Hepatobiliary Conditions: Signs and Symptoms

Hepatobiliary Conditions: Signs and Symptoms

• Jaundice is evident in the sclera of the eyes as a primary sign.
• Skin changes:
  • Yellow, orange, or greenish skin can occur.
  • Pallor (paleness)
  • Pruritus (itching)
  • Bruising
  • Spider angiomas (small, spider-like blood vessels on the skin)
  • Palmar erythema (redness of the palms, also known as liver palms), which may also involve throbbing or tingling sensations in the hands
  • Plantar erythema (redness of the soles of the feet)
• Nail Changes:
  • White nails of Terry
  • Leukonychia (white bands across the nail plate)
  • Clubbed nails
  • Koilonychia (spoon nails, characterized by concave nail beds)
• Musculoskeletal (MSK) Symptoms:
  • MSK symptoms can be the only presenting symptom or can occur alongside systemic signs or symptoms.
  • Pain associated with hepatic and biliary systems may manifest as:
    • Thoracic pain between the scapulae
    • Right shoulder pain
    • Right upper trapezius pain
    • Right interscapular pain
    • Right subscapular area pain

Systemic Causes and Locations of Pain

• Liver Disease:
  • Location of pain:
    • Thoracic spine T7-T10, midline to right side
    • Right upper trapezius and shoulder
• Gallbladder:
  • Location of pain:
    • Right upper trapezius and shoulder
    • Right interscapular area (T4-T8)

Gallbladder Disorders: Cholelithiasis

• The formation of gallstones that vary in shape and size
• Gallstones:
  • Consist of cholesterol and bile pigment or mixed content with calcium salts.
  • Small stones may be silent and excreted in bile.
  • Larger stones obstruct bile flow in cystic or common bile ducts causing severe pain, often referred to the subscapular area.
• Risk Factors:
  • Women are twice as likely to develop gallstones.
  • High cholesterol, obesity, multiparity, use of oral contraceptives or estrogen supplements, hemolytic anemia, alcoholic cirrhosis, and biliary tract infection increases the risk.
• Obstruction of a duct by large calculi can cause sudden severe waves of radiating pain.
  • Nausea and vomiting are usually present.
  • Continued pain can lead to jaundice.
  • Bile may back up into the liver and blood.
  • Ruptured gallbladder is a risk if obstruction persists.
  • Pain decreases if the stone moves into the duodenum.
  • Surgical intervention may be required.
• Solid material (calculi) forms in the bile, and obstruction of the biliary tract may occur due to gallstones.

Cholecystitis and Hepatitis

• Cholecystitis: Inflammation of the gallbladder and cystic duct.
• Hepatitis: Inflammation of the liver caused by:
  • Alcoholic liver disease (potentially with fatty liver)
  • Idiopathic reasons (potentially with fatty liver)
  • Viral hepatitis (local infection)
  • Infection elsewhere in the body
  • Infectious mononucleosis
  • Chemical or drug toxicity

Cirrhosis

• Progressive destruction of the liver leading to significant health issues
• Causes:
  • Alcoholic liver disease
  • Biliary cirrhosis
    • Associate with immune disorders
  • Post-necrotic cirrhosis
    • Linked with 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, and bile may back up, causing loss of lobular organization.
• Degenerative changes may be asymptomatic until the disease is well advanced.
• Liver biopsy and serologic tests used to determine cause and extent of damage.
• Functional losses with cirrhosis include decreased inactivation of hormones and drugs, necessitating careful monitoring of drug dosages to avoid toxicity.
• Additional effects:
  • Decreased removal of toxic substances.
  • Reduction of bile entering the intestine, which impairs digestion and absorption.
  • Backup of bile in the liver, leading to obstructive jaundice.
  • Blockage of blood flow through the liver.
  • Portal hypertension
  • Congestion in the spleen
    • Incrases hemolysis
  • Inadequate storage of iron
  • Congestion in intestinal walls and stomach
    • Impairs digestion and absorbtion
  • Esophageal varices
    • Hemorrhage
  • Ascites
    • Abdominal distention and pressure
• Decreased production of blood-clotting factors, impaired glucose and glycogen metabolism, and impaired conversion of ammonia and urea all occur.
• Initial manifestations may be mild and vague, including fatigue, anorexia, weight loss, anemia, and diarrhea.
• A dull ache pain may be present in the upper right abdominal quadrant.
• Advanced cirrhosis includes ascites and peripheral edema, increased bruising, and esophageal varices.
  • These varices may rupture, leading to hemorrhage or circulatory shock, as well as jaundice and encephalopathy.

Liver Cancer and Pain Referral Patterns

• Liver cancer primarily involves hepatocellular carcinoma, which is:
  • The most common primary tumor of the liver.
  • More common in cirrhotic livers and can be secondary to metastatic cancer.
• Initial signs may be mild and general, therefore, diagnosis usually occurs with advanced stages.
• Liver pain can occur over the liver, especially after exercises (hepatitis).
  • RUQ pain may be associated with right shoulder pain.
  • Both RUQ and epigastric pain can be present.
• Gallbladder pain is characterized by RUQ pain.
  • It may also be associated with right shoulder pain.
• Pain may involve back pain between the scapulae. Back pain may present alone as the main symptom.
• Common bile duct pain is linked to epigastric discomfort/heartburn (choledocholelithiasis) and RUQ pain.
  • It can also cause right shoulder pain and back pain between the scapulae.
• Pain can 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 (less often, ribs 11 and 12) can occur, which is aggravated by respiratory inspiration or eating.

Key Points to Remember

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

Gastrointestinal Disorders

• Psychoneuroimmunology involves the relationship between the enteric system, immune system, and brain.
  • Two-thirds of all immune activity occurs in the gut.
  • Related to disorders such as fibromyalgia, SLE, RA, and chronic fatigue syndrome.
• Gastrointestinal disorders can refer pain to several regions that mimic MSK issues, including the sternum, neck, shoulder, scapula, low back, sacrum, groin, or hip.
• Gastrointestinal conditions can refer pain to the back and shoulder, particularly the upper back.
  • This involves peptic ulcers, pancreatitis, and pancreatic cancer.
• Arthritis and migratory arthralgias occur in approximately 25% of patients with Crohn's disease.
• Appendicitis, Crohn's, and ulcerative collitis can all cause iliopsoas muscle abscesses, leading to hip, thigh, or groin pain.
• Antibiotics and NSAIDs are medications that most often induce gastrointestinal symptoms.
• Gastrointestinal manifestations include abdominal pain, dysphagia, odynophagia (painful swallowing), gastrointestinal bleeding (emesis, melena), and symptoms affecting eating.
• Other gastrointestinal manifestations include anorexia, nausea or vomiting, arthralgia, early satiety with weight loss, constipation, diarrhea, fecal incontinence, referred shoulder pain, epigastric pain with radiation to back, and neuropathy. Anorexia, nausea, and vomiting can be signs of a gastrointestinal disorder or other conditions, such as systemic infection.
• It can lead to serious complications like dehydration, acidosis, and malnutrition. Nausea is an unpleasant subjective feeling and is stimulated by distention, irritation, or inflammation of the digestive tract.
• Also stimulated by smells, visual images, pain, and chemical toxins or drugs. Vomiting may be triggered by distention or irritation in the digestive tract and stimuli from various parts of the brain.
• Also be response to unpleasant sights or smells, ischemia, pain or stress.
• Increased ICP or the stimulation of the chemoreceptor trigger zone may cause vomiting.
• Presence of blood (hematemesis)
• Coffee ground vomitus that has brown, granular material and indicates the action of hydrochloric acid on hemoglobin.
• Hemorrhage with red blood that may occur in vomitus or bile from the duodenum that has a deeper brown color.
• Recurrent vomiting with undigested food may indicate content from the lower intestine or a problem with gastric emptying or infection. Diarrhea is an excessive frequency of stools and stools are loose and watery consistency.
• Prolonged diarrhea may lead to dehydration, electrolyte imbalance, acidosis, and malnutrition.
• Common types of diarrhea:
  • Large-volume (secretory or osmotic) watery stool results from increased secretions into the intestine from the plasma.
    • Often related to an infection
  • Small-volume diarrhea is often caused by inflammatory bowel disease, with stool that may contain blood, mucus, or pus.
    • May be accompanied by abdominal cramps. Steatorrhea (fatty diarrhea) is characterized by frequent, bulky, greasy, loose stools and a foul odor.
• Steatorrhea is a characteristic of malabsorption syndromes like celiac disease or cystic fibrosis and affects fat, usually the first dietary component.
• Presence interferes with digestion of other nutrients and abdomen often becomes distended. Blood in stool may occur in normal stools, diarrhea, constipation, tumors, or an inflammatory condition.
• Red blood (usually from lesions in the rectum or anal canal)
• Occult blood small amounts, detectable with a stool test from small bleeding ulcers.
• Melena has dark-colored, tarry stool from significant bleeding in the upper digestive tract. Gas develops normally due to swallowed air, bacterial action on food, or certain foods or alterations in motility.
• Excessive gas may manifest as eructation (burping), borborygmus (rumbling sound in stomach/intestines), abdominal distention and pain, or flatulence.
• Constipation occurs through less frequent bowel movements. Causes of peristalsis include weakness of smooth muscle, inadequate dietary fiber, and inadequate fluid intake.
• Additional factors: failure to respond to the defecation reflex, immobility, neurologic disorders, medications (opiates), some antacids, iron medications, and obstructions caused by tumors or strictures. Visceral pain may manifest as a burning, dull, aching, cramping or diffuse, and colicky discomfort.

Pain Types

• Somatic pain receptors
  • Connected to spinal nerves
  • Causes reflexes of muscle
  • Has steady discomfort
  • Rebound and localized Malnutrition can be limited to a specific nutrient or generalized, often related to systemic conditions. Dysphagia: Difficulty swallowing is influenced by neurologic deficits and muscular disorders, which can be secondary to trauma.
• Commonly occurs following anterior cervical fusion or mechanical obstruction due to stenosis. Stenosis: Narrowing of the esophagus secondary to fibrosis.
• can cause radiation therapy Esophageal cancer can be found in the distal esophagus.

Diagnostic Gastrointestinal Conditions

• Can cause dysphagia in later cases, often along with having upper back pain.
• Poor diagnosis due to late manifestations.
• Can be caused by chronic esophagitis and Achlasia
• Genetic factors present Diet high in smoked foods and nitrites can be a cause
• Hiatal hernia can occur when one part of the stomach protrudes into the thoracic cavity.
• GERD causes inflammation on the distal esophagus which can be seen with Hiatial hernia.
• GERD will increase symtpoms when laying down
• Medicaitons can reduce reflux.
• Gastritis onsets acute gastritis
• Damage occurs from blood supply leading to constipation.
• Ulcers, nausea and vomiting
• Stomach ache is a symptom of gastric Ulcers
• If a patient has blood in stool
• Recurrent pancreatitis caused be tumors

Early and Late Stages Diseases

• Early Stages of diseases are tested by family history.
• Diets high in smoked foods and/or nitrates
• Dysphagia from an underlying cause
• Cancer can be genetic
• Early stages can be symptoms Early detection with a few of the risk factor can lead to positive results
• Peritonitis is common with an infection with trauma
• Obstructions lead to more bacteria
• Appendicitis and intestine complications

Functional Obstructions

• Lack of movement
• Small intestine
• Adhesions, Hernias masses can be causes
• Paralytic or a dynamic construction leads to paralysis.
• Toxins and bacteria lead to sepsis
• Malfunctions with peritonitis results
• Cheical peritonitis can result Enzymes, urine an many damages or issues.

Dysfunction System

• The urinary systems works to manage waste and many other important functions.
• Kidneys, bladder and ureters are close to other important aspects of the body Costovertebral problems
• Change in odor, amount or color
• Renal and pelvic problems can occur with abnormal waste amount
• Protein levels and blood amounts
• Urin can cause pain
• Cancer risk
• Age and race are risk factors
• Symptoms are important like pain with urination.

Urine/ stool symptoms can vary from color

• Urerthal and bowl changes.
• Screening can be different for women due to pain
• History can be an important factor
• Peliv floor or joint factors leading to cancer

Problems with urination and reproduction

• Incontinence
• Bacterial Changes and pain can refer from LB all the way to the knee
• Symptoms can indicate hormonal problems. Diabetes leads to issues as well
• Symptoms can be signs of hormones Cancer:
• Infections can be underlying
• Prognosis is more accurate to see the problems and cancer
• Can cause inflammation in the whole body Hypothroisim
• Auto factors
• weight gain, depression, hair loss and memory loss
• Hypocaralcalemia is common
• Calcium is low or high
• Low heart rate
• Constipation
• Cramps Hypercardial
• Low blood
• Increase heartrate
• Hormonal imbalance
• In some cases, bilateral can be symptoms

Diabietes

• Insulin deficit

• Too much glucose

• Auto factors

• Hypertension

• Fatigue

• Muscle weakness

• Can be similar to heart rate

• Dificulties

• Complications are acute and chronic

• Neuropathy

• Weakness

• Ulcers Shock

• Death

• Genrally the ages between 0-9 you may see symtpoms

• Type 2 increases the risk for infection

• HHNK Syndrome caused by imbalances during a fast heart rate

• Warning symptoms with blood levels are signs

• Hypo decreases

• Hyper increases

• May lead to heart or brain failure

• Complications is possible with DM that are high or low

• Endocrine

• Pain and discomfort are common in women Prostate with men

• Cancer symtpoms

• Age and weight are risk factors.

• hormons is what causes changes

Dysfunction:

• Genetic Factors
• Muscle aches
• Tumors
• Testicular torsion can occur with hormones Testicular pain and pelvic pain.
• Reproduction is different across races.
• Pregnancy and early puberty can be factors.
• hormone fluctuation Changes in shape
• Can cause fertility concerns
• Hormonal effects Can be cancerous and require hospitalization.
• Autoimmune is a contributing factor.