Timing Questions:
Since when
Ever before? How often? How long for? Investigations? Cause found?
All the time or come and go?
Getting worse?
Sudden/gradual onset
Symptoms relating to liver disease:
Jaundice skin/eyes/both
Pale stools? Dark urine?
Skin itching?
Bruising?
Nausea/vomiting/loss of appetite/fatigue/malaise
Abdo pain and SOCRATES (e.g.gallstones)
Fever/rigors/chills (e.g. cholangitis)
Prodromal viral symptoms: arthralgias, myalgias, rash
Symptoms related to decompensated liver disease:
Abdo swelling
Ankle swelling
Confusion
Bruising
Change in concentration
Haematemesis/melaena
Viral Hepatitis Questions: (hepatitis A, B, C, D, E; herpes simplex virus; varicella zoster virus; Epstein-Barr virus; cytomegalovirus [CMV]); other viral infections e.g. HSV, VZV; or an acute exacerbation of chronic viral hepatitis)
Travel history, diet e.g. Shellfish, contaminated food
Vaccination status- hep A and B
Occupation/hobbies e.g. Mushroom picking, exposure to vinyl chloride, sewage workers, healthcare worker/prison staff/police and needlestick injury
Sexual history and risk: sex abroad, sex with sex workers, men who have sex with men, known HIV
IVDU/intranasal drug use (ever), sharing needles, tattoos/piercings/acupuncture
Blood transfusions prior to 1992 or abroad/medical or dental procedures abroad/clotting factor disorders e.g. receiving factor 8+9 concentrates/haemodialysis
Jaundiced/ hepatitis contacts
Fx hepatitis (mother to child transmission)
Alcoholic Hepatitis/liver disease:
Alcohol consumption- quantity, strength, what
Daily/binging
CAGE questionnaire
Severity: drinking at work? Driving offences, dependence Q
Drug induced liver injury:
Thorough drug history including OTC meds/herbal meds/Chinese meds/dietary supplements/illicit drug use/anabolic steroids and other performance enhancing drugs. Amounts ingested and duration of use
Any new meds in last 6 weeks?
Antibiotics/ paracetamol (including amount ingested)
Recent surgery (halothane)
AntiTB drugs
Anti-epileptic drugs (valproate)
Statins
NSAIDs
Cancer questions:
Weight loss, anorexia, fatigue etc.
Hepatobiliary disease questions/other disorders:
Heart failure questions (right sided heart failure causing congestive hepatopathy)
Diabetes (thirst/polyuria), skin pigmentation, arthritis, hypogonadism, (Haemochromatosis)
Diabetes, obesity, hypertension, hypercholesterolaemia (Non-alcoholic fatty liver disease)
Pregnancy (gallstones, acute fatty liver of pregnancy)
PBC
Inflammatory bowel disease e.g. diarrhoea, fatigue (PSC)
Early onset emphysema (alpha 1 antitrypsin deficiency)
Tremor, personality change (Wilsons)
Ischemic hepatitis
Autoimmune hepatitis
Tropical infection. Take travel history.
Non-hepatic causes: Coeliac disease, Thyroid disease, muscle damage (e.g. heavy exercise, myositis)
Prehepatic jaundice e.g.haemolysis:
Tired/SOB on exertion/ palpitations (anaemia)
Recent travel, fever. (e.g. malaria)
PMH: liver, gallstones, cancer (metastases most often breast cancer, small cell lung cancer, lymphoma, melanoma, or myeloma), autoimmune problems, heart failure
Fx: liver problems
Sx :Smoking, Alcohol, Illicit drugs, Occupation, Travel, Sexual history, ethnic background
ICE
Systems review
Examination
Examine for signs of liver disease as per abdominal examination. Check BMI, BP.
Liver screen (select tests depending on magnitude of abnormality and acuteness of presentation):
FBC, U+E, LFT, Clotting, CRP, glucose, AST, GGT
Paracetamol level
Toxicology screen
Viral hep screen- HBsAg and Anti-HCV +/-(IgM anti-HBcoreAg, Hep B DNA, Hep C viral RNA+genotype) if acute consider: anti-HAV, CMV, EBV, plus hep D and Hep E if no other causes found
HIV, syphilis
Pregnancy test
Autoimmune screen: ANA, Antismooth muscle, antiLKM, Antimitochondrial, antigastric, antiparietal Ab, Immunoglobulins, plasma electrophoresis
AFP (alphafetoprotein)
Serum caeruloplasmin, plasma copper, 24 hour urinary copper (if <45 years)
Alpha 1 antitrypsin
Serum ferritin, iron studies, fasting transferrin sats
Fasting glucose/Hba1c, fasting lipid profile
US of liver with Doppler and upper abdomen. If suggestive of obstruction: MRCP/ERCP
Miscellaneous:
CK to look for muscle disorders
TFTs
AntiTTG (coeliac screen)
Serum cortisol if symptoms of addisons
Sarcoid tests e.g. ACE, Serum Ca
CT/MRI liver/fibroscan /ascitic tap
Liver biopsy