Antibiotics

Proton pump inhibitors

Constipation Opioids

Jaundice: hepatitis Paracetamol (overdose)

Pyrazinamide

Rifampicin

Isoniazid

Jaundice: cholestatic Flucloxacillin

Chlorpromazine

Co-amoxiclav

Liver fibrosis Methotrexate

Prehepatic jaundice

In haemolytic disorders, anaemic pallor combined with jaundice

may produce a pale lemon complexion. The stools and urine

are normal in colour. Gilbert’s syndrome is common and

causes unconjugated hyperbilirubinaemia. Serum liver enzyme

concentrations are normal and jaundice is mild (plasma bilirubin

<100 µmol/L (5.85 mg/dL)) but increases during prolonged fasting

or intercurrent febrile illness.

Hepatic jaundice

Hepatocellular disease causes hyperbilirubinaemia that is both

unconjugated and conjugated. Conjugated bilirubin leads to dark

brown urine. The stools are normal in colour.

Posthepatic/cholestatic jaundice

In biliary obstruction, conjugated bilirubin in the bile does not

reach the intestine, so the stools are pale. Obstructive jaundice

may be accompanied by pruritus (generalised itch) due to skin

deposition of bile salts. Obstructive jaundice with abdominal pain

is usually due to gallstones; if fever or rigors also occur (Charcot’s

triad), ascending cholangitis is likely. Painless obstructive jaundice

suggests malignant biliary obstruction, as in cholangiocarcinoma

or cancer of the head of the pancreas. Obstructive jaundice can

be due to intrahepatic as well as extrahepatic cholestasis, as in

primary biliary cirrhosis, certain hepatotoxic drug reactions (Box

6.8) and profound hepatocellular injury.

The physical examination • 103

6

The physical examination

General examination

Examination sequence

• Note the patient’s demeanour and general appearance.

Are they in pain, cachectic, thin, well nourished or obese?

Record height, weight, waist circumference and body

mass index (p. 29). Note whether obesity is truncal or

generalised. Look for abdominal striae or loose skin

folds.

• Inspect the patient’s hands for clubbing, koilonychia

(spoon-shaped nails) and signs of chronic liver disease

(Fig. 6.9), including leuconychia (white nails) and palmar

erythema.

• Alcohol consumption: calculate the patient’s intake in

units (p. 15).

• Smoking: this increases the risk of oesophageal cancer,

colorectal cancer, Crohn’s disease and peptic ulcer, while

patients with ulcerative colitis are less likely to smoke.

• Stress: many disorders, particularly irritable bowel

syndrome and dyspepsia, are exacerbated by stress and

mental disorders.

• Foreign travel: this is particularly relevant in liver disease

and diarrhoea.

• Risk factors for liver disease: these include intravenous

drug use, tattoos, foreign travel, blood transfusions, and

sex between men or with prostitutes and multiple sexual

partners. Hepatitis B and C may present with chronic liver

disease or cancer decades after the primary infection, so

enquire about risk factors in the distant as well as the

recent past.

Eyes

B Leuconychia

C Palmar erythema

A Spider naevus

General

• Skin pigmentation

• Loss of body hair

• Bruising

• Jaundice

Chest

• Gynaecomastia (in men)

• Breast atrophy (in women)

Hands

• Leuconychia

 (white nails) (B)

• Palmar erythema (C)

• Clubbing

Upper half of body

(above umbilicus)

• Spider naevi (A)

Abdomen

• Splenomegaly

• Hepatomegaly

 (but liver may be small)

• Dilated collateral

 vessels around

 umbilicus

Genitalia

• Testicular atrophy

Legs

• Oedema

• Hair loss

Fig. 6.9 Features of chronic liver disease.

104 • The gastrointestinal system

• late neurological features, which include spasticity,

extension of the arms and legs, and extensor plantar

responses.