Hepatobiliary Conditions: Signs and Symptoms

Hepatobiliary Conditions: Signs and Symptoms

• Jaundice is first evident in the sclera of the eyes.
• Skin changes associated with hepatobiliary conditions include yellow, orange, or greenish discoloration, pallor, pruritus, bruising, and spider angiomas.
• Palmar erythema (liver palms) may be accompanied by throbbing or tingling sensations in the hands.
• Nail changes include white nails of Terry, leukonychia (white bands across the nail plate), clubbed nails, and koilonychia (spoon nails with a concave nail bed).
• Musculoskeletal (MSK) symptoms can be the primary symptom or occur with other systemic signs.
• Pain associated with hepatic and biliary systems can manifest as thoracic pain between the scapulae, right shoulder pain, right upper trap pain, right interscapular pain, and right subscapular areas.

Systemic Causes and Locations of Pain

• Liver disease can cause pain in the thoracic spine (T7-T10) from midline to the right side, as well as in the right upper trapezius and shoulder.
• Gallbladder disorders can cause pain in the right upper trapezius and shoulder, and in the right interscapular area (T4-T8).

Cholelithiasis

• Cholelithiasis involves the formation of gallstones that vary in shape and size and may consist of cholesterol, bile pigment, or mixed content with calcium salts.
• Small stones may be silent and excreted in bile, while larger stones can obstruct bile flow in the cystic or common bile ducts, causing severe pain often referred to the subscapular area.
• Risk factors for gallstones include being female, high cholesterol, obesity, multiparity, use of oral contraceptives or estrogen supplements, hemolytic anemia, alcoholic cirrhosis, and biliary tract infection.

Obstruction of a Duct by Large Calculi

• Obstruction of a duct by large calculi causes sudden severe waves of radiating pain.
• Nausea and vomiting are usually present.
• Continued pain can lead to jaundice as bile backs up into the liver and blood.
• There is a risk of gallbladder rupture if the obstruction persists, but pain may decrease if the stone moves into the duodenum.
• Surgical intervention may be required.
• Calculi are solid materials that form in bile, and obstruction of the biliary tract may occur due to gallstones.

Cholecystitis and Hepatitis

• Cholecystitis is inflammation of the gallbladder and cystic duct.
• Hepatitis involves inflammation of the liver.
  • Causes include alcoholic hepatitis (often with fatty liver), idiopathic hepatitis (also with fatty liver), viral hepatitis (local infection), infection elsewhere in the body, infectious mononucleosis, and chemical or drug toxicity.

Hepatitis: Signs and Symptoms

• Preicteric (prodromal) stage symptoms include fatigue, malaise, anorexia, nausea, and general muscle aching.
• Icteric stage symptoms include the onset of jaundice, light-colored stools, darker urine, and a tender, enlarged liver with mild aching pain.
• Posticteric stage is a recovery stage characterized by a reduction in symptoms, but weakness may persist for weeks.

Cirrhosis

• Cirrhosis involves the progressive destruction of the liver, caused by:
  • Alcoholic liver disease
  • Biliary cirrhosis (associated with immune disorders)
  • Post-necrotic cirrhosis (linked to chronic hepatitis or long-term exposure to toxic materials)
  • Metabolic disorders (usually caused by genetic metabolic storage disorders)
• Extensive diffuse fibrosis interferes with blood supply, potentially causing bile to back up, leading to the loss of lobular organization.
• Degenerative changes may be asymptomatic until the disease is well advanced.
• Liver biopsy and serologic tests are used to determine the cause and extent of damage.
• Functional losses include decreased inactivation of hormones and drugs (requiring careful monitoring of drug dosages), decreased removal of toxic substances, and a reduction of bile entering the intestine, which impairs digestion and absorption.

Cirrhosis continued: Additional Manifestations

• Backup of bile in the liver leads to obstructive jaundice.
• Blockage of blood flow through the liver leads to portal hypertension and congestion in the spleen, which increases hemolysis and causes inadequate storage of iron.
• Congestion in the intestinal walls and stomach impairs digestion and absorption.
• Development of esophageal varices leads to hemorrhage.
• Development of ascites (accumulation of fluid in the peritoneal cavity) causes abdominal distention and pressure.
• Cirrhosis also results in decreased production of blood-clotting factors, impaired glucose and glycogen metabolism, and impaired conversion of ammonia and urea.

Initial and Advanced Manifestations of Cirrhosis

• Initial manifestations are often mild and vague, including fatigue, anorexia, weight loss, anemia, and diarrhea. A dull aching pain may be present in the upper right abdominal quadrant.
• Advanced cirrhosis can lead to ascites and peripheral edema, increased bruising, esophageal varices (which may rupture, leading to hemorrhage and circulatory shock), jaundice, and encephalopathy.

Liver Cancer

• Hepatocellular carcinoma is the most common primary tumor of the liver and is more common in cirrhotic livers.
• It can also be secondary to metastatic cancer.
• Initial signs are mild and general.
• Diagnosis usually occurs with advanced stages.

Pain Referral Patterns in Hepatic and Biliary Diseases

• Liver pain is felt over the liver, especially after exercise (or hepatitis) and RUQ pain, it may be associated with right shoulder pain; both RUQ and epigastric pain may be present with liver pain.
• Gallbladder pain is in the RUQ of the abdomen and may be associated with right shoulder pain; back pain between the scapulae can also occur.
• Common bile duct pain, also called epigastrum: heartburn (choledocholithiasis), and RUQ pain. This may be associated with right shoulder pain; both may be associated with back pain between the scapulae.

Key Characteristics of Gastrointestinal Pain

• Pain from liver, gallbladder, or common bile duct issues may be referred to the right side of the midline in the interscapular or subscapular area.
• Anterior rib pain (soreness or tenderness) at the tip of the 10th rib (or ribs 11 and 12) may be experienced.
• Aggravating activities include respiratory inspiration and eating.

Key Points to Remember about Liver Diseases

• Primary signs and symptoms of liver diseases vary and include GI symptoms, edema/ascites, dark urine, light-colored or clay-colored feces, and right upper abdominal pain.
• Skin changes associated with hepatic system: Pruritus, jaundice, pallor, orange or green skin, bruising, spider angiomas, palmar erythema.
• Intense exercise should be avoided when the liver is compromised.
• Severe liver dysfunction can impair peripheral nerve function, leading to neurologic symptoms like confusion, muscle tremors, asterixis, and balance and gait impairments or numbness/tingling (misinterpreted as carpal/tarsal tunnel syndrome).
• Referred shoulder pain may be the only presenting symptom of hepatic or biliary disease, manifesting as right shoulder/scapular and/or upper midback pain of unknown cause, where shoulder motion is not limited by painful symptoms, and patients cannot localize or pinpoint pain/tenderness.
• Gallbladder impairment can present as a rib dysfunction involving tenderness anteriorly over the tip of the 10th rib (or ribs 11 and 12).

Psychoneuralimmunology of Gastrointestinal Disorders

• There is a relationship between the enteric system, the immune system, and the brain.
• 2/3 of all immune activity occurs at the gut.
• This is related to disorders such as Fibromyalgia, SLE, RA, and CFS.

GI Disorders: Mimicking MSK Issues and Referral Patterns

• GI disorders can refer pain to regions that mimic musculoskeletal (MSK) issues, such as the sternum, neck, shoulder, scapula, low back, sacrum, groin, and hip.
• GI conditions can refer pain specifically to the back and shoulder.
• Common conditions that can cause upper back pain include peptic ulcers, pancreatitis, and pancreatic cancer.

Inflammatory Bowel Disease Manifestations

• Arthritis and migratory arthralgias occur in about 25% of patients with Crohn's disease.
• Appendicitis, Crohn's disease, and ulcerative colitis can all cause iliopsoas muscle abscesses, leading to hip, thigh, or groin pain.
• Antibiotics and NSAIDs are medications that most often induce GI symptoms.

General GI Manifestations

• Abdominal pain
• Dysphagia
• Odynophagia (painful swallowing)
• GI bleeding (emesis, melena)
• Symptoms affecting eating
• Anorexia
• Nausea or Vomiting
• Arthralgia
• Early satiety with weight loss
• Constipation
• Diarrhea
• Fecal incontinence
• Referred shoulder pain
• Epigastric pain with radiation to back
• Neuropathy

Anorexia, Nausea and Vomiting: Differential Diagnosis

• Anorexia, nausea, and vomiting can be signs of a GI disorder or another condition in the body, such as systemic infection, uremia (elevated nitrogenous substances in blood), emotional responses, motion sickness, elevated ICP, overindulgence of food/drugs, or pain.
• Anorexia and vomiting can cause serious complications like dehydration, acidosis, and malnutrition.

Vomiting - Subjective Feelings and Triggers

• Nausea is an unpleasant subjective feeling stimulated by distention, irritation, inflammation of the digestive tract, smells, visual images, pain, and/or chemical toxins and/or drugs.
• Vomiting may be triggered by distention or irritation in the digestive tract, stimuli from various parts of the brain, pain or stress, vestibular apparatus, increased ICP, or stimulation of the chemoreceptor trigger zone.

Characteristics of Vomiting

• Presence of blood (hematemesis) can present as coffee ground vomitus (brown granular material indicating the action of HCl on hemoglobin) or hemorrhage (red blood in vomitus), which also may be from bile in the duodenum.
  • A deeper brown color may indicate content from lower intestine.
• Recurrent vomiting of undigested food may indicate a problem with gastric emptying or infection.

Diarrhea - Types

• Diarrhea is defined as an excessive frequency of stools, usually of loose or watery consistency, and may be acute or chronic. It is frequently accompanied by nausea and vomiting when infection or inflammation develops, it may be accompanied by cramping pain, and prolonged diarrhea may lead to dehydration, electrolyte imbalance, acidosis, & malnutrition.
• There also other types like Large-volume (secretory or osmotic), which is watery stool resulting from increased secretions into intestine from the plasma, often related to infection and Small-volume diarrhea, often caused by inflammatory bowel disease, where stool may contain blood, mucus, and pus and may be accompanied by abdominal cramps.

Steatorrhea & Blood in Stool

• Steatorrhea (“fatty diarrhea”) can be identified via frequent bulky, greasy, loose stools and a foul odor. It is a characteristic of malabsorption syndromes (Celiac disease, cystic fibrosis),where fat usually is the first dietary component affected and its presence interferes with digestion of other nutrients.Also, an abdomen is often distended.

• Blood in stool May occur in normal stools, diarrhea, constipation, tumors, or an inflammatory condition. There is Frank blood, which is red blood that usually comes from lesions in rectum or anal canal, Occult blood, which can be small hidden amounts, detectable with stool test and may be caused by small bleeding ulcers and Melena , which is dark-colored, tarry stool and may result from significant bleeding in upper digestive tract

Gas

• Gas Develops normally due to Swallowed air, such as when drinking from a straw, Bacterial action on food and Certain foods or alterations in motility. Excessive gas may manifest as the following: Eructation: burping, Borborygmus: rumbling sound in stomach/intestines, Abdominal distention and pain and Flatulence

Constipation

• Constipation is Less frequent bowel movements that normal. some features include Small hard stools can be an Acute or chronic problem that results from May be causes by decreased peristalsis and Periods of constipation may alter with periods of diarrhea. There are a list of causes: Weakness of smooth muscle because of age or illness, Inadequate dietary fiber and Inadequate fluid intake

Visceral Pain

• Visceral pain, there could present a Burning sensation by inflammation and ulceration in GI trac, a dull aching pain that is Results of stretching of liver capsule Cramping or diffuse pain that is often inflammation, distention, stretching of intestines and finally Colicky, that can occur from recurrent smooth muscle spasms or contractions/Pain in response to severe inflammation

Somatic Pain Malnutrition

• Somatic pain may cause reflex spasm of underlying abdominal muscles and steady intense. and rebound tenderness when pressure is RELEASED
• Malnutrition may be limited to a specific nutrient or generalized, but also Limited malnutrition is generally related to a specific problem or Vitamin B12 deficiency or iron deficiency

Dysphagia

• Dysphagia is a Difficulty swallowing that includes Presentation with Pain with swallowing, o Difficulty swallowing liquids, Choking and coughing with trying to swallow

Gastrointestinal Cancer

• Esophageal cancer, that is Usually in distal esophageal, where the Significant dysphagia in later stages and also the Patient may present with upper back pain that May worse when swallowing food. There is also Poor prognosis b/c of late manifestations and Chronic esophagitis

Heatial Hernia & GERD

• Histal Hernias are when a Part of the stomach protrudes into the thoracic cavity with Reflux of food up the esophagitis. the only notable sign is Heartburn GERD are Periodic reflux of gastric contents into distal esophagus causes erosion and inflammation that are often found when they have a hiatal hernia and will be more Increased symptoms when laying down

Acute Gastritis

• Acute Gastritis is Gastric mocusa in inflamed that can be ulcerated may result in Infections, alleries and alcohol intakes a main sign is Gl irtations

Peptic Ulcers and Gastric Cancers

• Peptic ulcers are Most is caused H . pylori Infection and Gastric and Duodenal ulcers where patients will have a breakdown of mocusal barriars
• And Gastic Cancers is that patients are Asymptomatic in early stages an Risk factors.are high amounts of smoked foods

Acute Pancreatitis

• IsInflammation of pancreas is considerd a Acute from is considere a medical emergency

Peritoniosis

-Is results in bactenal peritnosis and there are potential causes. Signs and symptoms are Severe epigastric or abdominal pain radiating to back

Pancreatic Cancer

Risk factors include Smoking, Chrortc pancreattis there is a Frqueatly asymptomatic until wlle advanced.

Celiac, This is linked towards a malabsorbtion disorder

Chronic Inflammations

• Crohns Diseases a Mjor inflammatory bowl disease that may affects any area of digestive track

Ulcerative Colitis

Ulcerative Colotis also has a Mjor inflammatory bowl disease that affects the mucosa

Appedicitis

• Appedicitis have many sings and symptoms is often.General periumbiliaca a

Urrinary Analysys

• If the sample is Straw-colored, with mild odor, the Urinalysis will be classified as normal urine. If the sample is Cloudy and that is due to the presence pf proteins

Urin Analysis

• If the sample has Elevated protein there is sign of proteinu

Urine Incontinence

• If their person is Incontinence thats the Loss of voluntary control of the bladder

Urine tract infections can cause, dysuria urgency, frequency, and nocturia. Systemic signs may be present. Often cloudy plus unusal odors