Diseases » Liver conditions » Causes

Causes of Liver conditions

Liver conditions Causes: Book Excerpts

• Differential Diagnosis - Hepatomegaly
• Differential Diagnosis - Jaundice
• Differential Diagnosis - Hepatomegaly
• Differential Diagnosis - Jaundice in Infants – Direct
• Differential Diagnosis - Jaundice in Infants – Indirect
• Medical causes - Hepatomegaly
• Medical causes - Jaundice
• Medical causes - Asterixis [Liver flap, flapping tremor]
• Causes - Fatty liver
• Causes and incidence - Liver abscess
• Causes and incidence - Liver cancer
• Medical causes - Hepatomegaly
• Medical causes - Asterixis [Liver flap, flapping tremor]
• Medical causes - Jaundice [Icterus]
• Differential Overview - Hepatomegaly
• Differential Overview - Jaundice
• Causes - Fatty liver
• Causes - Liver abscess
• Causes - Liver cancer
• Medical causes - Hepatomegaly
• Medical causes - Jaundice
• Principal Causes of Hepatomegaly - Hepatomegaly
• Principal Causes of Unconjugated Hyperbilirubinemia - Jaundice
• Medical causes - Hepatomegaly
• Medical causes - Asterixis [Liver flap, flapping tremor]
• Medical causes - Jaundice [Icterus]

Liver conditions as a complication of other conditions:

Other conditions that might have Liver conditions as a complication may, potentially, be an underlying cause of Liver conditions. Our database lists the following as having Liver conditions as a complication of that condition:

• Alcoholism
• Anemias, Sideroblastic
• Biliary cirrhosis
• Crohn's disease
• Cystic Fibrosis
• Hemochromatosis
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis E
• Hepatitis X
• Malignant Jaundice
• Obstructive biliary disease
• Polycythemia
• Primary biliary cirrhosis
• Secondary Biliary Cirrhosis
• Small bowel bacterial overgrowth syndrome
• Wilson's Disease

Liver conditions as a symptom:

Conditions listing Liver conditions as a symptom may also be potential underlying causes of Liver conditions. Our database lists the following as having Liver conditions as a symptom of that condition:

• Acquired idiopathic sideroblastic anaemia
• Alpers Syndrome
• Alpha-ketoglutarate dehydrogenase deficiency
• Alstrom syndrome
• Alveolar echinococcosis
• Aromatase deficiency
• Athabaskan severe combined immunodeficiency
• Autoimmune polyendocrinopathy syndrome, type 1
• CDG syndrome type 1A
• CDG syndrome type 1B
• Chemical poisoning - Jet Fuel-8
• Chemical poisoning - Polychlorinated Dibenzofurans
• Complex 1 mitochondrial respiratory chain deficiency
• Congenital disorder of glycosylation type 1/IIX
• Congenital disorder of glycosylation type 1A
• Congenital disorder of glycosylation type 1B
• Congenital disorder of glycosylation type 1E
• Congenital disorder of glycosylation type 2A
• Congenital disorder of glycosylation type 2B
• Congenital Disorders of Glycosylation
• Congenital Disorders of Glycosylation Type Ia
• Diabetes, neonatal - congenital hypothyroidism - congenital glaucoma - hepatic fibrosis - polycystic kidneys
• Hemochromatosis
• Hemochromatosis type 1
• Hemochromatosis type 2
• Hemochromatosis type 3
• Hemochromatosis type 4
• Hereditary Hemochromatosis
• Lathosterolosis
• Liver disease - retinitis pigmentosa - polyneuropathy - epilepsy
• Mullerian derivatives - lymphangiectasia - polydactyly
• Multiple endocrine abnormalities - adenylyl cyclase dysfunction
• NADH CoQ reductase, deficiency of
• Navajo neurohepatopathy
• Steroid dehydrogenase deficiency - dental anomalies
• Wilson's Disease

Medical news summaries relating to Liver conditions:

The following medical news items are relevant to causes of Liver conditions:

• Australian Medical Association wants health warnings placed on alcohol products
• Blood test may be a diagnostic alternative to liver biopsy
• Coffee drinkers help their liver
• Early detection of alcohol abuse crucial
• Fatty liver disease becoming popular
• Fatty liver disease not linked to cancer development
• Hepatitis is a contagious often misdiagnosed disease
• Liver damage implicated in high blood pressure
• Liver disease is one of the biggest killers amongst diabetics
• Liver transplant recipient back into the swing of things
• Neonatal herpes proposed tracking
• Obesity leads to liver disease
• Pregnancy syndrome risks maternal and fetal death
• More news »

Related information on causes of Liver conditions:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Liver conditions may be found in:

• Risk factors for Liver conditions
• Hidden causes of Liver conditions

Causes of Liver conditions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Liver conditions.

Hepatomegaly: Differential Diagnosis
(In a Page: Signs and Symptoms)

Right heart failure

• Inflammatory disorders, resulting in tender hepatomegaly
  –Hepatitis (viral or drug-induced): Associated with jaundice, fever, nausea, vomiting, fatigue, diarrhea, weight loss
  –Alcoholic liver disease: Associated with liver failure and portal hypertension (e.g., caput medusae, spider angiomata, hemorrhoids, testicular atrophy, ALT is more than two times higher than AST)
• Infiltrative disorders
  –Fatty liver (NASH): Predisposing factors include middle age, obesity, female gender, diabetes, and hyperlipidemia
  –Sarcoidosis: Associated with cough, hilar lymphadenopathy; more common in blacks, women, ages 30–40
  –Hemochromatosis: Iron overload resulting in bronzed skin color, diabetes, abnormal iron panel
  –Wilson's disease: Copper excess resulting in liver failure, lenticular degeneration, and Kayser-Fleischer rings in cornea
• Neoplasms present with focal enlargement, arterial bruit and/or hepatic rub, and constitutional symptoms (e.g., fever, night sweats, weight loss)
  –Metastatic cancer is more common than primary liver cancers (colon, lung, breast)
  –Hepatocellular carcinoma is most common primary liver cancer (often due to chronic hepatitis or cirrhosis)
  –Hepatic adenoma or hepatic cysts
  –Leukemia/lymphoma

• Liver abscess
• Less common causes (“zebras”) include tricuspid regurgitation, Budd-Chiari syndrome, schistosomiasis, amyloidosis, kala-azar (visceral leishmaniasis), and HIV/AIDS

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Jaundice: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Viral hepatitis
  –Fatigue, anorexia, fever, nausea, vomiting, dark urine, light-colored (acholic) loose stools, RUQ pain, hepatomegaly, and/or pruritis

• Alcoholic hepatitis
  –Associated with fever, leukocytosis, and AST:ALT ratio >2

• Nonalcoholic steatohepatitis or nonalchoholic fatty liver disease
  –Associated with obesity, diabetes, hyperlipidemia and medications

• Cholecystitis
  –RUQ pain, fever, leukocytosis
  –Female, fertile, fat, forty
  –Murphy's sign: Pain upon palpation of the
  gallbladder while taking a deep breath

• Drugs and toxins
  –Acetaminophen, alcohol, estrogens, isoniazid, chlorpromazine, erythromycin, nitrofurantoin, rifampin

• Gilbert's syndrome
  
  –Decreased conjugation of bilirubin, especially with dehydration, fasting, infection

Sepsis

Malignancy (liver, pancreas, gallbladder/common bile duct, metastatic)

• Liver infiltration
  –Amyloidosis, lymphoma, sarcoidosis, tuberculosis

Total parenteral nutrition (usually requires at least 2 weeks of therapy)

Intravascular hemolysis

• Cholangitis
  –Charcot's triad of fever, RUQ pain, and jaundice

Sickle cell disease
–Chronic hemolysis, hepatic dysfunction

• Autoimmune hepatitis
  –May mimic viral hepatitis
  –Females >> males, often 10–30 years old
  –Associated with autoimmune disease
  (e.g., RA, UC, Sjögren's syndrome, thyroiditis)

Intrahepatic cholestasis of pregnancy
–Pruritus in third trimester
–Resolves after delivery

Hereditary cholestatic disorders (e.g., Dubin-Johnson syndrome, Rotor syndrome)

Physiologic jaundice of newborn

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hepatomegaly: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Inflammation
  –Most common infections: EBV; hepatitis A, B, C; CMV; TORCH
  –Less common infections: HIV, malaria, amebiasis, tuberculosis, toxocariasis, Borrelia burgdorferi
  –Drugs: Acetaminophen (commonly used in overdoses among adolescents), NSAIDs, isoniazid, sodium valproate, propothiouracil, halothane
  –Toxins: Tyrosinemia, galactosemia, vitamin A toxicity
  –Autoimmune hepatitis
  –Systemic lupus erythematosus

• Inappropriate storage
  –Glycogen storage diseases I–V
  –Lipids: Gaucher disease, Wolman disease, Niemann-Pick disease
  –Fat: Fatty acid oxidation defects, mucopolysaccharidoses
  –Metals: Wilson disease (copper), hemochromatosis (iron)
  –Abnormal proteins: α-1 antitrypsin deficiency (store abnormal protein product)
  –Peroxisomal disease: Zellweger
  –Mucopolysaccharidoses, types I–IV

• Infiltration
  –Hepatoblastoma
  –Hepatocellular carcinoma
  –Hemangioma
  –Histiocytosis
  –Extramedullary hematopoiesis
  –Chronic granulomatous disease
• Vascular congestion
  –Congestive heart failure
  –Budd-Chiari syndrome
  –Veno-occlusive disease
  –Suprahepatic web
• Biliary obstruction
  –Biliary atresia represents the most common cause of pediatric liver transplantation
  –Alagille syndrome
  –Cystic fibrosis
  –Primary sclerosing cholangitis
  –Inspissated bile syndrome
• Miscellaneous
  –Reye syndrome, bile acid synthetic disorder

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Jaundice in Infants – Direct: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Bile duct obstruction
  –Biliary atresia: Represents the most frequent cause for liver transplantation in the pediatric patient; prompt diagnosis is crucial, as patient outcome is better if intervention comes before 60 days of life
  –Choledochal cyst
  –Common bile duct gallstone
  –Choledochocele
  –Bile duct stricture
  –Alagille syndrome
  –Caroli disease
  –Congenital hepatic fibrosis

• Neonatal hepatitis
  –Idiopathic hepatitis: Diagnosis of exclusion that should be made only when other causes are excluded; accounts for 60% of patients with neonatal cholestasis
  –Infections: TORCH, hepatitis B, HIV, E. coli, adenovirus, enterovirus, parvovirus B16, tuberculosis, listeriosis, malaria

• Metabolic disorders
  –α-1 antitrypsin deficiency
  –Cystic fibrosis
  –Hypothyroidism
  –Neonatal iron storage disease
  –Amino acids: tyrosinemia
  –Carbohydrates: Galactosemia, fructosemia
  –Lipids: Niemann-Pick, Gaucher, Wolman, cholesterol ester storage disease
  –Mitochondropathies
  –Bile acid synthetic disorders
  –Peroxisomal: Zellweger syndrome
  –Urea cycle defects
• Toxins
  –Total parenteral nutrition
  –Drugs: Trimethaprim-sulfamethoxazole, anticonvulsants
• Miscellaneous
  –Sepsis/hypoperfusion
  –Erythrophagocytic lymphohistiocytosis
  –Extracorporeal membrane oxygenation
  –Trisomy 17, 18, 21
  –Neonatal lupus erythematosus
  –Donohue syndrome
  –Rotor syndrome
  –Dubin-Johnson syndrome
  –Byler disease (PFIC type 1)
  –Cholestasis of North-American Indians
  –Nielsen syndrome

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Jaundice in Infants – Indirect: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Icterus neonatorum (physiologic jaundice)
  –The most common form of indirect jaundice in infants under 14 days of age
  –Caused by increased bilirubin production with transient limited conjugation abilities
• Breast-feeding jaundice
  –Occurs in first week of life in 13% of breast-fed infants
  –Secondary to poor volume intake
• Breast-milk jaundice
  –Occurs in about 2% of breast-fed infants after day 7 of life
  –Secondary to glucuronidase in breast milk
• Hematologic: Hemolysis increases bili load
  –Rh incompatability
  –ABO incompatability
  –Glucose-6-phosphate dehydrogenase (G6PD) deficiency
  –Pyruvate kinase deficiency
  –Hereditary spherocytosis
  –Elliptocytosis
  –Thalassemia
  –Polycythemia
• Extravascular blood
  –Cephalohematoma
  –Trauma
  –Swallowed maternal blood
• Endocrinologic
  –Hypothyroidism
  –Maternal diabetes
• Sepsis
• Metabolic
  –Crigler-Najjar I
  –Crigler-Najjar II (Arias syndrome)
  –Crigler-Najjar III
• Cardiopulmonary
  –Congestive heart failure
  –Patent ductus arteriosus
  –Portal vein thrombosis
• Anatomic
  –Pyloric stenosis
  –Duodenal atresia/stenosis
  –Duodenal web
• Drugs
  –Oxytocin
  –Sulfonamides
  –Ceftriaxone
  –Chuen-Lin
• Lucey-Driscoll syndrome

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Hepatomegaly: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Amyloidosis

Amyloidosis is a rare disorder that may cause hepatomegaly and mild jaundice as well as renal, cardiac, and other GI effects.

Cirrhosis

Late in cirrhosis, the liver becomes enlarged, nodular, and hard Other late signs and symptoms affect all body systems

Respiratory findings include limited thoracic expansion due to abdominal ascites, leading to hypoxia. Central nervous system findings include signs and symptoms of hepatic encephalopathy, such as lethargy, slurred speech, asterixis, peripheral neuritis, paranoia, hallucinations, extreme obtundation, and coma. Hematologic signs include epistaxis, easy bruising, and bleeding gums. Endocrine findings include testicular atrophy, gynecomastia, loss of chest and axillary hair, or menstrual irregularities. Integumentary effects include abnormal pigmentation, jaundice, severe pruritus, extreme dryness, poor tissue turgor, spider angiomas, and palmar erythema.

The patient may also develop fetor hepaticus, enlarged superficial abdominal veins, muscle atrophy, right upper quadrant pain that worsens when he sits up or leans forward, and a palpable spleen. Portal hypertension — elevated pressure in the portal vein — causes bleeding from esophageal varices.

Diabetes mellitus

Poorly controlled diabetes in overweight patients commonly produces fatty infiltration of the liver, hepatomegaly, and right upper quadrant tenderness along with polydipsia, polyphagia, and polyuria

These features are more common in type 2 than in type 1 diabetes A chronically enlarged fatty liver typically produces no symptoms except for slight tenderness.

Granulomatous disorders

Sarcoidosis, histoplasmosis, and other such disorders commonly produce a slightly enlarged, firm liver.

Hepatic abscess

Hepatomegaly may accompany a fever (a primary sign), nausea, vomiting, chills, weakness, diarrhea, anorexia, an elevated right hemidiaphragm, and right upper quadrant pain and tenderness.

Hepatitis

In viral hepatitis, early signs and symptoms include nausea, anorexia, vomiting, fatigue, malaise, photophobia, a sore throat, a cough, and a headache Hepatomegaly occurs in the icteric phase and continues during the recovery phase

Also, during the icteric phase, the early signs and symptoms diminish and others appear: liver tenderness, slight weight loss, dark urine, clay-colored stools, jaundice, pruritus, right upper quadrant pain, and splenomegaly.

Leukemia and lymphomas

Leukemia and lymphomas are proliferative blood cell disorders that typically cause moderate to massive hepatomegaly and splenomegaly as well as abdominal discomfort

General signs and symptoms include malaise, a low-grade fever, fatigue, weakness, tachycardia, weight loss, bleeding disorders, and anorexia.

Liver cancer

Primary tumors commonly cause irregular, nodular, firm hepatomegaly, with pain or tenderness in the right upper quadrant and a friction rub or bruit over the liver Common related findings are weight loss, anorexia, cachexia, nausea, and vomiting

Peripheral edema, ascites, jaundice, and a palpable right upper quadrant mass may also develop. When metastatic liver tumors cause hepatomegaly, the patient’s accompanying signs and symptoms reflect his primary cancer.

Mononucleosis (infectious)

Occasionally, infectious mononucleosis causes hepatomegaly

Prodromal symptoms include a headache, malaise, and fatigue. After 3 to 5 days, the patient typically develops a sore throat, cervical lymphadenopathy, and temperature fluctuations. He may also develop stomatitis, palatal petechiae, periorbital edema, splenomegaly, exudative tonsillitis, pharyngitis and, possibly, a maculopapular rash.

Obesity

Hepatomegaly can result from fatty infiltration of the liver

Weight loss reduces the liver’s size.

Pancreatic cancer

In pancreatic cancer, hepatomegaly accompanies such classic signs and symptoms as anorexia, weight loss, abdominal or back pain, and jaundice Other findings include nausea, vomiting, a fever, fatigue, weakness, pruritus, and skin lesions (usually on the legs).

Pericarditis

In chronic constrictive pericarditis, an increase in systemic venous pressure produces marked congestive hepatomegaly Distended jugular veins (more prominent on inspiration) are a common finding

The usual signs of cardiac disease typically are absent; other features include peripheral edema, ascites, fatigue, and decreased muscle mass.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Jaundice: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Carcinoma

Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, a recurrent fever, and chills

Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right upper quadrant discomfort and tenderness, nausea, weight loss, and a slight fever. Examination may reveal irregular, nodular, firm hepatomegaly; ascites; peripheral edema; a bruit heard over the liver; and a right upper quadrant mass.

Withpancreatic cancer,progressive jaundice — possibly with pruritus — may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, a fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis

Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right upper quadrant pain, and a high fever with chills.

Cholecystitis

Cholecystitis produces nonobstructive jaundice in about 25% of patients

Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), a fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign and, possibly, abdominal distention and rigidity.

Cholelithiasis

Cholelithiasis commonly causes jaundice and biliary colic

It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes a fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cirrhosis

With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency

Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right upper quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis,fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Dubin-Johnson syndrome

With Dubin-Johnson syndrome, which is a rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40

Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.

Heart failure

Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure

Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites are a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hepatic abscess

Multiple abscesses may cause jaundice, but the primary effects are a persistent fever with chills and sweating

Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; an elevated right hemidiaphragm; and ascites.

Hepatitis

Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis

Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgia, myalgia, a headache, anorexia, photophobia, pharyngitis, a cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right upper quadrant pain and tenderness.

Pancreatitis (acute)

Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, the primary symptom of acute pancreatitis is usually severe epigastric pain that commonly radiates to the back

Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include a fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany — the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia

Hemolysis produces jaundice in the patient with sickle cell anemia

Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, swollen (painful) joints, a fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; a low-grade fever; and increased weakness, jaundice, and dyspnea.

Other causes

Drugs

Many drugs may cause hepatic injury and resultant jaundice

Examples include acetaminophen, phenylbutazone, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, 3-hydroxy-3-methylglutaryl reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and dilantin.

Treatments

Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.

A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Asterixis [Liver flap, flapping tremor]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Hepatic encephalopathy. A life-threatening disorder, hepatic encephalopathy initially causes mild personality changes and a slight tremor. The tremor progresses into asterixis — a hallmark of hepatic encephalopathy — and is accompanied by lethargy, aberrant behavior, and apraxia. Eventually, the patient becomes stuporous and displays hyperventilation. When he slips into a coma, hyperactive reflexes, a positive Babinski’s sign, and fetor hepaticus are characteristic signs. The patient may also experience bradycardia, decreased respirations, and seizures.

❑ Severe respiratory insufficiency. Characterized by life-threatening respiratory acidosis, severe respiratory insufficiency initially produces headache, restlessness, confusion, apprehension, and decreased reflexes. Eventually, the patient becomes somnolent and may demonstrate asterixis before slipping into a coma. Associated signs and symptoms of respiratory insufficiency include difficulty breathing and rapid, shallow respirations. The patient may be hypertensive in early disease but hypotensive later.

❑ Uremic syndrome. A life-threatening disorder, uremic syndrome initially causes lethargy, somnolence, confusion, disorientation, behavior changes, and irritability. Eventually, signs and symptoms appear in diverse body systems. Asterixis is accompanied by stupor, paresthesia, muscle twitching, fasciculations, and footdrop. Other signs and symptoms include polyuria and nocturia followed by oliguria and, then, anuria; elevated blood pressure; signs of heart failure and pericarditis; deep, gasping respirations (Kussmaul’s respirations); anorexia; nausea; vomiting; diarrhea; GI bleeding; weight loss; ammonia breath odor; and metallic taste (dysgeusia).

Other causes

❑ Drugs. Certain drugs, such as the anticonvulsant phenytoin, may cause asterixis.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Fatty liver: Causes
(Professional Guide to Diseases (Eighth Edition))

Chronic alcoholism is the most common cause of fatty liver in the United States and in Europe, with the severity of hepatic disease directly related to the amount of alcohol consumed. (Fatty liver can occur in people who consume as little as 10 oz of alcohol per week.) Other causes include malnutrition (especially protein deficiency), obesity, diabetes mellitus, jejunoileal bypass surgery, Cushing’s syndrome, Reye’s syndrome, pregnancy, large doses of hepatotoxins such as I.V. tetracycline, carbon tetrachloride intoxication, prolonged parenteral nutrition, and DDT poisoning. Whatever the cause, fatty infiltration of the liver probably results from mobilization of fatty acids from adipose tissues or altered fat metabolism.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Liver abscess: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

In pyogenic liver abscesses, the common infecting organisms are Escherichia coli, Klebsiella, Staphylococcus, Streptococcus, Bacteroides, and enterococcus. The infecting organisms may invade the liver directly after a liver wound or they may spread from the lungs, skin, or other organs by the hepatic artery, portal vein, or biliary tract. Pyogenic abscesses are generally multiple and commonly follow cholecystitis, peritonitis, pneumonia, and bacterial endocarditis.

An amebic abscess results from infection with the protozoa Entamoeba histolytica, the organism that causes amebic dysentery. Amebic liver abscesses usually occur singly, in the right lobe.

There are 8 to 16 cases of liver abscess for every 100,000 people hospitalized, and there is a 5% to 30% mortality rate. Most cases occur in people in their 60s and 70s.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Liver cancer: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The immediate cause of liver cancer is unknown, but it may be a congenital disease in children. Adult liver cancer may result from environmental exposure to carcinogens, such as the chemical compound aflatoxin (a mold that grows on rice and peanuts), thorium dioxide (a contrast medium formerly used in liver radiography), Senecio alkaloids, and possibly androgens and oral estrogens.

Roughly 30% to 70% of patients with hepatomas also have cirrhosis. (Hepatomas are 40 times more likely to develop in a cirrhotic liver than in a normal one.)

Whether cirrhosis is a premalignant state or alcohol and malnutrition predispose the liver to develop hepatomas is still unclear. Other risk factors are exposure to the hepatitis C virus and the hepatitis B virus.

Liver cancer accounts for roughly 1% of all cancers in the United States and for 10% to 50% in Africa and parts of Asia. Liver cancer is most prevalent in men (particularly men older than age 60), and incidence increases with age. It's rapidly fatal, usually within 6 months, from GI hemorrhage, progressive cachexia, hepatic failure, or metastasis.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Hepatomegaly: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyloidosis

This rare disorder can cause hepatomegaly and mild jaundice as well as renal, cardiac, and other GI effects.

Cirrhosis

Late in this disorder, the liver becomes enlarged, nodular, and hard. Other late signs and symptoms affect all body systems. Respiratory findings include limited thoracic expansion due to abdominal ascites, leading to hypoxia. Central nervous system findings include signs and symptoms of hepatic encephalopathy, such as lethargy, slurred speech, asterixis, peripheral neuritis, paranoia, hallucinations, extreme obtundation, and coma. Hematologic signs include epistaxis, easy bruising, and bleeding gums. Endocrine findings include testicular atrophy, gynecomastia, loss of chest and axillary hair, and menstrual irregularities. Integumentary effects include abnormal pigmentation, jaundice, severe pruritus and dryness, poor tissue turgor, spider angiomas, and palmar erythema.

The patient may also develop fetor hepaticus, enlarged superficial abdominal veins, muscle atrophy, right-upper-quadrant pain that worsens when he sits up or leans forward, and a palpable spleen. Portal hypertension—elevated pressure in the portal vein—causes bleeding from esophageal varices.

Diabetes mellitus

Poorly controlled diabetes in overweight patients commonly produces fatty infiltration of the liver, hepatomegaly, and right-upper-quadrant tenderness along with polydipsia, polyphagia, and polyuria. These features are more common in type 2 than in type 1 diabetes. A chronically enlarged fatty liver typically produces no symptoms except for slight tenderness.

Granulomatous disorders

Sarcoidosis, histoplasmosis, and other granulomatous disorders commonly produce a slightly enlarged, firm liver.

Heart failure

This disorder produces hepatomegaly along with jugular vein distention, cyanosis, nocturia, dependent edema of the legs and sacrum, steady weight gain, confusion and, possibly, nausea, vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Massive right-sided heart failure may cause anasarca, oliguria, severe weakness, and anxiety. If left-sided heart failure precedes right-sided heart failure, the patient exhibits dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachypnea, arrhythmias, tachycardia, and fatigue.

Hemochromatosis

This rare disease of iron metabolism causes hepatomegaly, altered skin pigmentation and, possibly, cardiac failure.

Hepatic abscess

Hepatomegaly may accompany fever (a primary sign), nausea, vomiting, chills, weakness, diarrhea, anorexia, elevated right hemidiaphragm, and right-upper-quadrant pain and tenderness.

Hepatitis

In viral hepatitis, early signs and symptoms include nausea, anorexia, vomiting, fatigue, malaise, photophobia, sore throat, cough, and headache. Hepatomegaly occurs in the icteric phase and continues during the recovery phase. Also, during the icteric phase, the early signs and symptoms diminish and others appear: liver tenderness, slight weight loss, dark urine, clay-colored stools, jaundice, pruritus, right-upper-quadrant pain, and splenomegaly.

Leukemia and lymphomas

These proliferative blood cell disorders commonly cause moderate to massive hepatomegaly and splenomegaly as well as abdominal discomfort. General signs and symptoms include malaise, low-grade fever, fatigue, weakness, tachycardia, anorexia, weight loss, and bleeding disorders.

Liver cancer

Primary tumors commonly cause an enlarged, irregular, nodular, firm liver with pain or tenderness in the right upper quadrant and a friction rub or bruit over the liver. Common related findings are anorexia, weight loss, cachexia, nausea, and vomiting. Peripheral edema, ascites, jaundice, and a palpable right-upper-quadrant mass may also develop. When metastatic liver tumors cause hepatomegaly, the patient’s signs and symptoms reflect his primary cancer.

Mononucleosis (infectious)

Occasionally, this disorder causes hepatomegaly. Prodromal symptoms include headache, malaise, and fatigue. After 3 to 5 days, the patient typically develops a sore throat, cervical lymphadenopathy, and temperature fluctuations. He may also develop stomatitis, palatal petechiae, periorbital edema, splenomegaly, exudative tonsillitis, pharyngitis and, possibly, a maculopapular rash.

Obesity

Hepatomegaly can result from fatty infiltration of the liver. Weight loss reduces the liver’s size.

Pancreatic cancer

In this disease, hepatomegaly accompanies such classic signs and symptoms as anorexia, weight loss, abdominal or back pain, and jaundice. Other findings include nausea, vomiting, fever, fatigue, weakness, pruritus, and skin lesions (usually on the legs).

Pericarditis

In chronic constrictive pericarditis, an increase in systemic venous pressure produces marked congestive hepatomegaly. Distended jugular veins (more prominent on inspiration) are a common finding. The usual signs of heart disease typically are absent; other features include peripheral edema, ascites, fatigue, and decreased muscle mass.

Other causes

Drugs

Hepatomegaly is a rare but serious side effect of drugs used to treat HIV-positive hepatitis, such as tenofovir and lamivudine.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Asterixis [Liver flap, flapping tremor]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Hepatic encephalopathy

A life-threatening disorder, hepatic encephalopathy initially causes mild personality changes and a slight tremor. The tremor progresses to asterixis—a hallmark of hepatic encephalopathy—and is accompanied by lethargy, aberrant behavior, and apraxia. Eventually, the patient becomes stuporous and displays hyperventilation. After slipping into a coma, the patient exhibits characteristic hyperactive reflexes, positive Babinski’s reflex, and fetor hepaticus. He also may experience bradycardia, decreased respirations, and seizures.

Respiratory insufficiency, severe

Characterized by life-threatening respiratory acidosis, severe respiratory insufficiency initially produces headache, restlessness, confusion, apprehension, and decreased reflexes. Eventually, the patient becomes somnolent and may demonstrate asterixis before slipping into a coma. Associated signs and symptoms of respiratory insufficiency include difficulty breathing and rapid, shallow respirations. The patient may be hypertensive in early disease but hypotensive later.

Uremic syndrome

Uremic syndrome is a life-threatening disorder that initially causes lethargy, somnolence, confusion, disorientation, behavior changes, and irritability. Eventually, signs and symptoms appear in diverse body systems. Asterixis is accompanied by stupor, paresthesia, muscle twitching, fasciculations, and footdrop. Other signs and symptoms include polyuria and nocturia followed by oliguria and then anuria, elevated blood pressure, signs of heart failure and pericarditis, Kussmaul’s respirations, anorexia, nausea, vomiting diarrhea, GI bleeding, weight loss, ammonia breath odor, and metallic taste (dysgeusia).

Other causes

Drugs

Certain drugs, such as the anticonvulsant phenytoin, may cause asterixis.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Jaundice [Icterus]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Agnogenic myeloid metaplasia

This myeloproliferative disorder of the bone marrow may cause jaundice. Its typical effects, however, are associated with anemia, including fatigue, weakness, anorexia, massive splenomegaly, hepatomegaly, purpura, and bleeding tendencies.

Carcinoma

Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, recurrent fever, and chills. Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right-upper-quadrant discomfort and tenderness, nausea, weight loss, and slight fever. Examination may reveal irregular, nodular, firm hepatomegaly, ascites, peripheral edema, a bruit heard over the liver, and a right-upper-quadrant mass.

With pancreatic cancer, progressive jaundice—possibly with pruritus—may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis

Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right-upper-quadrant pain, and high fever with chills.

Cholecystitis

This disorder produces nonobstructive jaundice in about 25% of patients. Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign, and, possibly, abdominal distention and rigidity.

Cholelithiasis

This disorder commonly causes jaundice and biliary colic. It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cholestasis

With benign, recurrent intrahepatic cholestasis, the patient experiences prolonged attacks of jaundice (sometimes spaced several years apart) accompanied by pruritus. Other signs and symptoms are similar to those of hepatitis—fatigue, nausea, weight loss, anorexia, pale stools, and right-upper-quadrant pain.

Cirrhosis

With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency. Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right-upper-quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis, fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Dubin-Johnson syndrome

With this rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40. Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.

Glucose-6-phosphate dehydrogenase deficiency

Acute intravascular hemolysis following ingestion of such drugs as quinine or aspirin causes jaundice, pallor, dyspnea, tachycardia, and malaise. Palpation may reveal splenomegaly and hepatomegaly.

Heart failure

Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure. Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hemolytic anemia (acquired)

This disorder may produce prominent jaundice along with dyspnea, fatigue, pallor, tachycardia, and palpitations. Rapid hemolysis causes chills, fever, irritability, headache, and abdominal pain; severe hemolysis causes signs of shock.

Hepatic abscess

Multiple abscesses may cause jaundice, but the primary effects are persistent fever with chills and sweating. Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; elevated right hemidiaphragm; and ascites.

Hepatitis

Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis. Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgias, myalgias, headache, anorexia, photophobia, pharyngitis, cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right-upper-quadrant pain and tenderness.

Leptospirosis

Severe leptospirosis (Weil’s disease) may cause jaundice. This disorder begins suddenly with a frontal headache, severe muscle aches in the thighs and lumbar area, cutaneous hyperesthesia, abdominal pain, nausea, conjunctival suffusion, and vomiting. Chills and a rapidly rising fever follow. Signs and symptoms of meningeal irritation include drowsiness, decreased mentation, stiff neck, and positive Kernig’s and Brudzinski’s signs. Right-upper-quadrant tenderness, hepatomegaly, and jaundice indicate hepatic involvement; proteinuria, pyuria, and hematuria indicate renal involvement. Epistaxis, hematemesis, melena, and hemoptysis may also occur.

Pancreatitis (acute)

Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, this disorder’s primary symptom is usually severe epigastric pain that commonly radiates to the back. Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany—the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia

Hemolysis produces jaundice in patients with this disorder. Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, (painful) swollen joints, fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; low-grade fever; and increased weakness, jaundice, and dyspnea.

Zieve syndrome

Caused by alcohol abuse, this relatively rare disorder produces abdominal pain and a sudden onset of severe jaundice. However, spider angiomas, ascites, and other signs of advanced liver disease are absent.

Other causes

Drugs

Many drugs may cause hepatic injury and resultant jaundice. Examples include acetaminophen, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, HMG-CoA reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and phenytoin.

Treatments

Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.

A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hepatomegaly: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Acute hepatitis

❑ Chronic hepatitis

❑ Cirrhosis

❑ Right heart failure

❑ Fatty liver

❑ Hepatocellular carcinoma

❑ Metastatic cancer

❑ Lymphoma/leukemia

❑ Liver cysts

❑ Hepatic vein obstruction (Budd-Chiari)

❑ Primary biliary cirrhosis

❑ Hemochromatosis

❑ Amyloidosis

❑ Gaucher

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Source: Field Guide to Bedside Diagnosis, 2007

Jaundice: Differential Overview
(Field Guide to Bedside Diagnosis)

Conjugated

❑ Viral hepatitis

❑ Gallstone obstruction

❑ Drugs

❑ Carotinemia

❑ Alcohol-induced hepatitis

❑ Cirrhosis

❑ Pregnancy (cholestatic)

❑ Postoperative

❑ Metastatic cancer

❑ Pancreatic cancer

❑ Ampullary carcinoma

❑ Hepatoma

❑ Sclerosing cholangitis

❑ Primary biliary cirrhosis

❑ Leptospirosis

❑ Hepatic vein obstruction (Budd-Chiari)

❑ Hemochromatosis

Unconjugated

❑ Hemolysis

❑ Gilbert syndrome

❑ Sepsis

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Source: Field Guide to Bedside Diagnosis, 2007

Fatty liver: Causes
(Handbook of Diseases)

The most common cause of fatty liver in the United States and Europe is chronic alcoholism, with the severity of liver disease directly related to the amount of alcohol consumed. Other common, non-alcohol-related causes include acquired immunodeficiency syndrome, drug toxicity, and pregnancy.

Other causes include malnutrition (especially protein deficiency), obesity, diabetes mellitus, jejunoileal bypass surgery, Cushing’s syndrome, Reye’s syndrome, carbon tetrachloride intoxication, prolonged total parenteral nutrition (TPN), and DDT poisoning.

Whatever the cause, fatty infiltration of the liver probably results from mobilization of fatty acids from adipose tissues or from altered fat metabolism.

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Source: Handbook of Diseases, 2003

Liver abscess: Causes
(Handbook of Diseases)

Underlying causes of liver abscess include benign or malignant biliary obstruction along with cholangitis, extrahepatic abdominal sepsis, and trauma or surgery to the right upper quadrant. Liver abscesses also occur from intra-arterial chemoembolizations or cryosurgery in the liver, which causes necrosis of tumor cells and potential infection.

The method by which bacteria reach the liver reflects the underlying causes. Biliary tract disease is the most common cause of liver abscess. Liver abscess after intra-abdominal sepsis (such as with diverticulitis) is most likely to be caused by hematogenous spread through the portal bloodstream. Hematogenous spread by hepatic arterial flow may occur in infectious endocarditis. Abscesses arising from hematogenous transmission are usually caused by a single organism; those arising from biliary obstruction, by mixed flora. Patients with metastatic cancer to the liver, diabetes mellitus, or alcoholism are more likely to develop a liver abscess. The organisms that predominate in liver abscess are gram-negative aerobic bacilli, enterococci, streptococci, and anaerobes. Amebic liver abscesses are caused by Entamoeba histolytica.

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Source: Handbook of Diseases, 2003

Liver cancer: Causes
(Handbook of Diseases)

The immediate cause of liver cancer is unknown, but it may be a congenital disease in children. Adult liver cancer may result from environmental exposure to carcinogens, such as the chemical compound aflatoxin (a mold that grows on rice and peanuts), thorium dioxide (a contrast medium formerly used in liver radiography), Senecio alkaloids, androgens, or oral estrogens.

Risk factors

Roughly 30% to 70% of patients with hepatomas also have cirrhosis. (Hepatomas are 40 times more likely to develop in a cirrhotic liver than in a normal one.) Whether cirrhosis is a premalignant state or alcohol and malnutrition predispose the liver to develop hepatomas is still unclear. Another risk factor is exposure to the hepatitis B virus, although this risk will probably decrease with the availability of the hepatitis B vaccine.

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Source: Handbook of Diseases, 2003

Hepatomegaly: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cirrhosis

In late cirrhosis, the liver becomes enlarged, nodular, and hard. Other late signs and symptoms affect all body systems. Respiratory findings include limited thoracic expansion due to abdominal ascites, leading to hypoxia. Central nervous system findings include signs and symptoms of hepatic encephalopathy, such as lethargy, slurred speech, asterixis, peripheral neuritis, paranoia, hallucinations, extreme obtundation, and coma. Hematologic signs include epistaxis, easy bruising, and bleeding gums. Endocrine findings include testicular atrophy, gynecomastia, loss of chest and axillary hair, or menstrual irregularities. Integumentary effects include abnormal pigmentation, jaundice, severe pruritus, extreme dryness, poor tissue turgor, spider angiomas, and palmar erythema.

The patient may also develop fetor hepaticus, enlarged superficial abdominal veins, muscle atrophy, right-upper-quadrant pain that worsens when he sits up or leans forward, and a palpable spleen. Portal hypertension — elevated pressure in the portal vein — causes bleeding from esophageal varices.

Diabetes mellitus

Poorly controlled diabetes in overweight patients can produce fatty infiltration of the liver, hepatomegaly, and right-upper-quadrant tenderness along with polydipsia, polyphagia, and polyuria. These features are more common in type 2 than in type 1 diabetes. A chronically enlarged fatty liver typically produces no symptoms except for slight tenderness.

Heart failure

Heart failure produces hepatomegaly along with jugular vein distention, cyanosis, nocturia, dependent edema of the legs and sacrum, steady weight gain, confusion and, possibly, nausea, vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Massive right-sided heart failure may cause anasarca, oliguria, severe weakness, and anxiety. If left-sided heart failure precedes right-sided heart failure, the patient exhibits dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, tachycardia, and fatigue.

Hepatitis

In viral hepatitis, early signs and symptoms include nausea, anorexia, vomiting, fatigue, malaise, photophobia, sore throat, cough, and headache. Hepatomegaly occurs in the icteric phase and continues during the recovery phase. Also, during the icteric phase, the early signs and symptoms diminish and others appear: liver tenderness, slight weight loss, dark urine, clay-colored stools, jaundice, pruritus, right-upper-quadrant pain, and splenomegaly.

Leukemia and lymphomas

Leukemia and lymphomas are proliferative blood cell disorders that commonly cause moderate to massive hepatomegaly and splenomegaly as well as abdominal discomfort. General signs and symptoms include malaise, low-grade fever, fatigue, weakness, tachycardia, weight loss, bleeding disorders, and anorexia.

Liver cancer

Primary tumors commonly cause irregular, nodular, firm hepatomegaly, with pain or tenderness in the right upper quadrant and a friction rub or bruit over the liver. Common related findings are weight loss, anorexia, cachexia, nausea, and vomiting. Peripheral edema, ascites, jaundice, and a palpable right-upper-quadrant mass may also develop. When metastatic liver tumors cause hepatomegaly, the patient’s accompanying signs and symptoms reflect his primary cancer.

Mononucleosis (infectious)

Occasionally, infectious mononucleosis causes hepatomegaly. Prodromal symptoms include headache, malaise, and fatigue. After 3 to 5 days, the patient typically develops sore throat, cervical lymphadenopathy, and temperature fluctuations. He may also develop stomatitis, palatal petechiae, periorbital edema, splenomegaly, exudative tonsillitis, pharyngitis and, possibly, a maculopapular rash.

Obesity

Hepatomegaly can result from fatty infiltration of the liver. Weight loss reduces the liver’s size. Obesity may also produce findings related to respiratory difficulties, hypertension, cardiovascular disease, diabetes, renal disease, gallbladder disease, and psychological difficulties.

Pancreatic cancer

In pancreatic cancer, hepatomegaly accompanies such classic signs and symptoms as anorexia, weight loss, abdominal or back pain, and jaundice. Other findings include nausea, vomiting, fever, fatigue, weakness, pruritus, and skin lesions (usually on the legs).

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Jaundice: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Carcinoma

Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, recurrent fever, and chills. Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or metastases to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right-upper-quadrant discomfort and tenderness, nausea, weight loss, and slight fever. Examination may reveal irregular, nodular, firm hepatomegaly, ascites, peripheral edema, a bruit heard over the liver, and a right-upper-quadrant mass.

With pancreatic cancer, progressive jaundice — possibly with pruritus — may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis

Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right-upper-quadrant pain, and high fever with chills. The patient may also report pruritus. Acholic or hypocholic stools may be present.

Cholecystitis

Cholecystitis produces nonobstructive jaundice in about 25% of patients. Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign and, possibly, abdominal distention and rigidity.

Cholelithiasis

Cholelithiasis commonly causes jaundice and biliary colic. It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cholestasis

With benign, recurrent intrahepatic cholestasis, the patient experiences prolonged attacks of jaundice (sometimes spaced several years apart) accompanied by pruritus. Other signs and symptoms are similar to those of hepatitis — fatigue, nausea, weight loss, anorexia, pale stools, and right-upper-quadrant pain.

Cirrhosis

With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency. Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right-upper-quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis, fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Glucose-6-phosphate dehydrogenase deficiency

Acute intravascular hemolysis following ingestion of such drugs as quinine or aspirin causes jaundice, pallor, dyspnea, tachycardia, and malaise. Palpation may reveal splenomegaly and hepatomegaly.

Heart failure

Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure. Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hemolytic anemia (acquired)

Acquired hemolytic anemia may produce prominent jaundice along with dyspnea, fatigue, pallor, tachycardia, and palpitations. Rapid hemolysis causes chills, fever, irritability, headache, and abdominal pain; severe hemolysis causes signs of shock.

Hepatitis

Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis. Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgias, myalgias, headache, anorexia, photophobia, pharyngitis, cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right-upper-quadrant pain and tenderness.

Pancreatitis (acute)

Pancreatitis can cause jaundice; however, this disorder’s primary symptom is usually severe epigastric pain that commonly radiates to the back. Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany — the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia

Hemolysis produces jaundice in patients with sickle cell anemia. Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, swollen joints (sometimes painful), fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; low-grade fever; and increased weakness, jaundice, and dyspnea.

Other causes

Drugs

Many drugs may cause hepatic injury and resultant jaundice. Examples include acetaminophen, phenylbutazone, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, HMG-CoA reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and dilantin.

Treatments

Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs. Postoperative jaundice may lead to edema and obstructed bile flow from the administration of halothane or from prolonged surgery resulting in shock, blood loss, or blood transfusion. A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Hepatomegaly: Principal Causes of Hepatomegaly
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Infection/inflammation
   1. Hepatitis
      1. Viral
      2. Bacterial
      3. Other infections
      4. Toxic
      5. Autoimmune
   2. Cholangitis
2. Hemolytic anemia
3. Cardiac disorders
4. Trauma
5. Bile duct obstruction
   1. Biliaryatresia
   2. Caroli disease
6. Vascular disorders
   1. Budd-Chiarisyndrome
   2. Venoocclusive disease
7. Neoplasia
8. Metabolic disorders
   1. Disordersof carbohydrate metabolism
      1. Galactosemia
      2. Hereditary fructose intolerance
      3. Glycogen storage disease
         1. Glycogenstorage disease type I
         2. Glycogen storage disease type III
         3. Glycogen storage disease type IV
         4. Glycogen storage disease type VI
   2. Disorders of amino acid metabolism
      1. Tyrosinemia
      2. Urea cycle defects
   3. Disorders of lysosomal storage
      1. Mucopolysaccharidoses
      2. Lipidoses
         1. Gaucher disease (Types I, II, III)
         2. Nieman-Pick disease (Types A, B, C)
         3. GM-1 gangliosidosis
         4. GM-2 gangliosidosis (Sandhoff disease)
      3. Glycoprotein disorders
         1. Fucosidosis(Types I, II)
         2. Sialidosis type II
      4. Wolman disease and cholesterol esterdisease
   4. Disorders of fatty acid oxidation
   5. Disorders of bile acid synthesis andtransport
   6. Alpha1-antitrypsin deficiency
   7. Wilson disease
   8. Reye syndrome
   9. Zellweger syndrome
9. Systemic disorders
   1. Obesity
   2. Diabetes mellitus
   3. Cystic fibrosis
   4. Malnutrition
   5. Connective tissue diseases
   6. Histiocytoses
   7. Total parenteral nutrition

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Jaundice: Principal Causes of Unconjugated Hyperbilirubinemia
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Neonatalonset
   1. Increasedbilirubin production
      1. Physiologic
      2. Hemolytic anemia
         1. Isoimmunization
         2. Red cell enzyme defects
            1. Glucose-6-phosphatedehydrogenase deficiency
            2. Pyruvate kinase deficiency
            3. Other enzyme defects
         3. Red cell membrane defects
            1. Hereditaryspherocytosis
            2. Hereditary elliptocytosis
            3. Hereditary stomatocytosis
            4. Infantile pyknocytosis
         4. Septicemia
      3. Polycythemia
      4. Enclosed hematoma
   2. Decreased bilirubin uptake, storage,or metabolism
      1. Physiologic
      2. Hypoxia and acidosis
      3. Hypoalbuminemia
      4. Increased serum fatty acids
      5. Septicemia
      6. Drugs
      7. Hypothyroidism
      8. Lucey-Driscoll syndrome (transientfamilial neonatal hyperbilirubinemia)
      9. Crigler-Najjar syndrome (types I andII)
   3. Increased enterohepatic circulation
      1. Physiologic
      2. Breast-feeding–related jaundice
      3. Intestinal obstruction
2. Postneonatal onset
   1. Increasedbilirubin production
      1. Hemolytic anemia
      2. Septicemia
   2. Decreased bilirubin uptake, storage,or metabolism
      1. Gilbertsyndrome
      2. Septicemia

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Hepatomegaly: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Amyloidosis.Amyloidosis is a rare disorder that may cause hepatomegaly and mild jaundice as well as renal, cardiac, and other GI effects.

Cirrhosis.Late in cirrhosis, the liver becomes enlarged, nodular, and hard. Other late signs and symptoms affect all body systems. Respiratory findings include limited thoracic expansion due to abdominal ascites, leading to hypoxia. Central nervous system findings include signs and symptoms of hepatic encephalopathy, such as lethargy, slurred speech, asterixis, peripheral neuritis, paranoia, hallucinations, extreme obtundation, and coma. Hematologic signs include epistaxis, easy bruising, and bleeding gums. Endocrine findings include testicular atrophy, gynecomastia, loss of chest and axillary hair, or menstrual irregularities. Integumentary effects include abnormal pigmentation, jaundice, severe pruritus, extreme dryness, poor tissue turgor, spider angiomas, and palmar erythema.

The patient may also develop fetor hepaticus, enlarged superficial abdominal veins, muscle atrophy, right upper quadrant pain that worsens when he sits up or leans forward, and a palpable spleen. Portal hypertension—elevated pressure in the portal vein—causes bleeding from esophageal varices.

Diabetes mellitus.Poorly controlled diabetes in overweight patients commonly produces fatty infiltration of the liver, hepatomegaly, and right upper quadrant tenderness along with polydipsia, polyphagia, and polyuria. These features are more common in type 2 than in type 1 diabetes. A chronically enlarged fatty liver typically produces no symptoms except for slight tenderness.

Granulomatous disorders.Sarcoidosis, histoplasmosis, and other such disorders commonly produce a slightly enlarged, firm liver.

Hepatic abscess.Hepatomegaly may accompany a fever (a primary sign), nausea, vomiting, chills, weakness, diarrhea, anorexia, an elevated right hemidiaphragm, and right upper quadrant pain and tenderness.

Hepatitis.In viral hepatitis, early signs and symptoms include nausea, anorexia, vomiting, fatigue, malaise, photophobia, a sore throat, a cough, and a headache. Hepatomegaly occurs in the icteric phase and continues during the recovery phase. Also, during the icteric phase, the early signs and symptoms diminish and others appear: liver tenderness, slight weight loss, dark urine, clay-colored stools, jaundice, pruritus, right upper quadrant pain, and splenomegaly.

Leukemia and lymphomas.Leukemia and lymphomas are proliferative blood cell disorders that typically cause moderate to massive hepatomegaly and splenomegaly as well as abdominal discomfort. General signs and symptoms include malaise, a low-grade fever, fatigue, weakness, tachycardia, weight loss, bleeding disorders, and anorexia.

Liver cancer.Primary liver tumors commonly cause irregular, nodular, firm hepatomegaly, with pain or tenderness in the right upper quadrant and a friction rub or bruit over the liver. Common related findings are weight loss, anorexia, cachexia, nausea, and vomiting. Peripheral edema, ascites, jaundice, and a palpable right upper quadrant mass may also develop. When metastatic liver tumors cause hepatomegaly, the patient's accompanying signs and symptoms reflect his primary cancer.

Mononucleosis (infectious).Occasionally, infectious mononucleosis causes hepatomegaly. Prodromal symptoms include a headache, malaise, and fatigue. After 3 to 5 days, the patient typically develops a sore throat, cervical lymphadenopathy, and temperature fluctuations. He may also develop stomatitis, palatal petechiae, periorbital edema, splenomegaly, exudative tonsillitis, pharyngitis and, possibly, a maculopapular rash.

Obesity.Hepatomegaly can result from fatty infiltration of the liver. Weight loss reduces the liver's size.

Pancreatic cancer.In pancreatic cancer, hepatomegaly accompanies such classic signs and symptoms as anorexia, weight loss, abdominal or back pain, and jaundice. Other findings include nausea, vomiting, a fever, fatigue, weakness, pruritus, and skin lesions (usually on the legs).

Pericarditis.In chronic constrictive pericarditis, an increase in systemic venous pressure produces marked congestive hepatomegaly. Distended jugular veins (more prominent on inspiration) are a common finding. The usual signs of cardiac disease typically are absent; other features include peripheral edema, ascites, fatigue, and decreased muscle mass.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Asterixis [Liver flap, flapping tremor]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Hepatic encephalopathy.A life-threatening disorder, hepatic encephalopathy initially causes mild personality changes and a slight tremor. The tremor progresses into asterixis—a hallmark of hepatic encephalopathy—and is accompanied by lethargy, aberrant behavior, and apraxia. Eventually, the patient becomes stuporous and displays hyperventilation. When he slips into a coma, hyperactive reflexes, a positive Babinski's sign, and fetor hepaticus are characteristic signs. The patient may also experience bradycardia, decreased respirations, and seizures.

Severe respiratory insufficiency.Characterized by life-threatening respiratory acidosis, severe respiratory insufficiency initially produces headache, restlessness, confusion, apprehension, and decreased reflexes. Eventually, the patient becomes somnolent and may demonstrate asterixis before slipping into a coma. Associated signs and symptoms of respiratory insufficiency include difficulty breathing and rapid, shallow respirations. The patient may be hypertensive in early disease but hypotensive later.

Uremic syndrome.A life-threatening disorder, uremic syndrome initially causes lethargy, somnolence, confusion, disorientation, behavior changes, and irritability. Eventually, signs and symptoms appear in diverse body systems. Asterixis is accompanied by stupor, paresthesia, muscle twitching, fasciculations, and footdrop. Other signs and symptoms include polyuria and nocturia followed by oliguria and, then, anuria; elevated blood pressure; signs of heart failure and pericarditis; deep, gasping respirations (Kussmaul's respirations); anorexia; nausea; vomiting; diarrhea; GI bleeding; weight loss; ammonia breath odor; and metallic taste (dysgeusia).

Other causes

Drugs.Certain drugs, such as the anticonvulsant phenytoin, may cause asterixis.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Jaundice [Icterus]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Carcinoma.Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, a recurrent fever, and chills. Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right upper quadrant discomfort and tenderness, nausea, weight loss, and a slight fever. Examination may reveal irregular, nodular, firm hepatomegaly; ascites; peripheral edema; a bruit heard over the liver; and a right upper quadrant mass.

With pancreatic cancer, progressive jaundice—possibly with pruritus—may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, a fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis.Obstruction and infection in the common bile duct cause Charcot's triad: jaundice, right upper quadrant pain, and a high fever with chills.

Cholecystitis.Cholecystitis produces nonobstructive jaundice in about 25% of patients. Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), a fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy's sign and, possibly, abdominal distention and rigidity.

Cholelithiasis.Cholelithiasis commonly causes jaundice and biliary colic. It's characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes a fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cirrhosis.With Laënnec's cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency. Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right upper quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren's contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis, fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Dubin-Johnson syndrome.With Dubin-Johnson syndrome, which is a rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40. Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.

Heart failure.Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure. Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hepatic abscess.Multiple liver abscesses may cause jaundice, but the primary effects are a persistent fever with chills and sweating. Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; an elevated right hemidiaphragm; and ascites.

Hepatitis.Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis. Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgia, myalgia, a headache, anorexia, photophobia, pharyngitis, a cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right upper quadrant pain and tenderness.

Pancreatitis (acute).Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, the primary symptom of acute pancreatitis is severe epigastric pain that commonly radiates to the back. Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner's or Cullen's sign. Other findings include a fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, dia-phoretic extremities; paresthesia; and tetany—the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia.Hemolysis produces jaundice in the patient with sickle cell anemia. Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, swollen (painful) joints, a fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; a low-grade fever; and increased weakness, jaundice, and dyspnea.

Other causes

Drugs.Many drugs may cause hepatic injury and resultant jaundice. Examples include acetaminophen, phenylbutazone, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and dilantin.

Treatments.Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.

A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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