Skip to main content

Abdominal examination - 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.

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


  1. What does it mean when its a smooth liver edge

    1. Smooth well demarcated liver edge is a normal finding. It is pathological if irregular...

  2. What does it mean when they say "soft edge" on my liver?


Post a Comment

Popular posts from this blog

Hypokalemia - Potassium replacement calculation

 DEFINITION  Hypokalemia is defined as a serum potassium level of less than 3.5 mmol/L. Normal level= 3.5-5.5 mmol/L. It is encountered in >20% of patients. Patients are usually asymptomatic but severe arrhythmias and rhabdomyolysis can occur. Non-specific complaints include easy fatiguability and skeletal muscle weakness. The preferred method of replacement is via the oral route but at times this is not possible. The article below will give you an idea about how to calculate the amount of KCl to be given I.V. 1) Potassium deficit in mmol is calculated as given below: K deficit  (mmol) = (K normal lower limit  - K measured ) x kg body weight x 0.4 2) Daily potassium requirement is around 1 mmol/Kg body weight. 3) 13.4 mmol of potassium found in 1 g KCl . ( molecular weight KCl = 39.1 + 35.5 = 74.6) Suppose we get an asymptomatic patient of  70 Kg with a serum potassium level of 3.0 mmol/L and he is on nil by mouth but having an adequate diuresis, w

The plantar reflex - Babinski's sign

The plantar response is an important test to identify an upper motor neuron lesion.  PROCEDURE  To elicit it, the muscles of the lower limbs must be relaxed. The outer edge of the sole of the foot is stimulated by firmly scratching a blunt object like a key or a stick along it from the heel towards the little toe. This is what  Joseph Babinski did in the year 1896. He described the 'great toe sign' that year and then in 1903 the 'toe abduction or fan sign'. Nowadays, a final medial movement across the sole of the metatarsus is also done. i.e. we start at the heel to the little toe and finally arcing to the big toe. The final arcing movement is absent in the original Babinski plantar response test. Babinski sign refers to a combination of 'the great toe sign' and the 'fan sign'.  SIGNIFICANCE  The normal response is plantar flexion of the toes (down going) and they are drawn together. More precisely, there is flexion of the big toe and addu

Apgar scoring - table, mnemonic

 INTRODUCTION  The  Apgar score  was devised in 1952 by Dr Virginia Apgar (anesthesiologist) as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after birth.  This helps to identify those requiring resuscitation and can also be used to predict survival in the neonatal period.   MNEMONIC  A mnemonic for learning purposes includes: A - Appearance (skin colour) P - Pulse (heart rate) G - Grimace (reflex irritability) A - Activity (muscle tone) R - Respiration  Another mnemonic is also useful:  How -   Heart rate Ready - Respiration Is -        Irritability This -    Tone Child -   Colour Apgar scoring is divided into 1 and 5-min scores.  1-MIN SCORE    Sixty seconds after complete birth, the five parameters specified in the table above must be evaluated and scored. A total score of 10 indicates that the baby is in the best possible condition. A score between 0-3 me

Differences between hyperemia and congestion

Hyperemia and congestion both indicate a local increased volume of blood in a particular tissue. Hyperemia is an active process that result from augmented blood flow due to arteriolar dilation (e.g. at sites of inflammation or in skeletal muscle during exercise). The affected tissue is redder than normal because of engorgement with oxygenated blood. Congestion, on the other hand, is a passive process resulting from impaired venous return out of a tissue. It may occur due to systemic causes like cardiac failure or a local cause like isolated venous obstruction. The tissue is cyanosed because the worsening congestion leads to accumulation of deoxygenated hemoglobin in the affected tissues. 

Edema - Definition, pathophysiology, causes, clinical features

 DEFINITION  Edema is an abnormal presence of excessive fluid in the interstitial space.  PATHOPHYSIOLOGY  The movement of water and low molecular weight solutes such as salts between the intravascular and interstitial spaces is controlled primarily by the opposing effect of vascular hydrostatic pressure and plasma colloid osmotic pressure. Normally the outflow of fluid from the arteriolar end of the microcirculation into the interstitium is nearly balanced by inflow at the venular end. A small residual amount of fluid may be left in the interstitium and is drained by the lymphatic vessels, ultimately returning to the bloodstream via the thoracic duct. Either increased capillary pressure, diminished colloid osmotic pressure or inadequate lymphatic drainage can result in an abnormally increased interstitial fluid i.e. edema. An abnormal increase in interstitial fluid within tissues is called edema, while fluid collections in the different body cavities are variously