Asterixis

Describes jerking movements of the hand when the wrist is in full extension (also known as a “flap”). Usually associated with hepatic encephalopathy or uremia.
 

Patient 1:

This is a middle-aged woman with cirrhosis related to primary biliary cholangitis.

Patient 2:

This is a 62-year-old male with Laennec’s cirrhosis who was admitted for confusion, and found to have asterixis on exam, consistent with hepatic encephalopathy.

Patient 3:

This is an older man with acute renal failure from acute tubular necrosis, who developed asterixis as a result of uremia. 

Patient 4:

This is an older woman  with Crohn’s disease (on infliximab) who was admitted to the hospital with fever of unknown origin and was found to have a Crohn’s flare with undetectable infliximab levels (caused by the development of antibodies to infliximab); hospital course was complicated by the development of anuric renal failure thought to be caused by contrast-induced nephropathy, resulting in the development of uremia. Shown here is asterixis, observed while the patient was on a phone call.