Hepatic encephalopathy physical examination
|
Hepatic encephalopathy Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Hepatic encephalopathy physical examination On the Web |
|
American Roentgen Ray Society Images of Hepatic encephalopathy physical examination |
|
Risk calculators and risk factors for Hepatic encephalopathy physical examination |
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
- Physical examination of patients with hepatic encephalopathy is usually remarkable for signs of personality changes, signs of altered level of consciousness, jerking movement of the limbs (asterixis), slurred speech, writing disturbances, monotonous voice and impaired memory[1][2][3]
Appearance of the patient
Vital signs
In patients with hepatic encephalopathy vital signs include:[6]
- Blood pressure may be normal, 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:[7]
- Yellow skin
- Protracted and disabling pruritus
- Spider angiomas
- Palmar erythema
HEENT
- Icteric sclera[7]
- Dilated pupils, sluggishly responsive to light[8]
- Ophthalmoscopic exam may be abnormal with findings of papilledema[9]
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)[10]
- Abdominal tenderness[11]
- A palpable liver in the epigastrium (hepatomegaly- feel with inspiration, relocate during expiration)[12]
Back
Physical examination of back is usually normal
Genitourinary
Physical examination of genitourinary system is usually normal
Neuromuscular
- Jerking movement of the limbs (asterixis) is highly suggestive of hepatic encephalopathy[3]
- Attention deficit and slow information processing[13]
- Abnormal paper and pencil tests[13]
- Altered mental status may be seen[14]
- Scoring on Glasgow coma scale may be low
- Clonus may be present[8]
- Hyporeflexia[15]
- Positive (abnormal) Babinski reflex[16]
- Bilaterally muscle weakness may be seen[4]
- Examination cranial nerves is usually normal
Extremities
- Athetosis (writhing, sinuous movements of the digits and extremities) may be present
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.
- ↑ 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.
- ↑ 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.
- ↑ 7.0 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.
- ↑ 8.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.