Alcoholic Liver Disease — Physical Examination Findings

INSPECTION

General Appearance

• Muscle wasting — temporal wasting and generalised sarcopenia from poor nutrition and alcohol's catabolic effect
• Jaundice — best detected by examining the sclera (scleral icterus) or under the tongue where elastin retains bilirubin; present in alcoholic hepatitis and decompensated cirrhosis
• Fetor hepaticus — a musty, sweet-smelling breath caused by portosystemic shunting of mercaptans; indicates advanced disease
• Abdominal distension — visible with significant ascites; the flanks bulge outward and the umbilicus may evert
• Peripheral oedema — ankle and leg oedema from hypoalbuminaemia and portal hypertension

Scleral icterus — Goldman-Cecil Medicine

Skin & Mucocutaneous Signs

• Spider naevi — vascular lesions with a central arteriole and radiating capillaries on the face, neck, and thorax; >5 are significant; caused by elevated oestrogen from impaired hepatic metabolism

Spider naevi — classic distribution on upper chest and neck

• Palmar erythema — bilateral erythema of the thenar and hypothenar eminences; suggests liver disease in men (can be normal in women)

Palmar erythema — Goldman-Cecil Medicine

• Dupuytren's contracture — retraction of the palmar fascia with finger contracture; a sign specifically associated with alcoholic liver disease (also seen in epilepsy and diabetes)
• Leuconychia (white nails / Terry's nails) — patches of white discolouration on the nails in advanced liver disease
• Petechiae and ecchymoses — from impaired clotting factor synthesis and hypersplenism
• "Paper money" skin — atrophic facial skin with fine telangiectasiae; a sign of advanced liver disease
• Parotid gland swelling — bilateral parotid enlargement characteristic of alcoholic patients
• Poor dentition — common in alcoholics; excessive caries suggest alcohol-related neglect

Signs of Feminisation / Hormonal Changes (cirrhosis)

• Gynaecomastia — breast tissue enlargement in men (elevated oestrogen:androgen ratio)
• Loss of axillary and pubic hair
• Testicular atrophy
• Caput medusae — dilated periumbilical veins from recanalization of the umbilical vein due to portal hypertension; seen on abdominal inspection

Neurological (visible on inspection)

• Asterixis ("liver flap") — ask the patient to dorsiflex both wrists with arms extended for 15 seconds; a coarse flapping tremor indicates hepatic encephalopathy
• Constructional apraxia — inability to draw a five-pointed star; found in encephalopathy without altered consciousness

PALPATION

Liver

• In alcoholic fatty liver and alcoholic hepatitis: the liver is enlarged (hepatomegaly), smooth, and tender — similar to acute viral hepatitis or hepatic congestion
• In cirrhosis: the liver may be small and shrunken (late cirrhosis) or feel hard and irregular with a nodular edge — due to fibrosis and regenerative nodules
• The liver edge is best felt starting from the right lower quadrant, moving upward; normally smooth and up to 2 cm below the costal margin
• A liver edge that is unusually firm or nodular is a reliable sign of cirrhosis
• In ascites, a dipping/balloting technique (quick pressure with fingertips below the rib cage) may be needed to detect the liver edge
• The scratch test (stethoscope over right upper quadrant, scratch from mid-abdomen toward liver): sound is amplified overlying the liver — useful when ascites obscures the edge

Spleen

• Splenomegaly — a palpable spleen tip is a reliable sign of portal hypertension in chronic liver disease; also present in acute alcoholic hepatitis and infiltrative diseases
• In decompensated cirrhosis the spleen may be massively enlarged

Ascites

• Fluid thrill (fluid wave) — place the medial border of one hand on the abdomen; an assistant presses the midline to prevent fat transmission; tapping one flank transmits a wave felt by the other hand — indicates significant (>1–2 L) ascites
• Shifting dullness (see percussion below)
• Abdominal wall hernias — umbilical or inguinal hernias may develop with chronic ascites
• Scrotal oedema — in long-standing ascites

Tenderness

• Right upper quadrant tenderness — characteristic of alcoholic hepatitis (tender hepatomegaly)
• Abdominal tenderness with ascites — raises suspicion for spontaneous bacterial peritonitis (SBP), although SBP may be painless

Other

• Palpable gallbladder — suggests biliary obstruction; should be distinguished from the liver edge
• Murphy sign (pain on palpation during inspiration) — suggests cholecystitis, not ALD per se, but may be a coexisting problem

PERCUSSION

Liver Span

• Normal liver span: 6–12 cm in the midclavicular line
• Reduced liver span: suggests cirrhotic shrinkage
• Increased liver span (hepatomegaly): found in alcoholic fatty liver, alcoholic hepatitis, hepatic congestion, or early cirrhosis with inflammation
• The liver is dull to percussion over the right upper quadrant; loss of dullness (tympany) below the right costal margin = small or absent liver

Ascites

• Flank dullness — percussion from midline toward the flank; a change from tympany (gas-filled bowel) to dullness at the flanks indicates fluid
• Shifting dullness — the definitive percussion sign: identify the tympany-to-dullness transition, then ask the patient to roll toward the examiner; if the point becomes tympanic, fluid has shifted — confirms ascites. Repeat on both sides for confirmation. This indicates the fluid pool moves to the most dependent part of the abdomen.

Splenomegaly

• Dullness to percussion between the 9th and 11th ribs in the left midaxillary line suggests splenomegaly; normally this area is tympanic (resonant due to bowel)

AUSCULTATION

Hepatic Bruit

• A hepatic arterial bruit over the right upper quadrant can be heard in hepatocellular carcinoma (a complication of cirrhosis) or, occasionally, in severe acute alcoholic hepatitis
• Also heard in hepatic haemangioma or arteriovenous fistulae

Venous Hum

• A venous hum (Cruveilhier-Baumgarten murmur) — a continuous humming sound heard at the epigastrium/umbilicus — indicates recanalization of the paraumbilical veins due to portal hypertension; correlates with caput medusae on inspection

Hepatic Friction Rub

• A friction rub over the liver indicates hepatic infarction, tumour, or perihepatitis; uncommon in pure ALD but possible in hepatocellular carcinoma complicating cirrhosis

Cardiorespiratory Findings

• Tachycardia and wide pulse pressure — hyperdynamic circulation from peripheral vasodilation in cirrhosis
• Crepitations (rales) and raised JVP — if hepatic congestion is due to concomitant cardiac disease
• Absent breath sounds at the base — hepatic hydrothorax (transdiaphragmatic passage of ascitic fluid, more commonly right-sided)

Summary Table