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Stanford Medicine 25 An Initiative to Revive the Culture of Bedside Medicine

#4 Examination of the Liver

Key Learning Points

  • Learn how to palpate the liver
  • Learn how to percuss the liver
  • Additional Learning Objective: Learn how to diagnosis abdominal pain from the abdominal wall

 

Palpation

The purpose of liver palpation is to approximate liver size, feel for tenderness and masses. Keep in mind that many of the findings of liver disease are found outside the abdomen.

Technique

  1. With patient supine, place right hand on patient's abdomen, just lateral to the rectus abdominis, well below lower border of liver dullness.
  2. Ask patient to take a deep breath and try to feel the liver edge as it descends.
  3. Be sure to allow liver to pass under the fingers of your right hand, note texture.
    • Pressing too hard may interfere.
Findings
  • Tenderness:
    • The normal liver may be slightly tender.
    • Greater tenderness suggests inflammation (e.g. hepatitis) or congestion (e.g. congestive heart disease).
  • Consistency
    • Firm, bluntness/rounding or irregularity of liver edge suggest an abnormality.
    • Obstructed, distended gallbladder may be palpable on the inferior liver edge.
    • Nodules may be palpable; rock hard and umbilicated (central dimple) nodules suggest malignancy.

 

Percussion

The purpose of liver percussion is to measure the liver size.

Technique

    1. Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move down.
    2. Percuss inferiorly until dullness denotes the liver's upper border (usually at 5th intercostal space in MCL). See 5-7-9 rule.
    3. Resume percussion from below the umbilicus on the midclavicular line in an area of tympany.
    4. Percuss superiorly until dullness indicates the liver's inferior border.
    5. Measure span in centimeters.
Findings
  • Liver span: commonly clinically under estimated.
    • Midclavicular line: normally 6-12cm.
    • Midsternal line: normally 4-8cm.
  • False positives for enlarged liver span: right pleural effusion, consolidated lung.
  • COPD may depress diaphragm and hence depress liver borders, but not span.

 

Patient presenting with abdominal pain? See this video to diagnose causes of pain related to the abdominal wall.