Expansion
Signs of hyperoestrogenism, portal hypertension and failed synthesis
Mnemonic
Work from the hands upwards, which is also the order of examination:
- Hands - clubbing, leuconychia (hypoalbuminaemia), palmar erythema, Dupuytren’s contracture, asterixis
- Arms - spider naevi (over 5 is significant, fill from the centre, in the distribution of the superior vena cava), bruising, scratch marks, tattoos, needle marks
- Face and eyes - jaundice in the sclera, anaemia, parotid enlargement, fetor hepaticus, Kayser-Fleischer rings in Wilson’s disease
- Chest - gynaecomastia, loss of body hair, spider naevi
- Abdomen - ascites, caput medusae, hepatosplenomegaly, testicular atrophy
- Legs - oedema
“The oestrogenic signs come from failure to metabolise oestrogen”: spider naevi, palmar erythema, gynaecomastia and testicular atrophy all share that mechanism, which is why they cluster.
Signs of decompensation are the ones that matter acutely: jaundice, ascites, encephalopathy (asterixis) and variceal bleeding, since compensated cirrhosis may show few signs at all.
Expansion
Hands and arms
- Palmar erythema, Dupuytren contracture, leuconychia, clubbing
- Asterixis (flapping tremor) in encephalopathy
- Bruising and scratch marks
Face and trunk
- Jaundice, most reliably seen in the sclerae
- Spider naevi: in the distribution of the superior vena cava; more than five is abnormal. Fill from the centre on release of pressure
- Gynaecomastia, loss of body hair, testicular atrophy
- Caput medusae, with flow away from the umbilicus
Abdomen
- Ascites with shifting dullness, splenomegaly, hepatomegaly or a small shrunken liver
Mechanisms organise the list neatly:
- Impaired oestrogen metabolism: spider naevi, palmar erythema, gynaecomastia, testicular atrophy
- Portal hypertension: caput medusae, splenomegaly, ascites, varices
- Failed synthesis: leuconychia (albumin), bruising (clotting factors)
- Failed detoxification: encephalopathy with asterixis, fetor hepaticus
Spider naevi and palmar erythema also occur normally in pregnancy and in the young.