Learn how to perform a liver-focused physical exam

Click here to learn the tips and tricks for a physical examination of a patient with liver disease. Read more now!
Last update26th Jan 2021

The physical examination of a patient may suggest the presence of liver disease and point towards an underlying cause. There are 14 common signs of chronic liver disease and cirrhosis that you may uncover during a physical exam:

  1. Jaundice
  2. Clubbing
  3. Gynecomastia
  4. Spider nevi
  5. Testicular atrophy
  6. Caput medusae
  7. Palmar erythema
  8. Dupuytren’s contracture
  9. Muscle wasting
  10. Raised jugular venous pressure
  11. Parotid gland enlargement
  12. Enlarged Virchow’s node
  13. Hepatic encephalopathy signs
  14. Neurologic symptoms

Now, let’s dive into each of these liver disease signs in a little more detail.

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Common signs of chronic liver disease and cirrhosis

Jaundice

We may find jaundice when examining the patient’s physical appearance. Jaundice is a yellow discoloration of the skin, mucous membranes, and sclera. This would mean that the bilirubin level in the blood is high, at least 2 mg / dL or higher.

Clubbing

Clubbing is another possible sign of chronic liver disease and cirrhosis. It involves a physical deformation of the fingernails.

Gynecomastia

Look for enlargement of breast tissue in males, also called gynecomastia. Gynecomastia is seen in up to two-thirds of patients with cirrhosis. It is thought to be due to the increased conversion of androgens to estradiol, which occurs in the setting of liver disease.

Spider nevi

Spider nevi, which are clusters of dilated blood vessels on the skin that consist of a central arteriole surrounded by smaller vessels, are also a common sign of chronic liver disease. Similar to gynecomastia, they are also due to an increase in estradiol concentrations.

Testicular atrophy

Also check your male patients for testicular atrophy, which may result from decreased androgen levels.

Caput medusae

You may also notice caput medusae (distended and engorged epigastric veins visible on the abdomen) radiating from the umbilicus. These are often a sign of liver disease.

Palmar erythema

Palmar erythema is reddish skin on the palm of the hand, which is also due to an increase in estradiol.

Dupuytren’s contracture

Dupuytren’s contracture results from thickening and shortening of the palmar fascia. This causes a flexion deformity of the fingers. While the cause is unknown, its presence is often associated with alcoholism and cirrhosis.

Muscle wasting

Muscle wasting may also be present and results from the inability of the liver to metabolize proteins. If muscle wasting is present (especially temporal and proximal muscle wasting), it suggests long-standing liver disease.

Raised jugular venous pressure

Another common sign of chronic liver disease and cirrhosis that you may uncover during a physical exam is raised jugular venous pressure. Raised jugular venous pressure implies right-sided heart failure which may cause hepatic congestion.

Parotid gland enlargement

Look for the presence of parotid gland enlargement. This is typically a feature of alcoholic liver disease, but not cirrhosis in general.

Enlarged Virchow’s node

An enlarged left supraclavicular node (Virchow’s node) suggests an underlying abdominal malignancy, such as stomach cancer, which could spread to the liver.

Hepatic encephalopathy signs

Features of hepatic encephalopathy may also be present in a patient with liver disease. These include an altered level of consciousness and neuromuscular disturbances such as a flapping tremor (e.g., asterixis).

Neurologic symptoms

Neurologic symptoms may also be seen in liver-associated diseases such as Wilson’s disease. In this disease, there is copper deposition in the basal ganglia and liver. Clinical features of Wilson’s disease include liver disease with parkinsonism.

Figure 1. Common signs of liver disease and cirrhosis that may be present during a physical examination.

How to perform a liver-focused abdominal exam

Examination of the abdomen should be performed in all patients with potential liver disease. There are three additional steps to perform when tailoring the abdominal exam for liver disease:

  1. Check liver size and consistency
  2. Assess spleen size
  3. Assess for ascites

Step 1: Check liver size and consistency

Liver size and consistency can be judged with palpation of the liver. A hard liver may denote underlying hepatocellular carcinoma. A tender liver is seen with viral hepatitis. A tender, acutely congested liver is due to right-sided heart failure.

Table 1. A hard liver upon palpation may be a sign of hepatocellular carcinoma, a tender liver is associated with viral hepatitis, and a tender, acutely congested liver is associated with right-sided heart failure.

Step 2: Assess spleen size

The size of the spleen is also important to assess. Splenomegaly is a well-established finding in cirrhosis and is due to portal hypertension.

Step 3: Assess for ascites

Make sure to look for the presence of ascites in your examination. Ascites is seen in decompensated cirrhosis. Patients with ascites will typically have flank dullness on examination. Patients may also have shifting dullness, which is a change in the location of dullness to percussion when the patient is turned (due to movement of the ascites).

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Recommended reading

  • Chalasani, N, Younossi, Z, Lavine, JE, et al. 2012. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology. Gastroenterology142: 1592–1609. PMID: 22656328
  • Fuchs, S, Bogomolski-Yahalom, V, Paltiel, O, et al. 1998. Ischemic hepatitis: clinical and laboratory observations of 34 patients. J Clin Gastroenterol26: 183–186. PMID: 9600366
  • Lok, ASF and McMahon, BJ. 2007. Chronic hepatitis B. Hepatology45: 507–539. PMID: 17256718
  • Moussavian, SN, Becker, RC, Piepmeyer, JL, et al. 1985. Serum gamma-glutamyl transpeptidase and chronic alcoholism. Influence of alcohol ingestion and liver disease. Dig Dis Sci30: 211–214. PMID: 2857631
  • Myers, RP, Cerini, R, Sayegh, R, et al. 2003. Cardiac hepatopathy: clinical, hemodynamic, and histologic characteristics and correlations. Hepatology37: 393–400. PMID: 12540790
  • Rej, R. 1978. Aspartate aminotransferase activity and isoenzyme proportions in human liver tissues. Clin Chem24: 1971–1979. PMID: 213206
  • van de Steeg, E, Stránecký, V, Hartmannová, H, et al. 2012. Complete OATP1B1 and OATP1B3 deficiency causes human Rotor syndrome by interrupting conjugated bilirubin reuptake into the liver. J Clin Invest122: 519–528. PMID: 22232210

About the author

Amer Wahed, MD FRCPath
Professor and Vice Chair (Clinical Pathology) and Associate Residency Program Director in the Department of Pathology and Laboratory Medicine at the University of Texas, Health Science Center at Houston, USA.
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