Description
The patient was an obese, elderly man who was of average
height. He looked deeply jaundiced.
On examination of his head he had marked parotid
enlargement. Apart from this there were no other abnormalities.
His hands did not show any abnormalities on examination.
There were erythematous plaques with silvery scales on his elbows.
There was no abnormality detected in his neck.
The chest did not show any spider naevi, hair growth looked
normal and there was no gynaecomastia.
On examination of the abdominal wall there appeared to be
fullness in the upper abdomen. There were large erythematous plaques with
silvery scales in the lower abdomen. On palpation a mass was palpable in the
right hypochondrium. The edge was well defined. The surface appeared nodular and
the consistency of the lump was hard. It was non-tender. It was not possible to
get between the lump and the costal margin. The percussion note over the lump
was dull and this dullness was continuous with the liver dullness, which had its
upper border at the fifth right intercostal space in the mid-clavicular line.
There was a systolic bruit over one of the nodules in the mass.
No other lumps were palpable there was no free fluid in the
abdomen.
Analysis
♥
Deep jaundice would suggest a hepatocellular cause for jaundice.
Obstructive jaundice is unlikely to be given as a case in a clinical examination
and haemolytic jaundice is unlikely to be so severe without the patient being
grossly anaemic and severely ill. (Page 291)
ª
Parotid enlargement would suggest alcohol abuse as a cause or a
contributory factor in the pathogenesis. (Page 296)
¨
Psoriasis (erythematous plaques with silver scales) may be
associated with cirrhosis of the liver if the patient was treated methotrexate.
At this point the diagnosis points to cirrhosis of the liver with alcohol or
cirrhosis as a cause. As the patient has deep jaundice it is likely to be a
complication of cirrhosis with decompensation. (Page
306)
§
The patient does not have any signs of hepatocellular dysfunction
hence it is difficult to substantiate a clinical diagnosis of cirrhosis. (No
white nails, no palmar erythema, no spider naevi, normal growth of body hair, no
gynaecomastia) (Page 305)
♥
There are no signs of portal hypertension (no petechiae, no flap,
no ascites, no enlargement of the spleen). Again this makes it difficult to
substantiate a clinical diagnosis of cirrhosis of the liver. (Subclinical
disease cannot be excluded) (Page 305)
ª
A hard nodular liver suggests cirrhosis of the liver, hepatoma or
metastases. We have not found any clinical features of cirrhosis so this leaves
the latter two. (Page 303)
¨
A bruit in the liver suggests hepatoma, metastases or alcoholic
hepatitis. There are no signs of hepatocellular failure (apart from jaundice)
hence alcoholic hepatitis is excluded. (Page 304)
§
This leaves the diagnosis as hepatoma or metastases. As there is
evidence for contributory factors for chronic liver disease (parotid enlargement
–alcohol, psoriasis-iatrogneic liver damage), the likely diagnosis is hepatoma
of the liver.
Diagnosis
♥
Hepatoma of the liver
ª
Chronic liver disease caused by:
Alcohol
Methotrexate
¨
Exclude:
Metastatic liver disease
