970  }} </ref>
*Scoring on [[Glasgow coma scale]] may be low
*[[Clonus]] may be present<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
*[[Clonus]] may be present<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
*[[Hyporeflexia]]<ref name="pmid13134644">{{cite journal| author=ADAMS RD, FOLEY JM| title=The neurological disorder associated with liver disease. | journal=Res Publ Assoc Res Nerv Ment Dis | year= 1953 | volume= 32 | issue=  | pages= 198-237 | pmid=13134644 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13134644  }} </ref>
*[[Hyporeflexia]]<ref name="pmid13134644">{{cite journal| author=ADAMS RD, FOLEY JM| title=The neurological disorder associated with liver disease. | journal=Res Publ Assoc Res Nerv Ment Dis | year= 1953 | volume= 32 | issue=  | pages= 198-237 | pmid=13134644 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13134644  }} </ref>
*Positive (abnormal) [[Plantar reflex|Babinski reflex]]<ref name="pmid28680841">{{cite journal| author=Djiambou-Nganjeu H| title=Hepatic Encephalopathy in Liver Cirrhosis. | journal=J Transl Int Med | year= 2017 | volume= 5 | issue= 1 | pages= 64-67 | pmid=28680841 | doi=10.1515/jtim-2017-0013 | pmc=5490964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28680841  }} </ref>
*Positive (abnormal) [[Plantar reflex|Babinski reflex]]<ref name="pmid28680841">{{cite journal| author=Djiambou-Nganjeu H| title=Hepatic Encephalopathy in Liver Cirrhosis. | journal=J Transl Int Med | year= 2017 | volume= 5 | issue= 1 | pages= 64-67 | pmid=28680841 | doi=10.1515/jtim-2017-0013 | pmc=5490964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28680841  }} </ref>
*Bilaterally [[muscle weakness]] may be seen<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457  }} </ref>
*[[Bilateral|Bilaterally]] [[muscle weakness]] may be seen<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457  }} </ref>
*
*Examination [[cranial nerves]] is usually normal
*
*
*____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Extremities===
*[[Clubbing]]
* [[Athetosis]] (writhing, sinuous movements of the digits and [[extremities]]) may be present
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==
{{Reflist|2}}{{WH}} {{WS}}
{{Reflist|2}}{{WH}} {{WS}}

Latest revision as of 15:48, 26 January 2018

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

In addition to changed level of consciousness, the hallmark of hepatic encephalopathy on the physical examination is the presence of asterixis. This is detected by having the patient hold out his outstretched arms and cocking his wrists back. In the presence of asterixis, there is a non-synchronized, intermittent flapping motion at the wrists. Asterixis is not specific to hepatic encephalopathy. It may also be seen in states such as renal failure and carbon dioxide retention.

Physical Examination

Appearance of the patient

Vital signs

In patients with hepatic encephalopathy vital signs include:[6]

Skin

Signs of liver disease may be seen, such as:[7]

HEENT

Neck

Physical examination of neck is usually normal.

Lungs

Physical examination of lungs is usually normal

Heart

Physical examination of heart is usually normal

Abdomen

Signs of liver disease may be seen such as:

Back

Physical examination of back is usually normal

Genitourinary

Physical examination of genitourinary system is usually normal

Neuromuscular

Extremities

References

  1. ↑ Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.
  2. ↑ al-Arif A, Sporn MB (1972). "2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei". Proc Natl Acad Sci U S A. 69 (7): 1716–9. PMC 426785. PMID 4340155.
  3. ↑ 3.0 3.1 Agarwal R, Baid R (2016). "Asterixis". J Postgrad Med. 62 (2): 115–7. doi:10.4103/0022-3859.180572. PMC 4944342. PMID 27089111.
  4. ↑ 4.0 4.1 Bleibel W, Al-Osaimi AM (2012). "Hepatic encephalopathy". Saudi J Gastroenterol. 18 (5): 301–9. doi:10.4103/1319-3767.101123. PMC 3500018. PMID 23006457.
  5. ↑ Salam M, Matherly S, Farooq IS, Stravitz RT, Sterling RK, Sanyal AJ; et al. (2012). "Modified-orientation log to assess hepatic encephalopathy". Aliment Pharmacol Ther. 35 (8): 913–20. doi:10.1111/j.1365-2036.2012.05038.x. PMC 3616137. PMID 22348593.
  6. ↑ Wannhoff A, Nusshag C, Stremmel W, Merle U (2017). "Slow ventricular tachycardia presenting with acute liver failure". SAGE Open Med Case Rep. 5: 2050313X17718100. doi:10.1177/2050313X17718100. PMC 5528920. PMID 28835821.
  7. ↑ 7.0 7.1 Dogra S, Jindal R (2011). "Cutaneous manifestations of common liver diseases". J Clin Exp Hepatol. 1 (3): 177–84. doi:10.1016/S0973-6883(11)60235-1. PMC 3940632. PMID 25755383.
  8. ↑ 8.0 8.1 Shawcross DL, Wendon JA (2012). "The neurological manifestations of acute liver failure". Neurochem Int. 60 (7): 662–71. doi:10.1016/j.neuint.2011.10.006. PMID 22067133.
  9. ↑ Crippin JS, Gross JB, Lindor KD (1992). "Increased intracranial pressure and hepatic encephalopathy in chronic liver disease". Am J Gastroenterol. 87 (7): 879–82. PMID 1615943.
  10. ↑ Losowsky MS, Scott BB (1973). "Ascites and oedema in liver disease". Br Med J. 3 (5875): 336–8. PMC 1586440. PMID 4579401.
  11. ↑ Riley TR, Koch K (2003). "Characteristics of upper abdominal pain in those with chronic liver disease". Dig Dis Sci. 48 (10): 1914–8. PMID 14627332.
  12. ↑ McCormick PA, Nolan N (2004). "Palpable epigastric liver as a physical sign of cirrhosis: a prospective study". Eur J Gastroenterol Hepatol. 16 (12): 1331–4. PMID 15618841.
  13. ↑ 13.0 13.1 Nabi E, Bajaj JS (2014). "Useful tests for hepatic encephalopathy in clinical practice". Curr Gastroenterol Rep. 16 (1): 362. doi:10.1007/s11894-013-0362-0. PMC 3918211. PMID 24357348.
  14. ↑ Rahimi RS, Elliott AC, Rockey DC (2013). "Altered mental status in cirrhosis: etiologies and outcomes". J Investig Med. 61 (4): 695–700. doi:10.2310/JIM.0b013e318289e254. PMID 23474970.
  15. ↑ ADAMS RD, FOLEY JM (1953). "The neurological disorder associated with liver disease". Res Publ Assoc Res Nerv Ment Dis. 32: 198–237. PMID 13134644.
  16. ↑ Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.

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