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Liver Disease Signs & Symptoms (ex. gynecomastia, bruising) | Hepatic Stigmata



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Hey everyone! In this lesson, we're going to  talk about hepatic stigmata or the signs and  

symptoms of liver disease. To begin, one  of the most commonly known signs of liver  

disease is jaundice. Now, jaundice is due  to hyperbilirubinemia - now bilirubin is  

a breakdown product of heme catabolism and  normally the liver deals with the bilirubin,  

and it actually will excrete the bilirubin  in bile. But if the liver is not functioning  

properly, bilirubin can start to accumulate  leading to hyperbilirubinemia. And bilirubin  

tends to bind to elastin, and elastin is  found in our skin and that's why we get  

this yellowish hue in our skin. Now a related  sign of liver disease, related to jaundice,  

is scleral icterus. Scleral icterus, you can think  of it as a jaundice of the sclera or the whites of  

your eyes. The whites of your eyes become yellow  and this is again due to hyperbilirubinemia and  

again there is actually elastin in the sclera of  your eyes and the bilirubin binds the elastin,  

and this is actually one of the first areas to  display yellow staining and is one of the first  

areas to display or to signal an issue with the  liver. Now another hepatic stigmata is ascites,  

and ascites is a collection of fluid within the  abdomen, and it is due to hypoalbuminemia. Now  

albumin is a highly abundant protein within our  blood - this protein is actually produced in the  

liver so the function of albumin in the blood is  to increase colloidal pressure to actually draw  

interstitial fluid back into the blood. Now,  if the liver is not functioning properly we do  

not get albumin produced in enough quantity  and this actually leads to hypoalbuminemia,  

which actually leads to a decreased or reduced  ability of the blood to actually pull back a  

lot of interstitial fluid back into the blood,  and we will see large accumulations of fluid  

in places like the abdomen and places like the  periphery, and this is why we see peripheral edema  

as well - we get a fluid accumulation because we  do not have enough albumin in our blood to pull  

back some of that fluid. Now another stigmata  of hepatic disease is bruising, and bruising is  

due to a decreased level of clotting factors.  Now there's several clotting factors that are  

produced in the liver, and when the liver is not  functioning properly we see a decreased production  

of these clotting factors which leads to bruising.  The next sign or symptom of liver disease is  

pruritis and pruritis is due to retained bile  acids. Now pruritis itself is actually itching,  

and what we see is that because of instances  where there is cholestasis, there is not adequate  

excretion of bile because of some problem due to  cirrhosis or some mass in the liver which is  

suppressing or reducing secretion of bile. We get  these retained bile acids - these retained bile acids  

cause this sensation of itching and this is why we  get pruritis. These patients often get excoriations  

as well from itching so much. Another stigmata of  liver disease is palmar erythema, and the palmar  

erythema is simply a reddening of someone's hands  and it typically are the palms of someone's hands.  

And it typically affects the hypothenar border, the area opposite to the thumb. In this  

picture, you actually see here where we see  a large reddening in the hypothenar area  

Palmar erythema is not only associated  with liver disease, but is also associated with other  

conditions - and one of the other conditions  we see this in is rheumatoid arthritis.

Another one is purpura. Now purpura itself is  simply red little spots and you might hear  

petechiae you might hear purpura or ecchymosis  they're all different just the similar red spots  

but in different sizes and purpura is due to or related to thrombocytopenia and  

thrombocytopenia is just lower than normal  levels of platelets in the blood. And a lot  

of times platelet suppression in liver disease is  secondary to a splenomegaly. So in liver disease  

and cirrhotic liver disease or any other liver  disease, where it causes a portal hypertension we  

see that there is a backup of venous return from  the liver to the spleen, leading to an enlarged  

spleen, and the spleen actually takes care  of and degrades platelets and red blood  

cells. And when we have an enlarged spleen, it  can actually start to degrade too many platelets  

we then get a thrombocytopenia, which can then  lead to petechiae/purpura in these patients.  

Another sign of liver disease is muscle wasting. Chronic liver disease is a  

catabolic state, which leads to a lot of muscle  wasting in different areas of the body. A lot of  

times you'll see it in the hands and sometimes  you can also see it in the temporalis muscles  

as well on the forehead - these areas of the head  can actually see wasting. Another sign of liver  

disease is xanthelasma. Now xanthelasma itself is  simply a buildup of fat around the eyes and it's  

a yellowing kind of accumulation of fat around the  eyes, and it's more related to cholestatic liver  

disease. Another one is bronze diabetes - now we call  this bronze diabetes because of the discoloration  

in the skin, and this you can see here in this  image that you can see quite a difference  

in the coloration of the skin in these patients.  And bronze diabetes is known as bronze diabetes  

because of this discoloration. And it's  associated with hemochromatosis, which is a genetic  

condition leading to an iron overload - these  patients have high iron levels, and it's called  

bronze diabetes because of the fact that these  iron depositions actually occur  

in the pancreas as well which leads to problems  in insulin production and secretion leading to  

diabetes so in these patients you see not only  a bronzing of their skin, but you can also see  

diabetes as well. Another hepatic stigmata is leukonychia. Leukonychia is a whitening of the nail bed  

Normally, you'll see it's usually  pink or red but in these patients, you see a  

whitening of the nail bed and this is related  to hypoalbuminemia as well. Another stigmata is  

nail clubbing, you can  see here with this patients that their fingers  

have a change in the angle of the nail. Now clubbing itself seems  

to be related to hypoxemia - it's typically  a sign of respiratory problems so you can see  

nail clubbing in respiratory diseases but you  can also see it in liver diseases as well. Now,  

an interesting phenomenon you might see with  liver disease is known as asterixis and what  

happens is if you get the patient to put their  arms straight in front of them and put their  

hands up in the air pointed like in such a way  like this (as you see in this in this diagram here),  

what happens is if you get them to close their  eyes you will see that they will actually drop  

their hand and then they will immediately bring  their hand back up - and we call this a "tremor flap"  

and this tremor flap occurs at the wrist and it is  bilateral so it happens in both hands and it seems  

to be related to any type of metabolic disease  it doesn't necessarily have to be liver disease  

but it can happen in other metabolic diseases as  well such as issues with the renal or respiratory  

systems and the cause of asterixis is not entirely  known. It seems to be due to an interruption of a  

postural pathway in the reticular formation which  leads to this type of tremor flap. Another stigmata  

of hepatic disease is caput medusae. In caput medusae, we see this kind of engorgement or dilation  

of veins near the umbilicus of the patient, so  if you look at their abdomen you might see this  

kind of engorgement of veins leading from near  their umbilicus or their belly button and this  

is more specifically a dilation of paraumbilical  veins, and you'll see that it'll actually radiates  

away from the umbilicus.  It is a result of portal hypertension leading  

to a backup of blood into these veins, leading  to this engorgement of these paraumbilical  

veins. Another sign that you might see with these  patients is hepatomegaly which is just an enlarged  

liver we know that because in a patient with  liver disease they can get vascular  

inflammation, it actually leads to an enlarged  or an increase in size of the liver, and this is  

how you can actually see these patients with it. It  actually causes a distended abdomen in a certain area (in  

the right upper quadrant), you'll see this enlarged  area of tissue, and this is actually hepatomegaly.  

Another stigmata of liver disease is spider nevi  and spider nevi are simply just dilations of  

blood vessels and they kind of lead to a radiation  of vessels and this is why it's called spider nevi,  

it kind of resembles a spider's web or a spider.  And the dilation of the blood vessels is actually  

due to high estrogen - now normally, the liver  actually metabolizes and clears estrogen but  

in liver disease there is a reduction/ clearance  of estrogen leading to higher levels of estrogen,  

leading to spider nevi or the dilation of these  blood vessels. High estrogen leads to another stigmata  

of liver disease, and that is gynecomastia - it's  enlarged breast tissue in males and this is again  

due to increased estrogen due to reduced clearance  of estrogen by the liver. Now this is another sign  

of liver disease, but it's not necessarily only  due to liver disease it can be due to other other  

hormonal issues as well - can be due to increased  estrogen just because of increased peripheral  

estrogen production but you could see this as a  stigmata of liver disease. Anyways guys, that was  

a lesson on hepatic sigmata - I hope you found this  video helpful. If you did, please like and subscribe  

for more videos like this one! And as always  thank you for watching, and I'll see you next time!