Learn how to take a liver-focused history

The initial evaluation of a patient should always start with an appropriate history. In the history, we are looking for potential risk factors of liver disease:

• Exposure to hepatotoxins
• Viral hepatitis
• Certain medical conditions

Possible hepatotoxins include excessive alcohol intake, medications (prescribed and over the counter ones including herbal remedies), and dietary supplements. As well, be sure to ask the patient about possible exposure to hepatotoxins such as mushrooms, and industrial agents such as vinyl chloride.

Individuals at risk for viral hepatitis are those who use intravenous (IV) drugs, have had blood transfusions (especially before 1992), have had sexual exposure to affected individuals, have body piercings or tattoos, or a history of travel to areas known to be endemic for hepatitis.

Certain medical conditions are associated with liver disease, so you should be aware of these when taking the patient’s history. For example, a patient with right-sided heart failure may develop congestive hepatopathy.

In hemochromatosis, iron is deposited in tissue with resultant tissue and organ damage. The main organs that are affected are the liver, pancreas, skin, joints, heart, and gonads. Individuals with hemochromatosis present with skin pigmentation, arthritis, diabetes mellitus, and cardiomyopathy.

Early-onset emphysema may be due to alpha-1 antitrypsin (AAT) deficiency, which is also a cause of liver disease.

As well, autoimmune thyroiditis may be a clue to concomitant autoimmune liver disease.

Pregnancy and inflammatory bowel disease may be associated with gallstones, which can interfere with liver and gallbladder function. Inflammatory bowel disease is also associated with primary sclerosing cholangitis.

When taking a patient history, ask about specific symptoms that are commonly associated with liver disease including jaundice, pruritus, gastrointestinal bleeding, coagulopathy, increased abdominal girth, and mental status changes.

Early cirrhosis can manifest as anorexia, weight loss, weakness, fatigue, and osteoporosis from inadequate vitamin D and calcium absorption. Decompensated cirrhosis presents with ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and variceal bleeding from portal hypertension.

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