Gastroenterology Tutorial

Cirrhosis

 

Jaundice

  • Means yellowing of the skin from elevated bilirubin, either from the destruction of red blood cells in hemolysis or more commonly from liver disease or obstruction of bile ducts.
  • Not seen until the bilirubin level is about twice the upper limit of normal (2.5-3 mg/dL).
  • Best seen in natural light, it’s often better seen in the sclera (whites) of the eyes, where it is known as scleral icterus
  • Can be seen early under the tongue.
  • Patients often don’t notice when they develop jaundice. “Jaundice is the disease that your friends diagnose.” -Sir William Osler.

 

 

Spider angioma

A form of telangiectasias where a central arteriole feeds telangiectasias, and is seen in conditions of estrogen excess, such as pregnancy and liver disease. In liver disease, the spider angiomas are most often seen in the face and chest areas (drained by the SVC), and is more commonly seen in alcoholic liver disease compared to other etiologies.

 

Palmar erythema

Erythema of the thenar/hypothenar portion of the hand with a pale central palm, seen in liver disease (likely from imbalance of estrogens to androgens).

 

Gynecomastia

Growth in breast tissue due to an imbalance of estrogens to androgens.

 

Caput medusa

Medusa was a Gorgon in Greek mythology, with snakes for hair. In IVC obstruction, the pattern of collateral veins is upwards towards the SVC, not radiating outwards. In portal vein thrombosis the pattern is towards the umbilicus (opposite of caput Medusa).

 

Ascites

Inspection of the abdomen in patients with ascites reveals symmetric distention with bulging flanks.

 

Terry’s nails

Terry’s nails describes white-colored opacification of most of the nail bed, sparing a narrow 1 to 2 mm band of normal pink to brown tissue at the distal end. The opacification results in disappearance of the lunula. Terry’s nails are a sign of systemic disease, such as cirrhosis, chronic heart failure, and chronic kidney disease.

 

Dupuytren’s contracture

Thickening of the palmar fascia, caused by a variety of conditions (hereditary, trauma, diabetes) but also associated with alcoholic liver disease.

 

 

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.

Pancreatitis

 

Cullen’s sign

Periumbilical hemorrhage rarely reported in retroperitoneal bleeding.

 

Grey Turner sign

Flank hemorrhage from retroperitoneal bleeding.

 

Inflammatory bowel disease

 

Erythema nodosum

Characterized by red, painful nodules (histologically it is a panniculitis) most often seen on the lower extremities (shins, calves, thighs, ankles) and it generally flares when the inflammatory bowel disease flares. Erythema nodosum is also seen in TB, sarcoidosis, some strep infections, and as an allergic response to certain medications.

 

Pyoderma gangrenosum

Painful nodules or pustules that progressively grow and ulcerate. Associated with autoimmune conditions, including inflammatory bowel disease.

 

Unilateral icterus

 

In a patient who previously underwent surgery for ocular melanoma and now has glass eye, the presence of unilateral icterus (of the normal eye) should raise suspicion for subsequent development of liver metastases.