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.