Mcwilliams sir 2012

PATIENT CARE I:
PRE- AND POST-PROCEDURE
EVALUATION

Primary and metastatic liver cancer

Justin McWilliams, MD
UCLA Interventional Radiology

Initial office visit for liver cancer

Pre-procedure decision-making

Post-procedure follow-up

INTERVENTIONAL ONCOLOGY CLINIC
INITIAL OFFICE VISIT – GENERAL PRINCIPLES

• Have a dedicated clinic day if possible
• Set aside a full hour for new patients
• Assume they have been told nothing (usually
true)
• Discuss all relevant treatment
options, including non-IR treatments
• Discuss prognosis with and without
treatment (no one else has)
• Explore patient’s goals and expectations
• Level V consultation

HEPATOCELLULAR CARCINOMA

• What would you like to know?
• Age
• Performance status
• Labs
• Child class
• Comorbidities


• Age 63
• Performance status normal
• Normal labs except Plt 100
• Child A
• No major comorbidity

• Imaging:
• Cirrhosis, splenomegaly, no ascites
• 4.7 cm HCC in right lobe (segment 6)
• 1.5 cm HCC in left lobe (segment 3)
• No vascular invasion, no extrahepatic disease

• The patient is referred to IR for consideration of locoregional therapy.

PRE-PROCEDURE DECISION-MAKING

What would you like to
do?
• Age 63
• Performance status normal DOWNSTAGE RESECTION
OLT THEN OLT (+/- RFA)
• Child A PVE THEN
• No major comorbidity RESECTION RFA TACE
(+/- RFA)
• Wants treatment
TACE TACE +
Y-90
AND RFA NEXAVAR
• 4.7 cm HCC in right lobe (seg 6)
• 1.5 cm HCC in left lobe (seg 3)
NEXAVAR SBRT NOTHING


• You chose OLT.
• This is the preferred treatment for cirrhotic
patients with low volume disease
• 75% 4-year survival if within Milan

• But, the patient is beyond Milan criteria!
• He has two HCCs and therefore both must be
under 3 cm to qualify for exception points.
• Modest expansion of the Milan criteria (UCSF)
may increase eligibility without worsening
outcomes, but this is not yet widely accepted
LESSONS LEARNED
• The patient has a MELD of 10 and dies on the list from Milan criteria:
tumor progression • One HCC up to 5 cm
• 2 or 3 HCC, each up to 3 cm
• No vascular invasion
• THE END
START • No extrahepatic disease
OVER

Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996; 334: 693–99.
Duffy JP, Vardanian A, Benjamin E, Watson M, Farmer DG, Ghobrial RM, Lipshutz G, Yersiz H, Lu DS, Lassman C, Tong MJ, Hiatt JR, Busuttil RW. Liver transplantation criteria for
hepatocellular carcinoma should be expanded: a 22-year experience with 467 patients at UCLA. Ann Surg. 2007 Sep;246(3):502-9; discussion 509-11.


• You chose DOWNSTAGE THEN OLT.
• This is a reasonable option for patients initially
beyond Milan criteria
• Rate of successful downstage = 24-69%
• 5-year survival if downstaged to OLT = 55-94%

• The patient undergoes TACE of the dominant lesion and
6 weeks later, RFA of the smaller lesion LESSONS LEARNED
UCSF downstage criteria:
• He is successfully downstaged, receives MELD • 1 lesion 5-8 cm
• 2 or 3 lesions, at least 1 being >3
exception points, and receives OLT 1 year later and <5 cm, total tumor diam <8 cm
• 4 or 5 lesions, all <3 cm, total tumor
diam <8 cm
• THE END • 3 month waiting period after
downstaging
START • No vascular invasion, no
extrahepatic disease
OVER

Gordon-Weeks AN, Snaith A, Petrinic T, Friend PJ, Burls A, Silva MA. Systematic review of outcome of downstaging hepatocellular cancer before liver transplantation in patients
outside the Milan criteria. Br J Surg. 2011 Sep;98(9):1201-8.


• You chose RESECTION.
• This is the preferred treatment in non-cirrhotics and
carefully selected Child A cirrhotics
• Normal bilirubin
• No portal HTN (no splenomegaly, platelets >100)
• 5-year survival up to 70% can be achieved in
early, solitary HCC
• Improved surgical techniques have reduced mortality
for major liver resection to <5%
LESSONS LEARNED
Consider resection for selected
• The patient undergoes R lobectomy and intra-op RFA of Child A cirrhotics with:
the L lobe lesion. His liver remnant is 30% of liver volume. • Solitary HCC (5-year OS 50-70%)
He goes into post-operative fulminant liver failure and dies.
• Large HCC (5-year OS ~30%)
• 2 or 3 HCC in same lobe (5-year
OS 30-40%)
• THE END • HCC with PV/HV invasion (5-year
START OS 20-40%)
OVER

Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation.
Hepatology 1999; 30: 1434–40.
Kishi Y, Hasegawa K, Sugawara Y, Kokudo N. Hepatocellular carcinoma: current management and future development – improved outcomes with
surgical resection. Int J Hepatology 2011; Epub 2011 Jun 23.


• You chose PVE THEN RESECTION.
• Pre-operative PVE improves perioperative
outcome for major hepatic resection
• PVE can achieve about 50% hypertrophy of
the future liver remnant (i.e. from 500 cc to
750 cc)

• The patient undergoes right PVE with increase in
FLR from 30% of liver volume to 45% of liver
volume. He undergoes successful R lobectomy
with intra-op RFA of the left lobe lesion, and is
tumor-free 3 years later. LESSONS LEARNED
Consider PVE if FLR is:
• THE END • <40% in cirrhotic patients
• <30% in post-chemo patients
START • <20% in non-cirrhotics
OVER

Palavecino M, Chun YS, Madoff DC, Zorzi D, Kishi Y, Kaseb AO, Curley SA, Abdalla EK, Vauthey JN. Major hepatic resection for hepatocellular carcinoma with or without
portal vein embolization: Perioperative outcome and survival. Surgery. 2009 Apr;145(4):399-405.


• You chose RFA.
• RFA is a potentially curative modality with
excellent tumor control rates in small tumors
• For tumors >3 cm, complete ablation rate with
single treatment decreases
• Tumor <3 cm = 91%
• Tumor 3-5 cm = 74%
• Tumor >5 cm = 36%
LESSONS LEARNED
• The patient undergoes RFA of both lesions. The left • RFA is treatment of choice in
lobe lesion is completely ablated, but the right lobe non-operative candidates
lesion recurs, and the patient dies 3 years later of with very early or early HCC
tumor progression. • Tumor size up to 3 cm
• No vascular invasion
START • No extrahepatic spread
• THE END • Child class A or B
OVER

Peng ZW, Zhang YJ, Chen MS, et al. Risk factors of survival after percutaneous radiofrequency ablation of hepatocellular carcinoma. Surg Oncol. 2008 Jul;17(1):23-31.
Crocetti L, de Baere T, Lencioni R. Quality improvement guidelines for radiofrequency ablation of liver tumours. Cardiovasc Intervent Radiol (2010) 33:11-17.
Guglielmi A, Ruzzenente A, Battocchia A, Tonon A, Fracastoro G, Cordiano C. Radiofrequency ablation of hepatocellular carcinoma in cirrhotic patients.
Hepatogastroenterology. 2003 Mar-Apr;50(50):480-4.


• You chose TACE.
• TACE reduces mortality in HCC compared
to symptomatic treatment (OR 0.54)
• But, it is non-curative
• 3-year survival ~25-30%
• DEB-TACE reduces liver toxicity and side
effects compared to cTACE

• The patient undergoes repeated TACE LESSONS LEARNED
procedures with initial response but eventual
tumor progression. He dies 2 years later. • TACE is first-line non-curative
therapy for non-surgical patients
with large or multifocal HCC who
• THE END do not have vascular invasion or
extrahepatic spread
START
OVER

Camma C, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. Radiology 2002.
Lammer J, et al. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc
Intervent Radiol (2010) 33:41-52.


• You chose TACE AND RFA.
• Combination TACE/RFA has been shown
to reduce local recurrence compared to
RFA alone
• 6% vs. 39% local progression rate for
tumors 3.1-5.0 cm

• The patient undergoes TACE of the dominant
lesion, followed by RFA of both lesions, with
complete response. He remains tumor-free
at follow-up.

• THE END START
OVER

Morimoto M, Numata K, Knodou M, Nozaki A, Morita S, Tanak K. Midterm outcomes in patients with intermediate sized hepatocellular carcinoma: a randomized controlled trial for
determining the efficacy of radiofrequency ablation combined with transcatheter arterial chemoembolization. Cancer 2010;116(23):5452-5460.


• You chose YTTRIUM-90 EMBOLIZATION.
• No RCTs
• Response rate and survival appear
similar to TACE in cohort studies
• Less side effects and hepatic toxicity

• The patient undergoes mesenteric mapping LESSONS LEARNED
followed by sequential lobar Y-90 treatment.
He has initial tumor response but dies 2 • Low embolic effect and mild
side effects may make Y-90
years later of tumor progression.
a good option for elderly
patients, patients with
reduced performance
• THE END status, and patients with
START
portal vein invasion
OVER

Sangro B, Carpanese L, Cianni R, et al; European Network on Radioembolization with Yttrium-90 Resin Microspheres (ENRY). Survival after yttrium-90 resin microsphere
radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology. 2011 Sep 2;54(3):868-78.


• You chose TACE + NEXAVAR.
• These treatments have each shown
survival improvement for patients with
intermediate or advanced HCC.
• The combination remains unproven
• One RCT showed longer time to
progression with addition of Nexavar to
TACE; another RCT showed no benefit
LESSONS LEARNED
• The patient undergoes TACE followed by • TACE + Nexavar is
Nexavar. He tolerates the treatment but promising but unproven for
eventually recurs, and dies 3 years later. intermediate and advanced
HCC
• Results of several RCTs are
START
• THE END expected in next 2 years
OVER

Sansonno D, Lauletta G, Russi S, Conteduca V, Sansonno L, Dammacco F. Transarterial chemoembolization plus sorafenib: a sequential therapeutic scheme for HCV-related
intermediate-stage hepatocellular carcinoma: a randomized clinical trial. Oncologist. 2012 Feb 14.
Kudo M, Imanaka K, Chida N, et al. Phase III study of sorafenib after transarterial chemoembolisation in Japanese and Korean patients with unresectable hepatocellular carcinoma.
Eur J Cancer. 2011 Sep;47(14):2117-27.


• You chose NEXAVAR.
• Oral multikinase inhibitor
• Extends survival from 7.9 to 10.7 months
in advanced HCC
• Diarrhea, weight loss, hand-foot
syndrome are common side effects

LESSONS LEARNED
• The patient does not have advanced HCC. SHARP inclusion criteria:
He progresses on Nexavar and dies 18 • Not candidate for
locoregional therapy
months later.
• ECOG 0-2
• Child A
START • Vascular invasion and
• THE END OVER
extrahepatic spread OK

Llovet JM, Ricci S, Mazzaferro V, et al. SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008 Jul 24;359(4):378-90.


• You chose SBRT.
• Stereotactic body radiotherapy is
noninvasive and shows efficacy against
small-medium HCC
• 73% response rate (usually partial)
• 60% 2-year survival
• Not yet enough data to recommend as part
of the HCC treatment paradigm
LESSONS LEARNED
• The patient undergoes SBRT with partial • SBRT is a promising
response of the tumors. They eventually recur noninvasive treatment for
and he dies 3 years later. small HCC that is ineligible
for locoregional treatment

• THE END START
OVER

Price TR, Perkins SM, Sandrasegaran K, Henderson MA, Maluccio MA, Zook JE, Tector AJ, Vianna RM, Johnstone PA, Cardenes HR. Evaluation of response after stereotactic body
radiotherapy for hepatocellular carcinoma. Cancer. 2011 Oct 24.


• You chose NOTHING.
• Patients always have the right to refuse
treatment
• Survival is dismal (3-17% at 3 years)

• The patient receives only supportive
care, and dies 1 year later.

• THE END

START
OVER

Camma C, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. Radiology 2002.


do?
• Age 83
• Not able to work, but up and about DOWNSTAGE RESECTION
>50% of waking hours (ECOG 2)
PVE THEN
• Child A RESECTION RFA TACE
(+/- RFA)
• Wants treatment TACE TACE +
Y-90
AND RFA NEXAVAR
• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING


do?
• Age 63
• ECOG 0 DOWNSTAGE RESECTION
• Plt 50, T bili 2.5
• Child B PVE THEN
• No major comorbidity RESECTION RFA TACE
(+/- RFA)
• Wants treatment
TACE TACE +
Y-90
AND RFA NEXAVAR
• 1.5 cm HCC in left lobe (seg 3)
NEXAVAR SBRT NOTHING

METASTATIC COLON CANCER

• What would you like to know?
• Age
• Performance status
• Labs
• Comorbidities
• Chemo regimens

• Age 55
• Performance status normal
• Normal labs except CEA 200
• Status post L colectomy and FOLFOX + Avastin, then 2nd
line Irinotecan with partial response
• 3 tumors now growing 6 months after last chemo

• Imaging:
• Three lesions in the right lobe (2 cm, 2 cm, 1 cm);
PET positive
• No extrahepatic disease

• The patient is referred to IR for consideration of
locoregional therapy.


do?
• Age 55
• Performance status normal SYSTEMIC
RESECTION
CHEMO
• Normal labs except CEA 200
RFA DEB-TACE
• Status post L colectomy, FOLFOX +
Avastin, Irinotecan

Y-90 HAI
• 1 cm lesion segment 5
• 2 x 2 cm lesions segment 8
SBRT NOTHING


• You chose RESECTION.
• Surgery is the standard treatment approach
for resectable mCRC
• 5-year survival 30-50% following hepatic
resection with curative intent
• Wedge vs anatomic resection is equivalent
as long as tumor-free margin achieved
• Need 30% residual liver post-chemo
LESSONS LEARNED
• The patient undergoes curative R lobectomy Risk factors for poor outcome
with 30% FLR, and slowly recovers. He remains with resection of mCRC:
disease-free for 4 years. • >3 tumors
• Tumor size >5 cm
• CEA > 200 ng/mL
• THE END
START
OVER

Alberts S. Update on the optimal management of patients with colorectal liver metastases. Crit Rev Oncol/Hematol (2012), doi:10.1016/j.critrevonc.2012.02.007.

25
• You chose SYSTEMIC
20

Median OS (months)
CHEMOTHERAPY.
15
• Chemotherapy prolongs survival for
patients with mCRC 10

5
• Median survival 18-21 months
0
• Once 1st and 2nd line chemo has
failed, 3rd line chemo yields response
rates <20% and survival ~9 months

• The patient is placed on cetuximab and
LESSONS LEARNED
irinotecan. He progresses after 6 months Once first and second line
and dies several months later. chemotherapy has failed, third
line chemotherapy rarely yields
START objective response.
• THE END OVER

Chong G, Dickson JL, Cunningham D, et al. Capecitabine and mitomycin C as third-line therapy for patients with metastatic colorectal cancer resistant to fluorouracil and irinotecan. Br
J Cancer. 2005 Sep 5;93(5):510-4.
Vincenzi B, Santini D, Rabitti C, et al. Cetuximab and irinotecan as third-line therapy in advanced colorectal cancer patients: a single centre phase II trial. Br J Cancer. 2006 Mar
27;94(6):792-7.


• You chose RFA.
• This is a safe, well tolerated procedure with
survival benefit in nonresectable mCRC
• 5-year survival 25-40%

• Meta-analysis shows that RFA is inferior to
resection for resectable mCRC, mostly due to
higher local recurrence rate

LESSONS LEARNED
• The patient undergoes RFA of all 3 lesions. He is Size is most important predictor
disease free for 3 years but then develops recurrence of survival for RFA of mCRC
and dies 1 year later.
• Median survival 41 months
if largest met < 3 cm
• Median survival 22 months
• THE END
START if largest met > 3 cm
OVER

Van Tilborg AA, Meijerink MR, Sietses C, et al. Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention. Br J Radiol.
2011 Jun;84(1002):556-65.
Veltri A, Guarnieri T, Gazzera C, et al. Long-term outcome of radiofrequency thermal ablation (RFA) of liver metastases from colorectal cancer (CRC): size as the leading prognostic
factor for survival. Radiol Med. 2012 Mar 19.


• You chose DEB-TACE.
• Irinotecan mounted on drug-eluting beads
• Only retrospective data available
• After failure of systemic chemo
• Response rate 75% at 12 months (including
15% complete response)
• Overall median survival 19 months
LESSONS LEARNED
• The patient undergoes 2 sessions of irinotecan DEB- DEB-TACE is a promising
TACE with partial response; he dies 18 months later therapy for chemoresistant
patients who are not surgical or
ablation candidates, but no
• THE END RCT are yet available.
START
OVER

Martin RC, Joshi J, Robbins K, et al. Hepatic intra-arterial injection of drug-eluting bead, irinotecan (DEBIRI) in unresectable colorectal liver metastases refractory to systemic
chemotherapy: results of multi-institutional study. Ann Surg Oncol. 2011 Jan;18(1):192-8.


• You chose Y-90.
• No RCT
• Retrospective data shows favorable response in
chemo-refractory patients
• Overall survival 12-17 months
• Low toxicity
• Prospective data supporting Y-90 use in 1 st or 2nd
line setting is accumulating LESSONS LEARNED
Selection criteria for Y-90 in mCRC
• Unresectable
• The patient has mesenteric mapping followed by right • ECOG 0-2
lobe infusion of resin microspheres. He has a partial
response and dies 18 months later. • Life expectancy >12 weeks
• Albumin >3, bili <2, no ascites
• No GI shunt, <30 Gy lung
• THE END exposure
START
OVER

Coldwell D, Sangro B, Wasan H, Salem R, Kennedy A. General selection criteria of patients for radioembolization of liver tumors: an international working group report. Am J Clin
Oncol. 2011 Jun;34(3):337-41.
Cosimelli M, Golfieri R, Cagol PP, et al; Italian Society of Locoregional Therapies in Oncology (SITILO). Multi-centre phase II clinical trial of yttrium-90 resin microspheres alone in
unresectable, chemotherapy refractory colorectal liver metastases. Br J Cancer. 2010 Jul 27;103(3):324-31.


• You chose HEPATIC ARTERY INFUSION.
• Direct infusion of FUDR (similar to 5-FU)
• Meta-analysis showed better response rate but
no survival benefit compared to systemic
chemo
• Problems: hepatic toxicity (biliary
sclerosis), catheter displacement, catheter
occlusion LESSONS LEARNED
The role of HAI, if any, is
unclear. Existing data used
• The patient undergoes pump insertion and HAI outdated chemotherapeutics
therapy with FUDR; he dies 1 year later. and had high incidence of
toxicity and catheter problems.
START Further study is needed.
• THE END
OVER

Bouchahda M, Lévi F, Adam R, Rougier P. Modern insights into hepatic arterial infusion for liver metastases from colorectal cancer. Eur J Cancer. 2011 Dec;47(18):2681-90.


• You chose SBRT.
• Limited data suggest efficacy against
oligometastatic disease
• 2-year local control 74%
• 2-year overall survival 83%
• Noninvasive

LESSONS LEARNED
• The patient undergoes SBRT of all 3 lesions The role of SBRT in mCRC is
without event. He dies of tumor progression unclear. It may have a role for
3 years later. patients with oligometastatic
disease who are not surgical or
RFA candidates.
• THE END START
OVER

van der Pool AE, Méndez Romero A, Wunderink W, Heijmen BJ, Levendag PC, Verhoef C, Ijzermans JN. Stereotactic body radiation therapy for colorectal liver metastases. Br J Surg.
2010 Mar;97(3):377-82.


• You chose NOTHING.
• Survival with supportive care alone after
failure of first and second-line
chemotherapy is dismal (3-4 months)

• The patient receives supportive care, and
dies 4 months later of progressive disease.

• THE END

START
OVER

Seidensticker R, Denecke T, Kraus P, et al. Matched-Pair Comparison of Radioembolization Plus Best Supportive Care Versus Best Supportive Care Alone for Chemotherapy
Refractory Liver-Dominant Colorectal Metastases. Cardiovasc Intervent Radiol. 2011 Jul 29.


do?
• Age 55
• Performance status normal SYSTEMIC
RESECTION
CHEMO
• Normal labs except T Bili 2.1
RFA DEB-TACE
• Status post L colectomy, FOLFOX +
Avastin, Irinotecan

Y-90 HAI
• 1 cm lesion segment 5
• 2 x 2 cm lesions segment 8
SBRT NOTHING

LIVER CANCER
POST-PROCEDURE FOLLOW-UP – IN-HOSPITAL

• Post-RFA • Post-TACE (overnight
• Contrast CT on the table admission)

• Recovery area for 2-3 hours • PCA
• MRI liver once awake enough • Zofran prn
• Discharge home with Vicodin • IVF
and Cipro • Dexamethasone (if non-
diabetic)
• Post-Y90 • [Cipro]
• Recovery area for 2-6 hours • AM labs: CBC, BMP, LFTs
• PPI + carafate • D/c Foley in AM
• [Medrol Dose-Pak] • Switch to PO
Vicodin, ambulate and d/c
home

LIVER CANCER
IN-HOSPITAL PROBLEMS

• Pain
• Just keep on PCA until controlled
• For chest pain after anesthesia have high
index of suspicion for MI

• Hypotension
• Evaluate groin (if arterial access)
• IVF
• Orthostatic? Oversedated?
• Consider stat CT
• Consider H&H, type and cross

• Transaminitis
• No action if not too high, and patient
doing well
• If AST/ALT > 300 or TB increases by >1
point, consider keeping until LFTs begin
to recover

LIVER CANCER
POST-DISCHARGE PROBLEMS

• Pain
• Occasionally lasts weeks after RFA
or TACE
• Motrin (anti-inflammatory), Vicodin
• Dual-phase CT if severe
• Endoscopy for pain >1 week after
Y90

• Fever
• Usually just PES
• Tylenol for fever <101.5
• High fevers, especially >1 week
after intervention, may require CT
to evaluate for biloma or abscess
(requires percutaneous drainage)

LIVER CANCER
POST-PROCEDURE FOLLOW-UP – CLINIC

• Post-RFA, TACE or Y90
• 1 month follow-up with
Eovist MRI
• Clinic visit on same day as
MRI
• CBC, BMP, LFTs, INR, AFP/
CEA
• Discuss results, treatment
plan
• If no residual disease, MRI
and clinic visit q3 months

THE END
JUMCWILLIAMS@MEDNET.UCLA.EDU

INITIAL OFFICE VISIT – HISTORY

1. HPI:
• Liver disease
• Severity of cirrhosis (Child class)
• Ascites, encephalopathy, varices
• Liver tumor
• Tumor symptoms
• Prior treatments
• Activity level


1. HPI:
2. PMH:
• Diabetes?
• CAD/CHF?
• Renal disease?
• Other malignancy?


1. HPI:
2. PMH:
3. PSH:
• Prior liver surgery?
• Hepatoenteric anastomosis?
• Orthopedic hardware?


1. HPI:
2. PMH:
3. PSH:
4. Meds:
• Nexavar?
• Diuretics?
• Lactulose?


1. HPI:
2. PMH:
3. PSH:
4. Meds:
5. Allergies:
• Iodinated contrast?
• Gadolinium?
• Antibiotics?


1. HPI:
2. PMH:
3. PSH:
4. Meds:
5. Allergies:
6. FH:
• Usually noncontributory
• Vertical transmission of Hep B?
• Hemochromatosis?
• Autoimmune disease?


1. HPI:
2. PMH:
3. PSH:
4. Meds:
5. Allergies:
6. FH:
7. SH:
• Alcohol/drug use?
• Quantity and duration
• Support system?

INITIAL OFFICE VISIT – REVIEW OF SYSTEMS

• How have you been feeling, in general?
• Fatigue or weight loss
• Chest pain
• Dyspnea
• Hematemesis, hematochezia
• Diarrhea or constipation
• Nausea or vomiting
• Urinary retention
• Anxiety or depression
• Rash/pruritis

INITIAL OFFICE VISIT – PHYSICAL EXAM

1. Vitals
2. General appearance – well or sick?
3. Icterus, fetor hepaticus
4. Heart rate/rhythm
5. Breath sounds
6. Abdominal exam for tenderness, palpable
mass, ascites, caput medusa
7. Peripheral pulses, edema, clubbing
8. Clarity of thought, asterixis
9. Spider angiomas, palmar erythema

Mcwilliams sir 2012

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