Doctor reveals the unexpected signs you have deadly liver disease

An estimated 80 to 100 million adults in the US may have fatty liver disease and are unaware of it.  

The liver often remains silent even when diseased, which is why diagnosis is frequently a surprise and occurs when the condition has reached the advanced stages. 

Nearly 96 percent of adults with non-alcoholic fatty liver disease (NAFLD), one of the most common forms of liver disease, are unaware of their condition, experts have warned.

While liver disease is hard to diagnose because the symptoms such as fatigue and nausea mimic other conditions, Toronto-based internal medicine specialist Dr Siobhan Deshauer says there are 12 tell-tale signs that she always looks for in patients. 

Liver disease can be caused by a wide range of factors, including viral infections such as Hepatitis B and C and Hepatitis A, alcohol abuse, metabolic disorders, medications, and genetic disorders. 

NAFLD specifically is primarily caused by metabolic dysfunction, not alcohol. It’s closely linked to obesity, insulin resistance, type 2 diabetes, high cholesterol, and high blood pressure. 

While many people may be familiar with jaundice (the yellowing of the skin), according to Dr Deshauer, the liver can reveal its distress in unexpected ways, starting at your fingertips.

‘Your fingernails are constantly growing through a complex, energy-intensive process,’ she said in a YouTube video. 

‘Because of that, changes in your overall health often show up there first – and liver disease is no exception.’

One of the first signs Dr Deshauer mentions is Muehrcke’s lines on fingernails.

She said: ‘These are horizontal white lines that run across the nails, not on the nail plate itself, but in the tissue underneath. 

‘You can test it yourself: apply pressure to the nail and the lines will temporarily disappear. Since they’re in the nail bed, they don’t grow out with the nail.’

These lines are linked to low levels of albumin, a crucial protein made by the liver that helps keep fluid in your blood vessels, transports hormones and drugs, and maintains pH balance.

Low albumin can lead to swelling, fatigue, poor healing, and drug buildup, often due to liver disease, kidney problems, or malnutrition. High albumin is rare and usually caused by dehydration. 

Another subtle but important clue is a condition called Terry’s nails.

‘Normally, nails have a pinkish hue due to blood vessels under the nail bed,’ Dr Deshauer explained. 

‘But with liver disease, that tissue changes and becomes pale. If the lunula, the half-moon at the base of the nail, is still visible, that’s normal. 

‘But when the whole nail is ghostly white, I start thinking about liver dysfunction.’

Like Muehrcke’s lines, Terry’s nails also reflect low albumin levels seen in liver failure.

Dr Deshauer also sounded the alarm about ‘nail clubbing’.

‘Ask someone to place their nails back-to-back,’ she says, demonstrating with her own hands in a YouTube video. 

‘If there’s a diamond-shaped gap between the nails, that’s normal. If not, and the nails appear bulbous or rounded, that’s clubbing.’

Clubbing can be genetic, but when new or unexplained, it often suggests chronic problems involving the heart, lungs, or liver.

A distended abdomen is another major warning sign of liver damage.

‘People often assume the person is pregnant,’ Dr Deshauer says, pointing to an image of a woman with a swollen belly. ‘But it’s actually ascites, fluid buildup in the abdomen caused by portal hypertension, a result of advanced liver scarring.’

Portal hypertension is high blood pressure in the vein that carries blood to the liver, usually caused by liver scarring (cirrhosis), leading to complications like variceal bleeding, fluid buildup, and spleen enlargement. 

This fluid can total more than 500floz in extreme cases, leading to difficulty breathing and severe discomfort. 

It can be treated with a procedure called paracentesis, where doctors drain the fluid with a needle. 

One of the more disturbing signs of liver disease is a phenomenon known as ‘caput medusae.’ 

This is a physical sign of portal hypertension impacting the intestines, spleen, pancreas, and liver, which manifests as engorged, snake-like veins radiating from the belly button area. 

‘As blood struggles to move through a scarred liver, it finds new routes. Tiny veins under the skin around the belly button start to bulge,’ Dr Deshauer said. 

‘It creates a web-like pattern we call caput medusae, named after the snake-haired figure from Greek mythology.’

It’s not just visible veins that are a problem. Internally, especially in the esophagus, veins called varices can swell up and burst.

Dr Deshauer warns that this is one of the most dangerous complications of liver disease because if a swollen, abnormal vein ruptures, it can trigger life-threatening bleeding.

A more common symptom of liver disease involves having a red flush on the palms, a condition known as palmar erythema.

‘It shows up over the thenar and hypothenar areas of the palm, but interestingly, it usually spares the center,’ says Dr. Deshauer. ‘The culprit? High estrogen levels.’

Estrogen levels rise in liver disease because the liver can’t break the hormone down properly. This can also lead to another telltale sign: spider nevi or tiny bursts of blood vessels.

This is true for both men and women. 

‘Spider nevi look like small red dots with tiny blood vessels radiating out,’ Dr Deshauer said. ‘If you press on them, they disappear – then refill when you release.’

While one or two may be normal, three or more suggest elevated estrogen, particularly when the person isn’t pregnant.

Moving back to the hands, if you spot muscle wasting, this could be a cause for concern. 

‘The liver helps metabolize nutrients and store energy,’ Dr Deshauer says. ‘When it’s failing, the body begins breaking down muscle for fuel.’

Early muscle wasting in liver disease can be seen as visible thinning or hollowing of the muscles in the hands and temples, with prominent bones and sunken areas. 

Another symptom known as Dupuytren’s contracture or the Viking grip also impacts the hands when it comes to liver disease.

‘This one is fascinating,’ Dr Deshauer said. ‘Dupuytren’s contracture is when the fascia of the palm thickens and tightens, pulling the fingers inward.’

Dr. Deshauer suggests trying the ‘tabletop test.’ This involves laying your palm flat on a surface. If you can’t touch the table fully, it may be due to a contracture.

The physician also recommends another test to detect liver problems. 

She said: ‘Ask the patient to hold their arms out and extend their wrists.

‘In cases of [a condition known as] hepatic encephalopathy, they’ll develop an involuntary flapping tremor – called asterixis.’

This neurological sign arises from ammonia buildup in the blood, a toxin that the liver normally clears. In advanced cases, patients may even develop confusion, personality changes, and, in extreme cases, coma.

One of the more subtle yet unpleasant ends of the spectrum, however, is bad breath. But it’s different than typical morning breath, Dr Deshauer says. 

‘There’s a smell I’ll never forget,’ she said. ‘It’s sweet, almost musty, and it comes from toxins like dimethyl sulfide that are exhaled in liver failure. 

‘We call it fetor hepaticus – literally, ‘foul odor of the liver.’

Bad breath generally occurs in the later stages of liver disease.  

The last two symptoms the doctor covers are jaundice and bruising.  

‘Jaundice happens when bilirubin builds up,’ Dr. Deshauer explains. ‘It turns the skin and eyes yellow, and even darkens urine to a tea color.’

Bilirubin is a byproduct of red blood cell breakdown, and when the liver can’t process it, levels spike.

And lastly, in liver disease, the liver stops producing thrombopoietin (TPO), which is the key hormone that signals the bone marrow to make platelets, leading to thrombocytopenia (low platelets). 

The liver is also responsible for synthesizing most blood-clotting factors, and its dysfunction leads to a decrease in these factors and impaired blood clotting.

These dysfunctions lead to unexplained bruising or excessive bleeding, which are sometimes the first outward signs of something wrong internally.