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!