The Liver Patient

The patient may be jaundiced, recovering from liver transpalnt, waiting for one, or some combination of the above.

The objective of this hot case is to arrive at a conclusion at the end, as to how one might categorise this hepatic jaundice:

  • Extrahepatic: i.e. intravascular haemolysis
  • Intrahepatic, i.e. failure of hepatic synthesis
  • Obstructive, i.e. failure of bile excretion
  • Acute vs. chronic

Previous hot cases with this sort of theme to them can be found below.

Examination of the Critically Ill Patient with Unexplained Jaundice

The standard introduction

  • The examiner will give you a history.

The prelude to the dance

  • Wash hands.
  • Gown and glove.
  • Ask, if relevant:
    • "Can I turn on all the lights?"
    • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
    • "Is there a language barrier?"
  • Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

  • Rhythm
  • Rate
  • Morphology: QRS width,
  • MAP and abnormal morphology of the arterial waveform
  • CVP and abnormal morphology of the CVP waveform
  • Ancillary waveforms eg. the PA catheter waveform
  • Oxygen saturation measurement, and the quality of the waveform
  • End-tidal CO2 waveform and level

Jaundice does not usually play interesting haemodynamic tricks. If one notices such tricks, something else is going on, and jaundice is merely the side-dish. One may have a severe cirrhosis which has decompensated due to SBP, for instance.

The Ventilator

One can ask the examiners the following questions:

  • How are we oxygenating this patient?
  • How are we ventilating this patient?
 

One should ask about the following parameters:

  • FIO2
  • PEEP
  • Peak pressure
  • Plateau pressure
  • Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

Urine catheter

  • The urine will be discoloured by bilirubin.
  • Anuria
  • Cloudyness or precipitate is interesting, but may be irrelevant.

Drains (surgical, intercostal, etc)

There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state.

The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.

Dialysis

A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:

  • Which modality is being used?
  • What is the dose of dialysis?
  • What is the rate of fluid removal?
  • How is the circuit anticoagulated?
  • How long has this filter lasted?

The CRRT may suggest that the patient has severe sepsis, or that the patient is affected by hepatorenal syndrome. CRRT may also be used to clear lactate in patients with poor hepatic function.

IABP / ECMO

The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:

  • VA or VV?
  • Flow rate
  • Fresh gas flow
  • Any recent problems with the circuit

If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.

The possibility that the jaundice is being caused by mehanical haemolysis should be considered. One may even consider asking whether the patient was already jaundiced before the extracorporeal circuit was connected.

Weird machinery

A MARS system may be by the bedside. It is unlikely to make an appearance, as the evidence for its use is weak.

A plasmapheresis system may be present, sugegsting an autoimmune cause of haemolysis (eg. TTP)

The patient may have a traction line attached to their Sengstaken-Blakemore tube, with a counterweight on the end.

Infusions

This stage is critically important. The drug and fluid infusions which would be worth noting are:

  • Vasopressors/inotropes
  • Antibiotics or - even more excitingly - antimalarial agents.
  • Blood products (massive transfusion)
  • IV immunoglobulin (autoimmune haemolytic anaemia)

EVD

One should observe the following features of an EVD:

  • Set height
  • Whether it is open or closed
  • The CSF colour - eg. is it full of blood?

Later, one should remember to ask for the CSF cell count and culture.

Patients with acute hepatic failure may require an EVD to assess and manage the increased ICP associated with acute pulmonary oedema.


The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.

Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:

  • Muscle wasting, obesity
  • The evidence of trauma, wound dressings, etc
  • The pattern of breathing (eg. whether there is a characteristic chest flail)
  • Rash of vasculitis
  • Abscesses/debridement sites of necrotising fasciitis
  • Massive ascites

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

  • Grab hold of both of the patient's hands.
  • "Mr Bloggs!" One pauses to observe for eye opening.
  • "Can you squeeze my hands?"
  • If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

Hands, nail signs, pulse and the arterial line.

First, one should spent a second assessing whether the hands are warm or cold.

Hand and hail signs one is particularly interested in during the jaundice hot case:

  • Splinter haemorrhages (vasculitis)
  • Janeway lesions or Osler's nodes (infective endocarditis)
  • Leukonychia of chronic liver disease

Nail signs in general are discussed in greater detail elsewhere.

Then, turn the hands over, to look for palmar erythema. Feel the radial pulse. It should be bounding and vasodilated. The patient should be warm.

Arms

Tone of the upper limbs

Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.

Cubital fossa

Examine the cubital fossa for

  • Peripheral lines
  • Evidence of multiple venepunctures, iatrogenic or recreational;
  • Evidence of chronic scarring due to habitual IV drug use.
  • Lymph nodes
  • Brachial pulse
  • The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

  • Inspect any central lines. This is very important! Later, one needs to mention them as either something you are considering as a source of sepsis, or something that is plainly not the source of sepsis.
  • It is important to ask the examiners: How old is this line?
  • Look again at the CVP

Palpate the neck:

  • Trachea: is it midline? Is there a new tracheostomy there?
  • Thyroid gland
  • Cervical lymph nodes
  • Carotid pulse - one side at a time!
  • Submandibular lymph nodes
  • Pre- and post-auricular lymph nodes

On the way up to the face, one should feel the temporal arteries; vasculitis may be a cause of jaundice.

Pupils, cranial nerves and the airway

The cranial nerves may not yield much in the examination of jaundice.

One may wish to perform a brief and focused examination:

Scleral icterus

Light reflex

Eye movements and nystagmus

Scleral icterus

Scleral icterus is said to be easier to detect than skin jaundice. However, generally speaking, if the patient is already jaundiced enough to become a CICM fellowship hot case, they will probably have a bilirubin so high that there is no additional diagnostic value in looking at the sclera. Do it anyway, and make it abundantly clear to the examiners that you are aware of it.

Light reflex

Ask the examiners to dim the room lights.

Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.

This tests CN II (afferent) and CN III (efferent).

Eye movements and nystagmus

The conscious patient will be able to follow the tip of the candidate's finger.

The pattern of movements should be tracing the six cardinal points: superior left, inferior left, superior center, inferior center, superior right, inferior right.

This tests CNs II, IV and VI.

Nystagmus in eye movements may suggest alcohol withdrawal.

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

If gynaecomastia is present, one should make it obvious to the examiners that one is aware of it.

Percussion:

One might wish to percuss the chest.

Changes in percussion resonance may be worth commenting on.

A pleural effusion may be uncovered in this fashion; it may be the extension of ascites.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

  • Apex
  • Left sternal edge, lower
  • Left sternal edge, upper
  • Right sternal edge, lower
  • Left sternal edge, upper
  • Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Specifically, one would be looking for a pericardial effusion, or the right-sided "heave" suggesting that there is right heart failure. Tricuspid regurgitation might also be nice.

The mechanical click of artifical valves may alert one to the fact that the red cells are probably being eaten up by the leaflets.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

  • Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).

Abdominal palpation

  • All quadrants should be palpated.
  • Then, feel for the liver edge; observe respiratory excursion
  • Then, feel for the spleen.
  • Then, try to ballot the kidneys. Enquire about renal tenderness.
  • If a caput medusae is present, one may wish to trace the pattern of venous drainage below the umbilicus (towards the legs = portal hypertension) to exclude inferior vena cava obstruction.

Abdominal percussion

  • This can double as a test for peritonism.
  • If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.
  • Percussing the borders of the liver and spleen may be a good way of determining their size more precisely.

Abdominal auscultation

  • One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal examination.

The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

  • There may be a rash of thrush, or a groin haematoma, or an external fixation device.
  • The posterior pelvis and sacrum should ideally be palpated for pitting oedema.
  • The groins should be palpated for lymphadenopathy
  • One should ask to roll the patient over, to look for pressure areas.

Examination of the lines

  • One should take notice of anything going into or coming out of the femoral vessels.
  • There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Why did this patient get an angiogram? What is the PiCCO for?

Examination of the genitals and rectum

  • A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.
  • One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
  • One should definitely ask about performing a PR.
  • If one is forbidden from performing the PR, one should ask about the following features:
    • Anal sphincter tone
    • Size and quality of the prostate
    • Presence of melaena or haemorrhoids

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

  • One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
  • One should palpate the larger muscles.
  • Pitting oedema should be palpated.
  • Test leg muscle tone.
  • Look for calf tenderness.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Power in the upper and lower limbs

Now is the time to properly start the neurological examination of this patient.

Power of the muscle groups may be tested in the following sequence:

  • Ankle dorsi and plantarflexion
  • Knee flexion and extension
  • Hip flexion, extension, adduction and abduction.

Time to sit the patient back up again.

  • Hand grip
  • Wrist dorsiflexion/palmarflexion
  • Elbow flexion/extension
  • Shoulder adduction / abduction

A thorough neurological examination is probably not called for.

However, one may wish to perform the finger-nose test and the heel-shin test to assess the cerebellar dysfunction which might be associated with chronic alcoholism.

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

  • Trends of blood pressure and heart rate
  • Temperature
  • Drain output
  • Urine output

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO

The laboratory investigations

One needs to show an interest in the following labs:

  • ABG
  • Routine bloods; specifically, one is looking for the full blood count, which contains a white cell count and eosinophil count.
  • Urinalysis
  • Culture results or at least the gram stain
  • Case-specific bloods:
    • LFTs
    • pancreatic enzymes
    • inflammatory markers
    • results of the vasculitic screen.
    • results of the hemolytic screen: particularly, the conjugated/unconjugated bilirubin fractions, Coombs test, reticulocyte count, and haptoglobin.
    • Coags

Ascitic fluid results may be available.

It might be interesting to ask about the lipase levels in the abdominal/pleural drain fluid.

Imaging and other investigations

One should always ask for the following:

  • ECG
  • CXR
  • Ultrasound of the liver / spleen

You sometimes want to see the following:

  • CSF analysis and culture result
  • CT or MRI results

 

Case presentation and discussion: when you have a good idea of what is going on

"The source of Mr Bloggs' jaundice is [insert clever diagnosis here]."

"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"I would approach the management of this issue in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"

Case presentation and discussion: when you don't have a clue

”This is a complex case and I’m not certain of the diagnosis. Though I suspect [hepatic failure, hamolytic anaemia], the alternative possibilities include [insert differentials]".

"I note the following features, supporting the diagnosis of blah [relevant features]"

"Additionally, I have identified the following clinical findings, which are not explained by this hypothesis:[insert list of findings]."

"I also note the following organ failures: [list organ problems]."

"The possible aetiologies responsible for these findings could include [list of differentials]".

"In order to discriminate between these differentials, I would like to perform the following investigations: [list of investigations]"

"Furthermore, I would like to enlist the help of the following specialties [insert list of consults], for whom I will have the following specific requests/questions: [what questions will you ask these specialist teams]"

Number of previous hot cases in this topic: 8

2015, Paper 2

Unspecified hospital in Adelaide

62-year-old female, day 5 ICU, admitted with decreased level of consciousness from hepatic encephalopathy, secondary to decompensated liver disease with acute renal failure and haematemesis. Findings on examination included signs of decompensated chronic liver disease and hepatic encephalopathy, intubated on minimal ventilatory support and haemodynamic stability.

Candidates were directed to provide a differential diagnosis for her decreased level of consciousness and to provide a management plan.

Discussion points included interpretation of investigations, precipitants of hepatic encephalopathy and prognostication.

2012, Paper 2

St Vincent’s Hospital

  • 37-year-old man with chronic liver failure and Gram negative sepsis who had an acute gastrointestinal haemorrhage. Clinical signs included stigmata of chronic liver disease, blood-stained airway and oliguria. Candidates were asked to examine him from the aspect of his acute GI bleed. Discussion related to the underlying causes and management of the GI bleed, coagulopathy in liver failure and hepato-renal syndrome.
2011, Paper 1

Westmead Hospital

  • 44-year-old female post resection of left lobe liver for hepatocellular carcinoma with background of partially corrected congenital heart disease.
2010, Paper 2

Flinders Medical Centre

  • A 45 year old male admitted with chronic liver disease and haematemesis. The discussion focusing on GI bleed management

Flinders Medical Centre

  • A 64 year old male admitted with altered sensorium and jaundice. Candidates asked to discuss an approach to altered sensorium in this context.
2010, Paper 1

Austin Hospital

  • 26 year old man 3 days post liver transplant for familial hypercholesterolaemia. Fully awake and extubated. Widespread xanthalasma and arcus. Sternotomy scar and leg scars from vein harvesting (previous CAGS and MVR). Scar and dressing from liver transplant surgery. Prosthetic valve sounds. Inplanted plasmapheresis port in situ. Prostacyclin infusion in progress. Candidates were told that he had had a liver transplant 3 days earlier for familial hypercholesterolaemia and were asked to assess whether he could be discharged to the ward.
2009, Paper 2

Royal Prince Alfred Hospital

  • A 56 year old man admitted with sepsis, shock and encephalopathy in the setting of a recent diarrhoeal illness. Current issues: Findings of liver disease, decompensated chronic liver disease, encephalopathy, spontaneous bacterial peritonitis,

Royal Prince Alfred Hospital

  • A 50 year old man admitted with GI bleed. Current issues: Linton tube, signs of chronic liver disease, TIPS procedure