[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;” margin_design_tab_text=””]

“This patient is feeling unwell.  Please examine their abdominal system and discuss your findings with the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/156179983″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” underline_digit=”no” separator=”yes” digit=”20″ title=”Minutes” text=”Station time”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” separator=”yes” digit=”10″ title=”Minutes” text=”Time for this encounter”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”6″ title=”Minutes” text=”Maximum time to examine your patient”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”4″ title=”Minutes” text=”Minimum time for discussion and questions”][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has numerous stigmata of chronic liver disease.

The clinical signs exhibited in this video include:

  1. Abscesses
  2. Cyanosis
  3. Testing for a liver flap
  4. Jaundice
  5. Leuconychia
  6. Muscle wasting (and a normal limb for comparison)
  7. Needle marks
  8. Peripheral oedema
  9. Pallor

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Peripheral Stigmata of Chronic Liver disease

There are up to twenty peripheral stigmata of chronic liver disease (CLD). Some of these are more common than others and while it is unlikely you will see most of them in the exam (see below), it is important you know about all of them and the causes and impact.


This is probably the most commonly known one and in the PACES exam, the one you are very unlikely to see. Florid icterus, as demonstrated in the video is an indication of decompensated liver failure and the patient would in turn be significantly unwell and likely needing high dependency care (and hence not likely be amenable to being wheeled into a pACES examination).

Milder jaundice can be a sign of chronic liver disease and may be present in a stable patient, and hence may be more difficult to discern, especially in those with darker skin. Ensure you look at the sclera as it is easier to determine whether it is white as it should be, or yellow.

Scratch marks

These are a sign of pruritus and which is commonly encountered in primary biliary cirrhosis, which is intensely pruritic and unpleasant for patients. Remember, look at all of the arms, not just what you are presented with, this is important for other signs in the arms for other conditions (such as fistulae) but also for scratch marks as well.


This is a sign of anaemia, and not specific to CLD, but in conjunction with other signs can help determine if there is CLD (especially if the patient is cirrhotic and therefore no liver will be palpated). The palms as well as the conjunctiva are good indicators for this.

Spider naevi/telangiectasia

These are arteriolar malformations, where the there are spider-like legs that spread out from a central arteriole and are focused on the areas that the superior vena cava drain (chest, arms and neck).


This is enlarged breast tissue and can be difficult for a doctor to identify what is normal for a patient versus newly abnormal. Hence the patient’s history and own perceptions are key here. However, in CLD it will not likely occur in isolation and, like pallor, be part of a syndrome of symptoms.

It is due to a reduced androgen to oestrogen ratio. Hence it can be due to decreased androgens or increased oestrogen and in CLD it is the latter.


Clubbing of fingers (and do not forget the toes) is an occasional effect of CLD. It is also associated with a number of other conditions, but CLD is on the of the most common.


It is not well understood how opacification of the nails develops, but it is a well recognised complication of hypoalbuminaemia, for which one of the most common causes is CLD. The thumbs and index fingers interestingly, tend to be affected first, before the other digits become affected.

Palmar erythema

The reddening of the palms can also be caused by a hyper dynamic circulation or be idiopathic. It is a generalised, non-specific sign, that must not taken in isolation but in context with other, more definitive clinical signs.


Purpura is a late sign of decompensation and hence you are unlikely to see it, in the context of a liver patient, in the PACES exam, but again, you should be aware of it and know of it.

Liver flap/asterixis

This should always be examined for in the abdominal clinical examination, but given that it is a sign of decompensation and the patient would likely need, at minimum significant medical input at this stage of their illness, it is unlikely they would be a suitable PACES patient. However, you should still test for it in the PACES exam as in your day-to-day practice to identify evidence of encephalopathy.

Dupuytren’s contracture

This sign can also be idiopathic, or traumatic in origin, but in the context of the right history and other clinical signs (including parotid hypertrophy) it is an indication of CLD, due to excess alcohol use.

Track marks

These are an indication of intravenous drug use, such as heroin, and also, if tattoos are also present (although be careful of assuming too much as tattoos have become very common and are not as uncommon as they once were) may indicate a viral cause for CLD such as hepatitis B or C.


This is a sign of dyslipidaemia and is commonly also present in those with coronary artery disease (but not all people with CAD have xanthelasmata). It is, in the context of CLD, indicitive of primary biliary cirrhosis being the cause.

Slate grey complexion

This is indicative of haemochromatosis, in the context of CLD.

Kayser-Fleischer rings

It is unlikely you will have seen, much less have in the PACES exam someone with advanced Wilson’s disease to the point of having CLD and Kayser-Fleischer rings. However, you should be aware of it as a cause, from a deficiency in copper metabolism.


Not a peripheral sign but…

Evidence of obstructive airways disease, in your day-to-day practice in a patient with CLD which is most likely due to alcohol will be, not from the rare alpha-1 antitrypsin deficiency but from concomitant use of excess alcohol and excess tobacco. However, in the context of the PACES exam, if you have a younger patient with the combination of the two (look for evidence in the abdominal station of surrounding paraphernalia such as inhalers, nebuliser machine, maybe even oxygen) then consider it as a diagnosis.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has numerous stigmata of chronic liver disease.  I would like to organise an ultrasound scan of his liver and baseline blood tests.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]