1. Jaundice is a marker of severity of liver disease, as well as a consequence of decompensation. Yellow discolouration is not usually seen until the serum bilirubin is >40μmol/L (twice the upper limit of normal), although the earliest signs of jaundice can be detected in the periphery of the conjunctivae, or in the buccal mucosa. Remember, there are other causes of jaundice in liver disease, such as Zieve’s syndrome (haemolysis and hyperlipidaemia in alcohol misuse), or biliary obstruction. 2. Cachexia can be established by demonstrating muscle and fat loss. Wasting of the temporalis muscle is an early sign of generalized muscle atrophy. A reduced triceps skin-fold thickness is a marker of loss of fat stores. This can be demonstrated by palpating for redundant skin over the triceps area between your thumb and forefingers. 3. Anaemia is most reliably demonstrated by looking for conjunctival pallor. This is thought to be more sensitive than looking for pallor of skin creases, nails, or other mucosal membranes. If there is no evidence of anaemia, it is an important negative to mention to the examiner. The principal causes of anaemia in chronic liver disease are blood loss from portal hypertensive gastropathy, alcohol excess causing bone marrow suppression and poor nutrition. 4. Other gastrointestinal (GI) causes of clubbing include inflammatory bowel disease (IBD), coeliac disease, GI lymphoma and rare causes of malabsorption such as tropical sprue and Whipple’s disease. 5. Leuconychia is a non-specific finding which is associated with hypoalbuminaemia as well as other conditions such as heart failure, renal disease, Hodgkin’s lymphoma (HL) and diabetes mellitus (see Case 8—Nephrotic Syndrome). 6. Palmar erythema reflects the vasodilated state of cirrhosis. Other causes of palmar erythema include hypercapnoea, rheumatoid arthritis, thyrotoxicosis, pregnancy, fever, and exercise. 7. Spider naevi are vascular lesions, with a central arteriole that supplies smaller surrounding vessels. Generally, the number and size correlate with the severity of liver disease, although they may occur in normal individuals and pregnancy. Spider naevi, palmar erythema, gynaecomastia, and loss of body hair are thought to be the consequence of altered sex hormone metabolism, and an increase in the oestradiol:free testosterone ratio.
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