CHRONIC LIVER DISEASE, CLD, is characterized by chronic abnormal functioning of liver due to various causes including hepatitis, alcoholic liver disease, non-alcoholic liver disease, autoimmune and certain medications. visit https://surgio.info/chronic-liver-disease/ for a complete case.

1. CHRONIC LIVER DISEASE
CHRONIC LIVER DISEASE, CLD, is characterized by chronic abnormal functioning of liver due to various
causes including hepatitis, alcoholic liver disease, non-alcoholic liver disease, auto immune and certain
medications. The criteria for labelling a disease chronic is duration of disease signs and symptoms more
than 6 months.
Presenting complains
The patient presents with complaint of:
 Weight loss
 Yellow discoloration of skin and eyes
 Abdominal distention
 Right hypochondrium pain
 Fatigue
 Leg swelling
 Altered sleep pattern, anxiety and agitation
 Diarrhea with blood
 Vomiting containing blood (Hematemesis)
Examination
Examination of liver disease comes under GIT examination. So we will follow these steps: general
physical examination and GIT examination
General Physical Examination
During general physical examination, start from hands and look for following sings:
 Clubbing
 Leukonychia
 Palmer Erythema
 Atrophy of Palmer Muscles
 Flapping Tremors (Examination of Flapping termers is explained later)
 Dupuytren’s Contracture
Eyes
 Color of Cornea
 Color of Conjunctiva
Prefer to note the color of cornea and conjunctiva in sun light
 Kayser Fleischer Rings
Kayser-Fleischer rings are a characteristic sign of Wilson's disease, which is a rare genetic disorder that
affects copper metabolism in the body. In Wilson's disease, copper accumulates in various organs,

2. including the liver, brain, and eyes, leading to a range of symptoms such as liver disease, neurological
problems, and psychiatric disturbances.
Face
Parotid swelling
Chest
 Spider Naive
Spider nevi appear as small, reddish or bluish lesions on the skin, often with a central feeding artery and
radiating branches resembling a spider or spider web. They are typically found on the face, neck, upper
chest, and arms.
Press on central feeding artery and note down if radiating branches disappear, then it is confirmed
spider nevi
 Loss of Hair (Hypogonadism)
Lower limb
 Bruising of lower limb
 Lower limb swelling
Here are few important points about lower limb edema
1. If lower limb edema and it leads to abdominal distention, Differential Diagnosis may include
Congestive Heart Failure
2. If there is abdominal distention and it leads to lower limb edema, Differential Diagnosis may
include Cirrhosis
3. If Abdominal distention is followed by Periorbital edema, differential Diagnosis may include
Nephrotic Syndrome
Clinical Presentation Possible Differential Diagnosis Additional Symptoms
Lower limb edema leading to abdominal distention Congestive Heart Failure -
Abdominal distention leading to lower limb edema Cirrhosis -
Abdominal distention followed by peri-orbital edema Nephrotic Syndrome -
Note that these are not exhaustive lists of all possible differential diagnoses for each clinical
presentation, but they include the information you provided in a tabular format. Other factors such as
patient history, physical examination findings, and diagnostic test results may be needed to confirm a
diagnosis.
GIT Examination
Inspection
Inspect the abdomen and confirm these signs:
 Scar: Past Traumatic or Surgical History

3.  Distention: May be Ascites
Fluid Thrill
A fluid thrill is a physical finding that can be observed during a physical examination of a patient with
ascites. Ascites is an abnormal accumulation of fluid in the peritoneal cavity, which is the space between
the abdominal organs and the abdominal wall.
To perform a fluid thrill test, the examiner places their hands on the patient's abdomen and applies
gentle pressure with their fingers on one side of the abdomen while tapping on the opposite side with
their other hand. If there is a significant amount of fluid present in the peritoneal cavity, the tapping will
produce a wave-like sensation that can be felt by the examiner's fingers on the other side of the
abdomen. This is known as a positive fluid thrill.
A positive fluid thrill is a reliable indicator of the presence of ascites, although other conditions such as
ovarian cysts or uterine fibroids can also produce a similar sensation. The presence of ascites can be
further confirmed by other physical exam findings such as bulging flanks, shifting dullness on percussion,
and a fluid wave test.
Shifting Dullness
To perform the shifting dullness test, the examiner asks the patient to lie flat on their back and then
percusses (taps) the abdomen with their fingers. The examiner then listens for changes in the sound
produced by the percussion. In a patient with ascites, the fluid will settle in the dependent areas of the
abdomen, usually in the flanks when the patient is lying down.
When percussing over the area of the abdomen with fluid, a dull or muffled sound is heard because the
fluid absorbs the sound waves. In contrast, when percussing over an area of the abdomen without fluid,
a more resonant or tympanic sound is heard.
As the patient rolls onto their side, the fluid shifts, and the area of dullness moves to the dependent
side, away from the site of percussion. This is known as shifting dullness and is a reliable indicator of the
presence of ascites.
Visible veins:
Caput Medusa: Clinical Sign of portal Hypertension. Veins are dilated around umbilicus and resembles
like head of snake.
Palpation
Ask the patient if there is any pain on palpation and note the face expressions.
Confirm these signs
 Hepatomegaly
 Splenomegaly
 Ascites
 Palpable Gall bladder
 Tumor
For Hepatomegaly:

4. To perform a palpation of the liver, the examiner should have the patient lie on their back with their
knees slightly bent and their arms at their sides. The examiner should then stand on the patient's right
side and place their left hand under the patient's back at the level of the 11th and 12th ribs to lift the
liver up and toward the palpating hand. The examiner should place their right hand on the patient's
abdomen just below the ribcage and press gently inward and upward toward the liver.
The liver should be felt as a firm, smooth, and slightly rounded edge just below the right costal margin
(the lower edge of the ribcage). If the liver is enlarged, it may extend below the costal margin and may
have a firm or irregular edge.
Splenomegaly:
To perform palpation of spleen, start gently palpation from Right Ileac Fossa and move diagonally
towards left hypochondrium 1 inch each time. The spleen is normally not palpable, but if it is enlarged, it
may be felt as a firm, smooth, and rounded mass below the left costal margin (the lower edge of the
ribcage). The spleen may also be tender to touch.
Percussion
Hepatomegaly
Clinically assessment of hepatomegaly is important in diagnosing liver disease.
 Start palpating in Right Ileac Fossa
 Progress up the abdomen 2 cm with each breath
 Confirm the lower border of liver by percussion
 Detect if smooth or irregular, tender or non-tender
 Identify the upper border by percussion
 Percussion for ascites has been described earlier
Ascites
Ascites may be transudative or exudative
Exudative
Carcinoma associated with clinical findings: Weight loss
Tuberculosis associated with clinical findings: weight loss + Fever
Transudative
Cirrhosis associated with clinical findings: Hepatomegaly, Splenomegaly, and Spider Nevi
Renal Failure associated with clinical findings: Generalized edema and Peripheral Edema
Congestive Heart Failure associated with clinical findings: Elevated JVP
Type of Ascites Associated Conditions Clinical Findings
Exudative Carcinoma Weight loss

5. Type of Ascites Associated Conditions Clinical Findings
Exudative Tuberculosis Weight loss + Fever
Transudative Cirrhosis Hepatomegaly, Splenomegaly, Spider Nevi
Transudative Renal Failure Generalized edema and Peripheral Edema
Transudative Congestive Heart Failure Elevated JVP
Flapping Tremors
Flapping tremors, also known as asterixis, is a type of involuntary movement that can be observed
during a physical examination. It is typically seen in patients with liver failure or other conditions that
cause metabolic encephalopathy.
To perform the flapping tremor test, the examiner should have the patient sit with their arms extended
in front of them, wrists dorsiflexed, and fingers spread apart. The examiner should then observe the
patient's hands for any flapping movements, which are characterized by a sudden drop of the hand and
a rebound back to the original position.
Case Presentation
A 67 year old patient presented with abdominal distention and breathlessness for one week.
HOPC
Abdominal Distention was acute in onset, progressive in nature associated with Lower Limb Edema and
altered sleep pattern and memory loss.
Breathlessness is gradual in onset, aggravated on lying down and relieved by sitting.
No history of Fever, Cough, Chest pain, Palpitation, Syncope, Seizures, Constipation, Hematemesis and
Melena
Past History
Patient is known case of Hypertension, Diabetes Mellitus and Chronic Kidney Disease
Personal History
Patient has altered sleep pattern, normal bowl and bladder, alcoholic and Non Smoker.
Examination
Patient is conscious and oriented to time, place and person. Pallor is positive, mild jaundice but no
cyanosis, clubbing and lymphadenopathy.

6. Vitals are as below
 Pulse Rate: 80 bpm
 Blood Pressure: 170/100
 Respiratory Rate: 27 breaths per minute
 Temperature: 98 F
Patient has reduced hair on body which indicates gynecomastia and spider nevi is positive.
On inspection
 Distended abdomen
 Herniated umbilicus
 No surgical scar
 No visible veins
 Flapping tremors present
Palpation
 No local rise of temperature
 Tense abdomen and no tenderness
 Spleen and liver are normal in size
 Murphy sign is negative
Percussion
 No shifting dullness
 Fluid thrill is positive
Auscultation
 No bowel sounds
Differential Diagnosis
Cirrhosis: Chronic liver disease caused by long-term liver damage, typically due to alcohol consumption
or hepatitis B/C. It can present with abdominal distention, gynecomastia, spider nevi, flapping tremors,
and altered sleep pattern.
Congestive Heart Failure: A condition where the heart is unable to pump enough blood to meet the
body's demands, leading to fluid buildup in the body, including the abdomen and lower extremities. It
can present with abdominal distention, breathlessness, and edema.
Nephrotic Syndrome: A kidney disorder that results in excessive protein loss in urine, leading to fluid
accumulation in the body, including the abdomen and peri-orbital region. It can present with abdominal
distention, lower limb edema, and altered sleep pattern.

7. Lab Diagnosis
ALT: 58 IU/L (elevated)
AST: 221 IU/L (elevated)
ALP: 57 IU/L (elevated)
Total bilirubin: 14.8 mg/dL (elevated)
Direct bilirubin: 4.5 mg/dL (elevated)
Albumin: 2.2 g/dL (decreased)
Total protein: 7.3 g/dL (decreased)
INR: 1.5 (elevated)
Confirm Diagnosis
Patient is diagnosed as Chronic Liver Disease