Abdominal examination - liver

Liver

Examination sequence:

1) Start the palpation in the right iliac fossa. If you start in the right lumbar or right hypochondrium you may miss a massively enlarged liver.

2) The radial border of the right hand is used to feel the liver. The hand must be placed flat on the abdomen. Make sure you do not poke the patient’s abdomen with your finger tips.

3) Now your right hand is kept stationary and the patient is asked to take a deep breath. During inspiration the diaphragm becomes flat and pushes the liver downwards. Try feeling the edge when the patient inspires.

4) As the patient breathes out, move your hand up the abdomen for 1-2cm. Step 3) is then repeated.

5) Repeat step 4) till you reach the costal margin or you detect the edge of the liver.

6) If you feel the edge, then you have to work out whether it is a true enlargement of the liver or the latter has been displaced downwards by a hyperinflated lung e.g. in a case of emphysema. To check this, you have to percuss the lung on the right hemithorax. The lower 3-4 intercostal spaces are usually dull to percussion. If resonant then it is most probably a hyperinflated lung.

7) If true enlargement is concluded then measure the distance below the costal margin in the midclavicular line in cm.

Another way to perform the examination is:

1)  Place both of your hands side by side flat on the abdomen in the right iliac fossa lateral to the rectus muscles with the fingers pointing towards the ribs. Feel the edge of the liver with the pulp of your fingers, not your nails.

2) Repeat steps 3) to 7) as above but using the two hands side by side method.

Other method, like using the left hand at the back and palpating using the right hand in front, is also commonly used but it is less accurate.

Now if you have an enlarged liver you have to describe it in terms of:

a) Surface – smooth or irregular

b) Edge – smooth or irregular

c) Consistency – soft, firm or hard

d) Tenderness

e) Pulsatile

f) Audible bruit.

Causes of hepatomegaly:

1) Chronic parenchymal liver diseases like alcoholic liver disease, autoimmune hepatitis, viral hepatitis, primary biliary cirrhosis. Hepatic enlargement occurs mainly at the beginning of the diseases. Later on, due to fibrosis, it shrinks. In these conditions the liver is usually firm in consistency and regular surface.

2) Malignancy which can be primary hepatocellular cancer or secondary metastatic cancer. In hepatocellular cancer, an audible bruit may be heard while metastatic deposits give an irregular surface (sometimes nodular) with hard consistency but without tenderness.

3) Right sided heart failure in which the lung will be soft in consistency and can be tender.  If the failure is due to tricuspid regurgitation then we can feel a pulsatile liver.

4) Hematological disorders like lymphoma, leukemia, polycythemia and myelofibrosis.

5) Rare cases like amyloidosis, Budd-Chiari syndrome and glycogen storage disorders.

Note:

1) Always request the patient to flex the knees before the examination in order to relax the abdominal wall.

2) Normal length of liver in midclavicular line is <12 cm. Mean length for women=7 cm, men= 10.5 cm.

3) Single handed palpation is better for lean individual while bimanual for obese/muscular individuals.

4) Normal liver is palpable in the cases of emphysema as mentioned above but also if there is a right-sided pleural effusion, Riedel’s lobe or deep diaphragmatic excursion.

Liver disease	Palpation	Size
Acute hepatitis	Smooth; surface tender	Enlarged
Chronic hepatitis	Firm liver edge	Enlarged, especially left lobe
	Nodules rare; tender
Fulminant hepatitis	Tender surface	Shrinking size
Cirrhosis	Non-tender, firm	Variable; late stages, liver decreases in size
Hepatocellular carcinoma (hepatoma)	Nodules, if present, large and hard	Moderate to massive enlargement
	Non-tender
Metastatic carcinoma	Large nodules, irregular surface	Enlarged
	Non-tender
Fatty liver	Smooth surface	Enlarged
Right heart failure	Soft, smooth, tender	Mild to massive enlargement