Diagnostic Tests for Reye's Syndrome
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HEPATOMEGALY:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine diagnostic studies include a CBC, sedimentation rate, ANA test, Monospot test, chemistry panel, chest x-ray, EKG, and flat plate of the abdomen.
If viral hepatitis is suspected, a hepatitis profile should be ordered. If congestive heart failure is suspected, a venous pressure and circulation time and pulmonary function tests should be done. A CT scan of the abdomen will assist in the diagnosis of metastatic carcinoma and often find a primary source for the metastasis. Metastatic neoplasms and the various forms of cirrhosis may be diagnosed by liver biopsy, but one should keep in mind that it is dangerous to do a liver biopsy if biliary cirrhosis is suspected. Gallbladder ultrasound or cholecystography should be done if cholecystitis and cholelithiasis are suspected. Transhepatic cholangiography or ERCP may need to be done. Exploratory surgery may be the only way to get a diagnosis, especially in obstructive jaundice.
The various infectious diseases will need antibody titers and skin tests to pin down the diagnosis. For example, a brucellin antibody titer or a Monospot test can be done. Skin tests for the various fungi and tuberculosis can be done.
The various hemolytic anemias may be diagnosed by blood smears, a sickle cell preparation, serum haptoglobin, and hemoglobin electrophoresis. The reticuloendothelioses require liver biopsy. Hemochromatosis is also diagnosed by liver biopsy, but a test for serum iron and iron-binding capacity should also be done. Wilson's disease is diagnosed by serum copper and ceruloplasmin tests. Venography will diagnose hepatic vein thrombosis.
Most physicians prefer to refer the patient with hepatomegaly to a gastroenterologist once the preliminary studies have been done. This would be the most cost-effective approach.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hepatomegaly:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Hepatomegaly is seldom a patient’s chief complaint. It usually comes to light during palpation and percussion of the abdomen.
If you suspect hepatomegaly, ask the patient about his use of alcohol and exposure to hepatitis. Also ask if he’s currently ill or taking any prescribed drugs. If he complains of abdominal pain, ask him to locate and describe it.
Inspect the patient’s skin and sclera for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (commonly occurring in cirrhosis). Next, inspect the contour of his abdomen. Is it protuberant over the liver or distended (possibly from ascites)? Measure his abdominal girth.
Percuss the liver, but be careful to identify structures and conditions that can obscure dull percussion notes, such as the sternum, ribs, breast tissue, pleural effusions, and gas in the colon. (See Percussing for liver size and position.) Next, during deep inspiration, palpate the liver’s edge; it’s tender and rounded in hepatitis and cardiac decompensation, rocklike in carcinoma, and firm in cirrhosis.
Take the patient’s baseline vital signs, and assess his nutritional status. An enlarged liver that’s functioning poorly causes muscle wasting, exaggerated skeletal prominences, weight loss, thin hair, and edema.
Evaluate the patient’s level of consciousness. When an enlarged liver loses its ability to detoxify waste products, the result is accumulation of metabolic substances toxic to brain cells. As a result, watch for personality changes, irritability, agitation, memory loss, an inability to concentrate and poor mentation, and — in a severely ill patient — coma.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Hepatomegaly:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Hepatomegaly is seldom a patient’s reason for seeking care. It usually comes to light during palpation and percussion of the abdomen.
If you suspect hepatomegaly, ask the patient about his use of alcohol and exposure to hepatitis. Also ask if he’s currently ill or taking any prescribed drugs. If he complains of abdominal pain, ask him to locate and describe it.
Inspect the patient’s skin and sclerae for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (common in cirrhosis). Next, inspect the contour of his abdomen. Is it protuberant over the liver or distended (possibly from ascites)? Measure his abdominal girth.
Percuss the liver, being careful to identify structures and conditions that can obscure dull percussion notes, such as the sternum, ribs, breast tissue, pleural effusions, and gas in the colon. (See Percussing for liver size and position.) Next, palpate the liver’s edge during deep inspiration; it’s tender and rounded in hepatitis and cardiac decompensation, rocklike in carcinoma, and firm in cirrhosis.
Take the patient’s baseline vital signs, and assess his nutritional status. An enlarged liver that’s functioning poorly causes muscle wasting, exaggerated skeletal prominences, weight loss, thin hair, and edema.
Evaluate the patient’s level of consciousness. When an enlarged liver loses its ability to detoxify waste products, metabolic substances toxic to brain cells accumulate. As a result, watch for personality changes, irritability, agitation, memory loss, inability to concentrate, poor mentation, and—in a severely ill patient—a coma.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hepatitis:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. General examination. Common findings in viral, alcoholic, or drug-induced hepatitis include fever, jaundice, scleral icterus, weight loss, muscle tenderness or weakness, and a palpable tender liver. Ecchymosis or petechiae indicates significant clotting factor abnormalities and, coupled with a small liver which diminishes in size, is suggestive of severe hepatitis or impending hepatic failure.
B. Chronic liver disease results in progressive liver dysfunction, fluid retention, and portal hypertension. The liver plays a key role in the detoxification of endogenous hormones, drugs, and ingested substances. Abnormalities in estrogen metabolism have often been considered the cause of peripheral stigmata such as spider angiomata, palmar erythema, gynecomastia, parotid enlargement, and testicular atrophy.
C. Does the abdominal examination reveal hepatosplenomegaly? Modest enlargement of the liver occurs in acute viral and chronic hepatitis, whereas marked enlargement (>10 cm below the costal margin) is seen in alcoholic hepatitis. Ascites, prominent abdominal collateral veins, bruits, rubs, abdominal masses, or a palpable gallbladder can also indicate hepatitis, whereas a small liver can indicate cirrhosis.
Testing
Laboratory tests differentiate between hepatocellular disorders (e.g., viral hepatitis) and cholestatic syndromes (e.g., primary biliary cirrhosis and bile duct obstruction).
A. Liver function tests (LFTs)
1. Elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are nonspecific indicators of hepatocellular damage and do not distinguish viral from drug-induced hepatitis. Alcoholic liver disease is suggested when the AST:ALT ratio is greater than 2:1.
2. Total serum bilirubin is not a sensitive indicator of hepatic dysfunction. Hepatitis impairs the excretion phase of bilirubin metabolism, resulting in an elevated direct (conjugated) bilirubin greater than 0.1 mg/dl.
3. γ-Glutamyl transpeptidase (GGT) is a very sensitive indicator for minimal hepatocellular damage. Elevations are seen in alcoholic liver disease before other LFTs are abnormal.
4. Alkaline phosphatase indicates cholestasis or obstruction. Approximately 75% of patients with prolonged cholestasis have alkaline phosphatase values increased fourfold or greater.
5. Immunoglobulins (IgA, IgG, IgM) in acute hepatitis are normal or minimally increased. A moderate increase is seen in chronic active or autoimmune hepatitis. Indices are useful in monitoring response to immunotherapy.
6. Circulating autoantibodies (e.g., antinuclear, smooth muscle, liver-kidney microsomal) may be seen in autoimmune hepatitis.
B. Hepatitis serology. Serologic testing (anti-HDV, anti-HCV) is now available for each type, except hepatitis E virus (HEV) (5) (Fig. 9.1). Hepatitis G virus (HGV) and GB virus C (GBV-C) are the most recently discovered hepatitis viruses (2). HGV is present in asymptomatic blood donors and, although it is thought to cause chronic hepatitis, no causal relationship between HGV and hepatitis has been convincingly established (3).
C. Radiologic and diagnostic procedures
1. Abdominal films are useful in detecting splenomegaly.
2. Ultrasound is helpful in detecting gallstones in patients with jaundice and in detecting mass lesions (tumors or liver abscesses).
3. Abdominal computerized tomography aids in the diagnosis of mass lesions of the liver and abnormalities of the gallbladder.
4. Percutaneous needle biopsy of the liver permits an accurate diagnosis of diffuse parenchymal disorders such as hepatitis, drug reaction, cirrhosis, and liver tumors.
Diagnostic assessment
Viral hepatitis can be diagnosed by a thorough history and serology used in tandem. Individual susceptibility to hepatic injury in drug-induced hepatitis can be affected by genetic factors, age, gender, nutritional status, exposure to other drugs and chemicals, systemic disease, and other factors (4). Liver injury produced by drugs is either cytotoxic (hepatocellular), cholestatic, or a combination of the two. Knowledge of these mechanisms is extremely important in diagnosing the inciting agent. Alcoholic hepatitis is identified by the history coupled with the typical laboratory abnormalities. Chronic hepatitis requires elevated LFTs for at least 6 months and can result from infection with HBV or HCV, alcoholic liver disease, drug toxicity, or autoimmune causes. Liver biopsy is required for accurate assessment and classification of chronic hepatitis. Although effective vaccines are available for HAV and HBV and have yielded protection for decades, vaccines for HCV and HEV are only in early development and no vaccine exists for HDV.
References
1. Schiff ER, Sorrell MF, Maddrey WC. Diseases of the liver, 8th ed. Philadelphia:
Lippincott Williams & Wilkins, 1999:234–235, 919–921.
2. Blum HE. Update hepatitis A-G. Digestion 1997;58(Suppl 1):33–36.
3. Zimmerman HJ. General aspects of drug-induced liver disease. Gastroenterol Clin North Am 1995;24:739–757.
4. Kools AM. Hepatitis A,B,C,D, and E. Update on testing and treatment. Postgrad Med 1992;91:109–114.
5. Schiff ER. Update in hepatology. Ann Intern Med 1999;130:52–59.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hepatomegaly:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. How does a clinician diagnose hepatomegaly?
1. Palpation and percussion. Evaluation of the liver is difficult given its irregular shape and its location within the abdomen. Approach palpation of the right upper quadrant from one of two directions: palpate from below using the fingertips to palpate superiorly or from above with the fingertips hooked over the lower rib. Either method is facilitated by the patient’s deep inspiration. Palpation must include the midline to identify an enlarged left lobe of the liver. On palpation, note the liver position, the extent of its palpation below the costal margin, and its texture and consistency. Palpate for the lower edge and percuss for the upper margin. These two points give the highest accuracy in estimating liver size. If the margin is not palpated but hepatomegaly is suspected, then attempt direct percussion of both margins.
2. Auscultation. The “scratch method” (gently stroking or scratching the skin surface in a parallel plane while listening with the stethoscope for change in sound and intensity of frequency) has been used to identify margins; however, a recent study by Tucker comparing ultrasound to the results of the scratch test found that this test was unreliable and inaccurate (3). Auscultation of the right upper quadrant has been described and several findings can be noted: friction rubs, bruits, and abnormal pulsations.
3. Other associated signs. Associated physical examination findings include jaundice, vascular spiders, palmar erythema, gynecomastia, ascites, splenomegaly, testicular atrophy, peripheral edema, Dupuytren’s contracture, parotid enlargement, and encephalopathy. Although none of these physical examination signs are pathognomonic for hepatobiliary disease, their presence in the setting of hepatomegaly support further diagnostic testing.
B. How accurate is the physical assessment? Palpation of the liver 2 cm below the costal margin correlates with a 50% chance of having hepatomegaly on further diagnostic workup. A 63% chance exists that a palpable liver relates to liver disease (4). The converse is also true: A nonpalpable liver could also be enlarged, therefore, the need for further assessment should be based on clinical context and associated signs. The liver span has classically been measured in the midclavicular line, although some have suggested that the use of the midclavicular line is too inaccurate. Several studies have attempted to establish a new reference point but no consensus has developed. Direct percussion (lightly tapping with index finger) is more accurate in identifying the extent of the margins than indirect percussion. Indirect percussion (heavy tapping of one finger against another finger held against the body firmly) often will not illicit a change over the thin lower margin or detect a change at the upper margin, depending on the contour of the diaphragm and the volume of the lower lungs (2). Nuclear medicine scintigraphy or ultrasound study defines hepatomegaly as greater than 15.5 cm. Studies comparing physical examination to these modalities have not shown physical examination to be accurate or consistent, with high interexaminer differences. Skrainka et al. evaluated liver size estimation by direct percussion, indirect percussion, palpation, and ultrasound. His results demonstrated that experienced clinicians (medicine consultants) accurately assessed liver size compared with ultrasound and that direct percussion measurements correlated the best with liver size in all groups (5).
Testing
A. What are appropriate diagnostic tests in the setting of hepatomegaly? An ultrasound of the right upper quadrant should be obtained, as well as a chest x-ray, and kidney, urinary tract, and bladder studies. Initial laboratory evaluation should include a complete blood count, electrolytes, creatinine, glucose, liver enzyme testing (alanine aminotransferase, aspartame transferase, γ-glutamyl transpeptidase, alkaline phospatase), and true liver function tests (albumin, prothrombin time, partial thromboplastin time and bilirubin). If liver enzymes are elevated, a hepatitis serology panel is added. Nondiagnostic ultrasound or hepatic masses should prompt computed tomography scan. Further differential testing is shown in Table 9.7.
B. Liver biopsy is indicated for unexplained hepatomegaly or jaundice, persistent abnormal liver tests, chronic viral hepatitis, suspected cirrhosis or portal hypertension, primary or secondary malignancy, suspected hemochromatosis, suspected Wilson’s disease, and hepatic dysfunction following liver transplantation.
Diagnostic assessment
How are the physical examination findings used to form a differential diagnosis?
A. Smooth nontender liver: suspect fatty infiltration, congestive heart failure (CHF), portal cirrhosis, primary biliary cirrhosis, lymphoma, portal obstruction, hepatic venous thrombosis, hepatic vein thrombosis, lymphocytic leukemia, amyloidosis, schistosomiasis, or kala-azar.
B. Smooth tender liver: suspect early CHF, acute hepatitis, amoebic abscess, or hepatic abscess.
C. Nodular liver: suspect late portal cirrhosis, tertiary syphilis, hydatid cyst, or metastatic carcinoma.
D. Very hard nodular liver: nearly always indicates metastatic carcinoma.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hepatomegaly:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
The mean liver span is 10.5 cm in men and 7 cm in women. Larger span
correlates with greater height. A span 2 to 3 cm larger or smaller than these values is considered abnormal. The liver may be palpable but not enlarged (normal span) with emphysema, right-sided pleural effusion, Riedel lobe, and thin body habitus.
An hepatic arterial bruit is heard with alcoholic hepatitis or cancer, either primary or metastatic. A friction rub may be heard with perihepatitis, metastatic cancer, or after liver biopsy.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Hepatomegaly:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Inspect the patient’s skin and sclerae for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (often occurring in cirrhosis). Next, inspect the contour of his abdomen. Is it protuberant over the liver or distended (possibly from ascites)? Measure his abdominal girth.
Percuss the liver, but be careful to identify structures and conditions that can obscure dull percussion notes, such as the sternum, ribs, breast tissue, pleural effusions, and gas in the colon (See Percussing for liver size and position.) Next, during deep inspiration, palpate the liver’s edge; it’s tender and rounded in hepatitis and cardiac decompensation, rocklike in carcinoma, and firm in cirrhosis.
Take the patient’s baseline vital signs, and assess his nutritional status. An enlarged liver that’s functioning poorly causes muscle wasting, exaggerated skeletal prominences, weight loss, thin hair, and edema.
Evaluate the patient’s level of consciousness. When an enlarged liver loses its ability to detoxify waste products, the result is accumulation of metabolic substances toxic to brain cells. As a result, watch for personality changes, irritability, agitation, memory loss, inability to concentrate and poor mentation, and — in a severely ill patient — coma.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hepatomegaly:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Normal vs Enlarged Liver
First step in diagnosis is to decide whetherliver is enlarged. Because palpation of liver edge can be misleadingdue to displacement by other organs or unusual contour, liver spanshould be measured. Once it is established that liver is enlarged,specific cause needs to be determined.
Clinical Presentations
Hepatomegaly can occur as isolated findingwith or without splenomegaly, with jaundice, with significant increasein serum aminotransferases, in association with systemic disorders,with persistent vomiting and altered consciousness, or with progressiveneurologic deterioration (Boyle, 1996).
Enlarged Liver as Isolated Finding with or without Splenomegaly
Diagnostic possibilities include
Mass (tumor,cyst, abscess)Congenital hepatic fibrosisHepatic outflow obstructionFatty liverMetabolic disease (tyrosinemia, Gaucherdisease type I, Niemann-Pick disease type B, glycogen storage diseasetype IV, Wolman disease, cholesterol ester disease) Jaundice
Disorders causing hepatomegaly and jaundiceare discussed in Chap. 36, Jaundice.
Increased Serum Aminotransferase Levels
When hepatomegaly and increased serum aminotransferaselevels are found, several disorders should be considered:
HepatitisA, B, C, and DDrug-induced hepatitisAutoimmune hepatitisAlpha1-antitrypsindeficiencyWilson diseaseSclerosing cholangitis Association with Systemic Disorders
Hepatomegaly may occur with the followingsystemic disorders:
CardiacfailureSystemic infectionDiabetes mellitusCystic fibrosisConnective tissue diseasesHematologic disorders (sickle celldisease, leukemia)SarcoidosisInflammatory bowel diseaseHistiocytoses Persistent Vomiting and Altered Consciousness
Disorders that cause persistent vomiting,alteration in consciousness, and hepatomegaly include
Fulminanthepatic failureReye syndromeMetabolic disordersUrea cycledefectsFatty acid oxidation disordersOrganic acidemiasRespiratory chain defectsDisorders of gluconeogenesisCarbohydrate metabolism disorders (glycogenstorage diseases I and III, hereditary fructose intolerance) Progressive Neurologic Deterioration
Disorders that cause progressive neurologicdeterioration and hepatomegaly include
Lysosomalstorage diseases (Gaucher disease, Niemann-Pick disease, GM-1 gangliosidosis,mucopolysaccharidoses)Wilson diseaseZellweger syndrome Lab Tests
If hepatomegalyor hepatosplenomegaly occurs without jaundice, several tests should beconsidered initially:CBC and differentialReticulocyte countLiver function tests including serumaspartate aminotransferase, alanine aminotransferase, alkaline phosphatase,total protein, albumin, fractionated bilirubinsedimentation rateSerum alpha1-antitrypsinand Pi phenotypeSerum ceruloplasminProthrombin and activated partial thromboplastintimesUAUrine for reducing sugars Selection of radiographic imaging procedures(e.g., abdominal U/S and CT) depends on suspected diagnosis.Percutaneous liver biopsy is diagnostic of many disorders.In children with hepatomegaly and jaundice,see Chap. 36, Jaundice.In children with another type of presentation,refer to possible causes in each category. Investigations shouldbe tailored to suspected diagnosis.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Hepatomegaly:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Hepatomegaly is seldom a patient's chief complaint. It usually comes to light during palpation and percussion of the abdomen.
If you suspect hepatomegaly, ask the patient about his use of alcohol and exposure to hepatitis. Also ask if he's currently ill or taking any prescribed drugs. If he complains of abdominal pain, ask him to locate and describe it.
Inspect the patient's skin and sclera for jaundice, dilated veins (suggesting generalized congestion), scars from previous surgery, and spider angiomas (commonly occurring in cirrhosis). Next, inspect the contour of his abdomen. Is it protuberant over the liver or distended (possibly from ascites)? Measure his abdominal girth.
Percuss the liver, but be careful to identify structures and conditions that can obscure dull percussion notes, such as the sternum, ribs, breast tissue, pleural effusions, and gas in the colon. (See Percussing for liver size and position.) Next, during deep inspiration, palpate the liver's edge; it's tender and rounded in hepatitis and cardiac decompensation, rocklike in carcinoma, and firm in cirrhosis.
Take the patient's baseline vital signs, and assess his nutritional status. An enlarged liver that's functioning poorly causes muscle wasting, exaggerated skeletal prominences, weight loss, thin hair, and edema.
Evaluate the patient's level of consciousness. When an enlarged liver loses its ability to detoxify waste products, the result is accumulation of metabolic substances toxic to brain cells. As a result, watch for personality changes, irritability, agitation, memory loss, an inability to concentrate and poor mentation, and—in a severely ill patient—decreased level of consciousness.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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