Clinical Features

Patients are often initially asymptomatic.

Fatigue, malaise, anorexia, and weight loss

Pruritus

Jaundice

Telangiectasia: most commonly spider angiomata

Caput medusae: paraumbilical dilation of subcutaneous veins

Palmar erythema (plantar erythema also possible) [7]

Petechiae and purpura

Generally dry and atrophic

White nails with ground-glass opacity (also known as “Terry nails”)

Nail clubbing

Lacquered lips, smooth red tongue

Nausea, vomiting

Hepatomegaly (possibly causing dull RUQ pain)

Splenomegaly

Ascites

Hyperestrogenism

• Changes in the hepatic metabolization of sex hormones cause an imbalance in the estrogen-androgen ratio, resulting in a marked increase in systemic estrogen levels.

• In men, increased estrogen levels cause feminization.

  • Gynecomastia

  • Hypogonadism (e.g., testicular atrophy, reduced libido, erectile dysfunction, infertility)

  • Decreased body hair (e.g., loss of chest hair, a female pattern of pubic hair distribution)

• In women, a massive increase in estrogen can cause amenorrhea.

Asterixis

Fetor hepaticus: bad breath with a characteristic sweet, pungent smell caused by an accumulation of dimethyl sulfide

Dupuytren contracture

Peripheral edema

Hemochromatosis: dark, bronze skin color, and diabetes (bronze diabetes)

Wilson disease

• Neurological/psychiatric symptoms (parkinsonism and personality changes)

• Indirect hyperbilirubinemia due to hemolysis.

Alpha‑1 antitrypsin deficiency: lung emphysema before 50 years of age [