Hepatic encephalopathy physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];{{AE}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 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.
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
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 of patients with hepatic encephalopathy is usually remarkable for: signs of personality changes, signs of altered level of consciousness, observing jerking movement of the limbs(asterixis), slurred speech, writing disturbances, voice monotonous and Impaired memory.[1][2][3]
- The presence of asterixis on physical examination is highly suggestive of hepatic encephalopathy.[3]
Appearance of the Patient
Vital Signs
In patients with hepatic encephalopathy vital signs include:[5]
- Blood pressure may be normal or low or high.
- Hypothermia or hyperthermia may be present
- Tachycardia with regular pulse may be present
Skin
Signs of liver disease, may be seen such as:[6]
- Yellow skin
- Protracted and disabling pruritus
- Spider angiomas
- Palmar erythema
-
Description (Adapted from Dermatology Atlas)
-
Description (Adapted from Dermatology Atlas)
HEENT
- Icteric sclera[6]
- Dilated pupils, sluggishly responsive to light[7]
- Ophthalmoscopic exam may be abnormal with findings of papilledema[8]
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:
- Fluid collection in the abdomen (ascites)[9]
- abdominal tenderness[10]
- A palpable liver in the epigastrium(hepatomegaly)[11]
Back
Physical examination of back is usually normal.
Genitourinary
Physical examination of genitourinary system is usually normal.
Neuromuscular
- Patient may be unoriented to persons, place, and time[12]
- Altered mental status may be seen[13]
- Glasgow coma scale can be reduced
- Clonus may be present[7]
- Hyporeflexia[14]
- Positive (abnormal) Babinski reflex[15]
- Bilaterally muscle weakness may be seen[4]
- ____ (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
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
References
- ↑ Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.
- ↑ 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.
- ↑ 3.0 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.
- ↑ 4.0 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.
- ↑ 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.
- ↑ 6.0 6.1 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.
- ↑ 7.0 7.1 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.
- ↑ 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.
- ↑ Losowsky MS, Scott BB (1973). "Ascites and oedema in liver disease". Br Med J. 3 (5875): 336–8. PMC 1586440. PMID 4579401.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ ADAMS RD, FOLEY JM (1953). "The neurological disorder associated with liver disease". Res Publ Assoc Res Nerv Ment Dis. 32: 198–237. PMID 13134644.
- ↑ 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.