Stigmata of Cirrhosis / Portal Hypertension

  • Jaundice
  • Spider Angiomata on chest (pix)
  • Enlarged liver (palpate / percuss)
  • Distended abdominal veins (pix)
  • Ascites (see below)
  • Gynecomastia
  • Palmar Erythema
  • Testicular Atrophy (I don’t routinely check for this)


  • ↓ Platelet Count
  • Low Serum Albumin
  • ↑ Prothrombin Time (INR ≥1.5)
  • ↑ Bilirubin
  • ↑ ALT/AST (but may be normal)
  • Ultrasound (nodular liver; ascites; splenomegaly; liver may be enlarged or shrunken (if advanced)
  • CT Scan (can also find varices, masses)

Examining for Ascites (Shifting Dullness)

1.  Patient lies supine, percuss for resonance (or tympany) vs. dullness:
  • Periumbilical area (“top” of abdomen)
  • Flank (“bottom” of abdomen)
2.  Roll pt. almost onto side, so umbilicus is now “bottom” & flank “top”
  • Percuss areas again for change in tone
  • If no change in tones, no shift
  • If umbilical area at “bottom” becomes dull, & flank at “top” resonant (or tympanic), fluid inside has shifted
  • NOTE:  Not sensitive unless abdomen distended; need lots of fluid