Learn how to take a liver-focused history

What aspects of a patient’s history are important when assessing liver diseases? Click here to find out more!
Last update26th Jan 2021

The initial evaluation of a patient should always start with an appropriate history. In the history, we are looking for potential risk factors of liver disease:

  • Exposure to hepatotoxins
  • Viral hepatitis
  • Certain medical conditions

What are some common hepatotoxins?

Possible hepatotoxins include excessive alcohol intake, medications (prescribed and over the counter ones including herbal remedies), and dietary supplements. As well, be sure to ask the patient about possible exposure to hepatotoxins such as mushrooms, and industrial agents such as vinyl chloride.

Figure 1. Common hepatotoxins include excess alcohol, medications, supplements, mushrooms, and industrial agents.

Which patients are at risk for viral hepatitis?

Individuals at risk for viral hepatitis are those who use intravenous (IV) drugs, have had blood transfusions (especially before 1992), have had sexual exposure to affected individuals, have body piercings or tattoos, or a history of travel to areas known to be endemic for hepatitis.

Figure 2. Risk factors for viral hepatitis include intravenous (IV) drug use, blood transfusions, sexual exposure to affected individuals, piercings and tattoos, and travel to areas at high-risk for hepatitis.

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Which medical conditions are associated with liver disease?

Certain medical conditions are associated with liver disease, so you should be aware of these when taking the patient’s history. For example, a patient with right-sided heart failure may develop congestive hepatopathy.

In hemochromatosis, iron is deposited in tissue with resultant tissue and organ damage. The main organs that are affected are the liver, pancreas, skin, joints, heart, and gonads. Individuals with hemochromatosis present with skin pigmentation, arthritis, diabetes mellitus, and cardiomyopathy.

Early-onset emphysema may be due to alpha-1 antitrypsin (AAT) deficiency, which is also a cause of liver disease.

As well, autoimmune thyroiditis may be a clue to concomitant autoimmune liver disease.

Pregnancy and inflammatory bowel disease may be associated with gallstones, which can interfere with liver and gallbladder function. Inflammatory bowel disease is also associated with primary sclerosing cholangitis.

Figure 3. Medical conditions commonly associated with liver disease include right-sided heart failure, hemochromatosis, alpha-1 antitrypsin (AAT) deficiency, autoimmune thyroiditis, gallstones, and primary sclerosing cholangitis.

What are some common symptoms of liver disease?

When taking a patient history, ask about specific symptoms that are commonly associated with liver disease including jaundice, pruritus, gastrointestinal bleeding, coagulopathy, increased abdominal girth, and mental status changes.

Figure 4. Common symptoms of liver disease include jaundice, pruritus, gastrointestinal (GI) bleeding, coagulopathy, increased abdominal girth, and changes in mental status.

Early cirrhosis can manifest as anorexia, weight loss, weakness, fatigue, and osteoporosis from inadequate vitamin D and calcium absorption. Decompensated cirrhosis presents with ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and variceal bleeding from portal hypertension.

Table 1. Symptoms of early cirrhosis include anorexia, weight loss, weakness, fatigue, and osteoporosis. Symptoms of decompensated cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and variceal bleeding.

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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
Amer is a 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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