A Liver Runs through It: Diagnosing and Managing Hepatic Disease in the Primary Care Setting

Primary care physicians should be aware of the signs and symptoms of common liver conditions, and incorporate the latest laboratory tests and diagnostic procedures into practice.

At the 2013 Pri-Med East Conference and Exhibition, Sanjiv Chopra, MD, MACP, Professor of Medicine, Harvard Medical School, Senior Consultant in Hepatology, Beth Israel Deaconess Medical Center, discussed the utility of laboratory tests and diagnostic procedures used to evaluate liver disease, and presented a number of case studies so the audience could relate the concepts to their own practice.

Chopra covered an enormous amount of valuable technical material at lightning speed, showing many slides outlining lab results and the corresponding multiple conditions that they could possibly indicate. He also showed several pictures of diseased livers from his practice (eg, hepatic hemangioma, vascular structures, rupture of an umbilical hernia).

These cases included a self-described “social drinker” with hepatomegaly, a chronic alcoholic with a recent history of headaches, and a patient that had consumed too much acetaminophen. Interestingly, Chopra told the audience he prescribes acetaminophen to his liver patients—but not to exceed two grams in 24 hours.

While discussing the topic of serum aminotransferases, Chopra presented the example of a patient in whom AST (aspartate aminotransferase) and ALT (alanine aminotransferase) were elevated, yet the liver biopsy was normal. In a case such as this, Chopra said to suspect muscle source, showing the audience a picture of a body builder. This was the first example he provided of the “MCAT” acronym for remembering four causes of unexplained ALT elevations: muscle/disease/injury (CPK, creatine phosphokinase), celiac sprue (TTG antibody, tissue transglutaminase), adrenal insufficiency (cortisol), and thyroid dysfunction (TSH, thyroid-stimulating hormone).

Chopra advised primary care physicians to look at the patient’s palms for the stigmata of chronic liver disease, such as palmar erythema. He said to also look for “paper money skin” skin (ie, telangiectasias). Additionally, he said that ophthalmologists need to get involved in diagnosis and screening for liver disease (eg, the Kayser-Fleischer Ring eye findings in Wilson’s Disease), telling the audience that “You and I would miss it.”

While a liver biopsy is considered to be the best test for liver disease, it is invasive and subject to complications. Non-invasive alternatives for evaluating the degree of hepatic fibrosis (or hepatic stiffness) include Fibrotest (Fibrosure) and Fibroscan, which are useful because whereas a liver biopsy samples only 1/50,000th of the whole liver, these tests sample 1/500th of the whole liver.

After reviewing all the technical material, Chopra shared a medical limerick illustrating the outward signs and symptoms of liver disease: “An older Miss Muffett, decided to rough it, and lived upon whiskey and gin. Red hands and a spider, developed outside her, such are the wages of sin”‑‑diagnosis: spider angiomas and palmar erythema. Chopra also quoted St. Jerome (c. 347-419 C.E.): Alius tementi aqualiculo mortem parturit—“That one, with his swollen belly, is pregnant with his own death” (ie, ascites).

Chopra concluded his talk by showing a picture of the deadly mushroom amanita phalloides (aka the “death cap”). Chopra said he sees hundreds of patients with damaged livers from eating this mushroom because they did not know that boiling it does not kill the toxin. His advice: “Buy your mushrooms in the store; don’t pick them off the ground.”