History
Acute liver disease may present dramatically with acute anorexia, nausea and vomiting. There may be intolerance to the sight and smell of food, to alcohol and to cigarette smoke. An intense itch may develop in the skin and this may precede the development ofjaundice, which may be noticed by the family before the patient. As jaundice appears, other symptoms may disappear. The patient may now notice dark urine and pale stools. There may now be right-sided abdominal discomfort caused by an enlarged or inflamed liver, or by an obstructed biliary tree. However, many patients have asymptomatic liver disease which is found incidentally as hepatosplenomegaly on routine examination, abnormal liver biochemistry or haematology (high mean cell volume or low platelets) on routine screening.
Complications of liver disease include liver cell failure and portal hypertension. Hepatic encephalopathy tends to develop insidiously as liver cells fail, and a history of mood change, confusion and somnolence is often obtained from the family. Portal hypertension may be associated with a history of abdominal swelling and peripheral oedema, but the patient may become aware of this only when they have difficulty in putting on their shoes or trousers. Gastrointestinal blood loss may indicate the presence of oesophageal varices or reflect a coagulation defect caused by liver disease or associated thrombocytopenia. Key symptoms in liver disease are summarised in Table 62. It is important in the history to ask about:
Table 62. Common symptoms and signs in liver disease
| Symptoms | Signs |
| Mental confusion | Encephalopathy |
| Delirium tremens | Xanthelasmata |
| Anorexia | Jaundice |
| Nausea | Spider naevi |
| Vomiting blood | Parotid enlargement |
| Jaundice and itch | Scratch marks |
| Abdominal pain | Loss of axillary hair |
| Abdominal swelling | Gynaecomastia |
| Tremor | Hepatomegaly |
| Loss of libido | Splenomegaly |
| Swelling of ankles | Bleeding at venepuncture |
| | Bruising |
| | Ascites |
| | Dilated veins |
| | Tremor/flap |
| | Tendon xanthomata |
| | White nails |
| | Liver palms |
| | Loss of pubic hair |
| | Testicular atrophy |
| | Dependent oedema |
• previous jaundice - hepatitis or gallstones
• recent drug therapy - including self-administered drugs, drug misuse and herbal remedies
• alcohol intake
• close contact with a jaundiced person or someone in a high-risk group
• recent blood transfusion or injections
• sexual activity and proclivity
• occupation - health professional, farmer, sewer worker
• family history of liver disease
• foreign travel
• recent eating of shellfish, salads, etc. in risk areas of the world
• hobbies - canoeing, swimming, other watersports.