Differential Diagnosis

Hepatic and Biliary Disorders

Hepatic and Biliary Disorders

Hepatic and Biliary systems consist of the liver, gallbladder and common bile duct

Skin changes (jaundice) may be the first manifestation of hepatic disease

First noted in the eye as a yellow hue Skin will become pale and yellow as the

bilirubin level elevates further

Liver Enzymes

ALP 30-115 U/L ALT (SGPT) 8-20 U/L AST (SGOT) 8-20 U/L Bilirubin Total: 0.2-1.0 mg/dl

Conjugated<0.2 mg/dl

Unconjugated<0.8mg/dl

Liver Enzymes

Bilirubin– Measured: total and direct– Conjugated (direct)

Increased with biliary obstruction, hepatitis, cirrhosis

– Unconjugated (indirect) Increased with hemolysis, Gilbert’s syndrome

Hepatic and Biliary Disorders

Disorders of the hepatic and biliary systems can be associated with thoracic pain between the scapulae, right shoulder, right upper trap, or right subscapular pain

Liver disease can lead to osteomalacia, osteoporosis, vertebral wedging, vertebral crush fractures, kyphosis, and osteoarthropathy of the wrist and ankles

Hepatic and Biliary Disorders

Hepatic and Biliary Disorders

When ammonia is not detoxified by the liver, it is transported to the brain, and glutamine production is increased in the brain. This impairs neurotransmission and alters CNS function.

Neurological symptoms include confusion, sleep disturbances, muscle tremors, hyperreactive reflexes and asterixis

Peripheral nerve function can be impaired as disorders progress

Hepatic and Biliary Disorders

Asterixis (flapping tremors)– Motor disturbance– Patient is unable to maintain wrist extension with

the upper extremity in a flexed position– Patient exhibits quick, irregular extensions and

flexions of the wrist when attempting to extend the hand

– Altered neurotransmission results in this movement dysfunction

– When present with numbness/tingling, is often misdiagnosed as CTS

Hepatic and Biliary Disorders

Hepatitis

Acute or chronic inflammation of the liver Can be caused by a virus, a chemical, a drug

reaction or alcohol abuse Initial symptoms of fatigue, weight loss,

malaise, nausea, vomiting, diarrhea and flu-like symptoms are followed by jaundice

Recovery phase lasts 3-4 months, during which time the patient generally feels well but fatigues easily

Hepatitis

A B C D E G

Hepatitis

Rheumatic diseases can occur in conjunction with hepatitis B and C

Be suspicious of patients who present with arthralgia and have past history of hepatitis or risk factors for hepatitis

Other red flags:– Joint or muscle pain disproportionate to physical

findings– Palmar tenderness with RA and hepatitis risk

factors

Hemochromatosis

Most common genetic disorder causing liver failure Excessive iron is stored in parenchymal organs with

eventual development of fibrosis Arthralgias and arthropathy may develop and are

often confused with RA or OA 2nd and 3rd MCP joints are involved first Knees, hips, shoulders and LB may be affected Acute synovitis with pseudogout of the knees may

occur

Cirrhosis

Chronic hepatic disease caused by destruction of liver cells and replacement of connective tissue by fibrous bands

Alcohol abuse is the most common cause in the U.S.

Hepatic blood flow diminishes with moderate exercise, so rest periods are advised and activity level is adjusted based on disease progression

Cirrhosis

Liver with CirrhosisNormal Liver Cells

Ascites

Condition that develops as cirrhosis progresses

Abnormal accumulation of fluid in the peritoneal cavity as a result of portal backup and loss of proteins

Abdominal hernias and lumbar lordosis are common with ascites and patients may present with c/o groin or LBP

Ascites

Hepatic Encephalopathy

Neurological disorder resulting from the inability of the liver to detoxify ammonia in the intestine

Clinical manifestations vary depending on the severity of neurological involvement

Initial symptoms may be unsteady gait and difficulty ambulating

Liver cancer

Metastatic tumors to the liver occur 20 times more often than primary liver tumors

The liver is one of the most common sites of metastasis from other primary cancers

In most cases, liver function is not altered until 80-90% of the liver is replaced by carcinoma

Cholelithiasis

The presence or formation of gallstones 5th leading cause of hospitalization among

adults Incidence increases with age, obesity, high

cholesterol/low fiber diet, DM, liver disease, and elevated estrogen levels

Women > Men Results in cholecystitis (inflammation of the

gallbladder)

Cholelithiasis

Cholelithiasis

Cholecystitis

Pain in the right upper quadrant and epigastrium Pain increases with movement and inspiration Pain may radiate into the right shoulder and between

the scapulae Pain may described as constant or colicky Pain is usually worse after eating a meal, especially

high in fat May be accompanied by chills, fever, jaundice,

nausea, anorexia and vomiting

Lipid Profile

Components– Total Cholesterol– LDL– HDL– Triglycerides

Lipid Profile

Total cholesterol– <200 desirable– 200-239 borderline– >240 high

Triglycerides– <1.8 mmol/L

Lipid Profile

HDL– <40 Low– >60 High

LDL (mg/ml)– <100 Normal– 100-129 Above Normal– 130-159 Borderline– 160-189 High– >190 Very High

Hyperlipidemia

Hypercholesterolemia: Atherosclerosis– Primary

Genetic

– Secondary DM High Caloric Intake

Atherosclerosis

Risk Factors– Hypercholesterolemia– Smoking– DM– Obesity, decreased exercise– Increased BP– Infectious agents

Can affect platelets, smooth muscle and/or macrophages

Atherosclerosis

Lesions– Fatty streaks– Atheromatous plaques– Complicated lesions

Clinical Manifestations– Ischemia (pain) to infarct– Any organ or tissue

References

Cirrhosis of the Liver. Retrieved 6/4/07 from the World Wide Web. http://www.mayoclinic.com/health/cirrhosis/DS00373/DSECTION=causes.

Gallstones pictures. Retrieved 6/24/08 from the World Wide Web. http://www.curezone.com/image_gallery/gallbladder_removed/

Goodman CC, Snyder TE. 2007. Screening for Hepatic and Biliary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p409-435.

Porth CM, editor. 2002. Pathophysiology Concepts of Altered Health States, 6th edition. Philadelphia, PA: Lippincott Williams & Wilkins, p431.

Porth CM, editor. 2005 Pathophysiology Concepts of Altered Health States, 7th edition. Philadelphia, PA: Lippincott Williams & Wilkins, Figure 40-4 and 40-7.

Swartz N. 1989. Textbook of Physical Diagnosis: Health and Examination. Philadelphia, PA: WB Saunders. In : Goodman CC, Snyder TE. 2007. Screening for Hepatic and Biliary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p422.