Signs and Symptoms of Cirrhosis
The most common signs and symptoms of cirrhosis include ascites, jaundice, hepatomegaly, splenomegaly, portal hypertension manifestations (esophageal varices, caput medusae), palmar erythema, spider nevi, and hepatic encephalopathy. These findings reflect progressive liver damage and fibrosis that characterize cirrhosis.
Physical Examination Findings
General Appearance and Vital Signs
- Cachexia and muscle wasting
- Jaundice (yellowing of skin and sclera)
- Fever (may indicate infection, particularly spontaneous bacterial peritonitis)
Abdominal Findings
Ascites: Fluid accumulation in the peritoneal cavity detected by:
Hepatomegaly: Enlarged, sometimes painful liver 1
Splenomegaly: Enlarged spleen due to portal hypertension 1
Caput medusae: Dilated periumbilical veins
Expanded gallbladder fossa 1
Skin Findings
- Spider nevi: Small, spider-like blood vessels visible on the skin
- Palmar erythema: Redness of the palms
- Jaundice: Yellowing of skin and sclera
- Pruritus: Itching
- Bruising/ecchymosis: Due to coagulation abnormalities 1
Neurological Findings (Hepatic Encephalopathy)
- Asterixis (flapping tremor): Characteristic sign of hepatic encephalopathy 1
- Psychomotor slowing 1
- Sleep-wake inversion 1
- Temporospatial disorientation 1
- Impaired consciousness ranging from mild confusion to coma 1
Vascular Findings
- Portal hypertension signs:
- Esophageal varices (detected on endoscopy)
- Hemorrhoids
- Slow or reversed portal vein flow on Doppler ultrasound 1
Laboratory and Imaging Findings
Laboratory Abnormalities
- Hypoalbuminemia: Low serum albumin 2
- Hypergammaglobulinemia: Elevated gamma globulins 2
- Thrombocytopenia: Low platelet count 2
- Prolonged prothrombin time/elevated INR: Coagulation abnormalities 1
- Elevated bilirubin: Causing jaundice
Imaging Findings
- Liver surface nodularity: Particularly of the anterior left lobe 1
- Atrophic right lobe with hypertrophied caudate lobe 1
- Coarsened or heterogeneous hepatic echotexture on ultrasound 1
- Narrow hepatic veins (right hepatic vein <5 mm) 1
- Enlarged caudate-to-right lobe ratio (modified ratio >0.90) 1
Complications of Cirrhosis
Gastrointestinal Complications
- Variceal bleeding: Life-threatening hemorrhage from esophageal or gastric varices 1
- Portal hypertensive gastropathy: Mucosal changes in the stomach
Infectious Complications
- Spontaneous bacterial peritonitis (SBP): Infection of ascitic fluid without intra-abdominal source 1
- Symptoms: Abdominal pain, fever, altered mental status
- Diagnosed by paracentesis with neutrophil count >250/mm³ in ascitic fluid 1
Neurological Complications
- Hepatic encephalopathy: Spectrum from minimal cognitive changes to coma 1
- Covert HE: Detectable only by specialized testing
- Overt HE: Clinically apparent cognitive dysfunction
Renal Complications
- Hepatorenal syndrome: Progressive renal failure in advanced cirrhosis
Clinical Pearls and Pitfalls
High specificity, low sensitivity: Most physical signs of cirrhosis have high specificity (75-98%) but low sensitivity (15-68%), meaning their absence doesn't rule out cirrhosis 3.
Decompensation markers: The presence of ascites, hepatic encephalopathy, or variceal bleeding indicates decompensated cirrhosis with worse prognosis 1.
Diagnostic accuracy: No single physical finding is pathognomonic for cirrhosis, but a constellation of findings increases diagnostic certainty 2.
Differential diagnosis: Consider other causes of similar findings:
- Ascites: Heart failure, nephrotic syndrome, peritoneal carcinomatosis
- Encephalopathy: Metabolic disorders, drug effects, Wernicke's encephalopathy 1
One-third already cirrhotic at diagnosis: Approximately one-third of patients with autoimmune hepatitis already have cirrhosis at the time of diagnosis due to delayed recognition 1.
Remember that cirrhosis represents end-stage liver disease from various etiologies, and identifying the underlying cause (alcohol, viral hepatitis, NAFLD, autoimmune) is crucial for management and prognosis.