Propedeutics in Hepatology
Veronika Zvárová, Ľubomíra Horňáková
Department of Internal Medicine and Gastroenterology
University Hospital Brno and Masaryk University
spring 2020
History
History is the first and basic examination method that has the highest diagnostic yield
• FH – genetic disease in family – hemochromatosis, M.Wilson., infectious hepatitis
• PH – infectious disease – EBV,CMV, hepatitis, vaccination, risky sexual intercourse
travelling history, digestive disorders, diabetes mellitus, hypertension
• PA: drug type, NSAID, ATB, hormonal treatment, imunosupressants,
chemotherapy, anesthesia, steroids, natural preparations – herbs, mushrooms!!
• Habits: smokes from - to, how many cigarettes a day, how long, date of giving up
alcohol – beer, wine, spirits, how much per day on average, regularity of
consumption
• GA - menstruation – from - to, regular, irregular, hormone replacement
therapy IVF, hormone contraceptives
• SH – risk at workplace – chemical industry, laboratory etc.
• FF - urination – dark urine?, stool color – pale/black, weight +/-, skin color,
appetite
Clinical examination
• SUBJECTIVELY
tiredness, yellowing of skin and whites, gastric and intestinal dyspepsia anorexia,
nausea, feeling of fullness, sleep disorders, irregular menstrual cycle,
loss of libido, abdominal volume increase, pruritus, nonspecific pain in the
right hypochondrium
• OBJECTIVELY
in the early stages of liver disease asymptomatic, manifestations with more
extensive disability
➢ observation – spider nevi located in the upper part of the trunk, palmar
erythema, disappearance of hair on the chest, dilated veins in the
abdominal wall - sometimes called caput Medusae, icterus, ascites, muscle
hypotrophy, swelling, tremor
➢ palpation – enlarged liver (size, margin, consistency, pain), enlarged
spleen, tension ascites, hepatojugular reflux
➢ percussion – importance in determining liver size
➢ auscultation – friction murmurs, so-called "scratching" - application
stethoscope to proc. xiphoideus and craniocaudal scratch the
medoclavicular line on the skin - determination of liver size KIESLICHOVÁ, Eva. Operační výkon u pacienta s jaterní
cirhózou. In: Sepse Ostrava [online], 2017. Dostupné z:
http://www.sepseostrava.cz/sepse/sbornik/2017/2-
Kieslichova-operacni-vykon-u-pacienta-s-cirhozou-
OSTRAVA-8.2.2017.pdf
Laboratory examination
• Tests reflecting hepatocyte disorders - ALT, AST, AST elevation prognostically more
severe, ALT and AST elevation 3-20x - acute and chronic hepatitis, toxic damage,
alcohol liver damage, acute ischemia, circulatory shock, "De Ritis Ratio" index –
AST / ALT more than 2 - alcoholic liver disease
• Tests reflecting disorder at the level of bile ducts and canalicular system - ALP
GGT, isolated GGT value - chronic alcohol abuse etc.
• Synthetic activity of liver - albumin, prealbumin, cholinesterase, coagulation
factors
• Blood count - anemia, macrocytosis, thrombocytopenia
• Bilirubin, bile acids
• Examination of autoantibodies - when autoimmune hepatitis is suspected (ANA,
ASMA, AMA, LKM ..)
• Serological examination - if viral hepatitis is suspected
• Specific examinations - urine collection / 24h for Cu in Wilson's disease, iron
metabolism in hemochromatosis (Fe, sat Fe, ferritin), alpha1 antitrypsin
Imaging methods
• Abdominal ultrasonography - noninvasive method, easily available, basic
examination method in differential diagnosis of hepatopathy (steatosis, cirrhosis,
liver lesions)
• CEUS – contrast-enhacend ultrasound of liver disease- ultrasound using contrast
medium (gas microbubbles) to improve visualization and characterization of
anatomic structures and lesions
• Elastography of the liver – the latest method, noninvasive, nonpainful, measuring
the degree of stiffness (fibrosis) of liver tissue, event. biopsy replacement
• CT liver (computed tomography)- disadvantage - radiation exposure, application of
iodinated contrast media with risk of allergic reaction and nephrotoxicity
advantage - evaluation of liver lesions, vascular supply of liver
• MR liver - noninvasive, radiation-free, contrast media have lower nephrotoxicity,
allergy is rare, evaluation of liver lesion lesions, MR 80-100% sensitivity, lesions
specificity over 96% (like CT)
• MRCP (magnetic resonance cholangiopancreaticography) - diagnosis of primary
sclerosing cholangoitis according to the typical bile duct imagine, event. ERCP PET
/ CT,
• PET / MR – detection of liver metastases of GIT tumors, used in oncology care
Endoscopic methods in hepatology
• Gastroscopy - used in the diagnosis and treatment of portal hypertension
(esophageal varices, portal gastropathy…)
➢ diagnostic - screening – patients with liver cirrhosis
➢ therapeutic -
a) acute - finding the source of
bleeding + endoscopic treatment (sclerotization,
esophageal varices ligation)
b) elective - preventive treatment for
patients at risk of bleeding
• Colonoscopy, rectoscopy, enteroscopy - used
in the diagnosis of pathologies resulting from portal hypertension (eg rectal
varices, colopathy in portal hypertension, etc.)
• ERCP – diagnostic and therapy of biliary obstruction
cs.wikipedia.org
Special examination in hepatology
Ascites puncture - miniinvasive method, ascites puncture under ultrasound control or
by percussion using a thin puncture needle
➢ diagnostic - removal of small amounts of ascitic liquid- ideally
straw-yellow liquid
• neutrophil count, higher than 0.25x10 9 / l - spontaneous bacterial peritonitis
• cytological examination – presence of malignant cells
• amount of protein - transudate / exudate
• microbiological examination
• biochemical examination (eg ascites amylase)
➢ therapeutic - so-called paracentesis, to drain off the fluid from abdomen to make
the patient more comfortable and reduce swelling
Liver biopsy - is a procedure in which a small needle is inserted into the liver to collect
a tissue sample for histological examination, local anesthesia
➢ non-targeted biopsy – in patients with suspected parenchymal liver disease, such
as chronic hepatitis or cirrhosis, dry matter of Cu and Fe
➢ targeted biopsy - to a specific lesion, such as a suspected tumor
Therapeutic methods
• TIPS (transjugular intrahepatic portosystemic shunt)
- is an artificial channel within the liver that establishes communication between the
inflow portal vein and the outflow hepatic vein
- performed by an intervention radiologist,
- miniinvasive procedure - transjugularly
- it is used to treat portal hypertension which
frequently leads to intestinal bleeding
- risk of worsening liver encephalopathy
Percutaneous Transhepatic Drainage (PTD)
- malignant / benign biliary stenosis, that cannot be solved endoscopically
- short-term external drainage - palliative treatment to reduce bilirubin
- long-term external-internal drainage - lifetime of the drain about 6-12 weeks,
necessary regular changes and regular flushing
- putting a stent (plastic or metallic) in malignant biliary stenosis
ANDREWS, MD, R. Torrance. Tips schematic.In: Wikipedia [online]. 2011. Dostupné
z: https://upload.wikimedia.org/wikipedia/commons/c/c9/Tips_schematic.JPG