Clinical Features

Clinical presentation of acute liver disease is variable. Symptoms of hepatocellular necrosis accompanying viral hepatitis include anorexia, nausea, vomiting, and low-grade fever. Cholestatic disease is accompanied by jaundice of varying degree, pruritus, clay-colored stools, and dark urine. Biliary colic implies acute obstructive cholestasis of extrahepatic or mechanical etiology, as in common duct gallstones or rapidly growing tumors. Cholestasis resulting from intrahepatic processes and infiltrative disease presents more insidiously with the slow development of jaundice and few other constitutional complaints.

Chronic liver disease often presents with complications of advancing cirrhosis and portal hypertension that include abdominal pain, ascites, gastrointestinal bleeding, fever, and altered mental status. However, progressive generalized fatigue is not uncommonly the only symptom of chronic liver disease in the absence of supervening complications.

Features of history are sometimes useful: sexual behaviors, travel, volume and duration of alcohol use, illicit drug use, consumption of nutritional supplements (vitamin A), history of blood transfusions, needle-stick blood exposures, herbal remedies, mushroom ingestion, or raw oyster consumption. Family history may be revealing. Gilbert's syndrome is a relatively common and benign familial condition revealed by periodic modest elevations in unconjugated bilirubin, particularly in response to the stress of an acute illness. Family history of jaundice (elevated conjugated bilirubin) may indicate the presence of Dubin-Johnson or Rotor syndrome. Ihe differential diagnosis of familial severe premature liver disease includes Wilson's disease, hemochromatosis, or a -,-antitrypsin deficiency. Ihese uncommon disorders are mentioned because the emergency physician routinely sees and hence screens a large number of patients and is therefore more likely to encounter such diseases.

Physical findings of acute hepatitis are often limited to moderate enlargement of the liver and tenderness. Chronic liver disease is accompanied by a host of physical findings, including sallow complexion, appendicular wasting, palmar erythema, distinctive cutaneous spider nevi, parotid gland enlargement, and testicular atrophy and gynecomastia in males. Ihe liver may be uniformly enlarged and firm or, in advanced cirrhosis, shrunken and grossly nodular. Splenomegaly and ascites accompany portal hypertension.

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