Examination of the Liver
The liver is enlarged in a number of important clinical diagnoses. Palpation and percussion of the liver are important techniques for identifying hepatomegaly.
Introduction to the Liver Examination
The signs of liver disease are for the most part to be found OUTSIDE the abdomen. The goal of this Stanford Medicine 25 session is for you to be able to list these signs from head to foot.
Palpation During the Liver Exam
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 foundoutside the abdomen.
- With patient supine, place right hand on patient's abdomen, just lateral to the rectus abdominis, well below lower border of liver dullness.
- Ask patient to take a deep breath and try to feel the liver edge as it descends.
- Be sure to allow liver to pass under the fingers of your right hand, note texture.
- Pressing too hard may interfere.
- The normal liver may be slightly tender.
- Greater tenderness suggests inflammation (e.g. hepatitis) or congestion (e.g. congestive heart disease).
- 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 During the Liver Exam
The purpose of liver percussion is to measure the liver size.
- Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move down.
- Percuss inferiorly until dullness denotes the liver's upper border (usually at 5th intercostal space in MCL). See 5-7-9 rule.
- Resume percussion from below the umbilicus on the midclavicular line in an area of tympany.
- Percuss superiorly until dullness indicates the liver's inferior border.
- Measure span in centimeters.
- 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.
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
The Stanford Medicine 25
- Pelvic Exam
- Ankle and Foot Exam, Approach to
- Gait Abnormalities
- Fundoscopic Exam
- Ankle Brachial Index
- Cerebellar Exam
- Hand Exam
- Lymph Node Exam
- Cardiac Second Sounds
- Pulsus Paradoxus and Blood Pressure Measurement Techniques
- Neck Veins & Wave Forms
- Precordial Movements in the Cardiac Exam
- Pulmonary Exam: Percussion & Inspection
- Examination of the Spleen
- Examination of the Liver
- Liver Disease, Head to Foot
- Ascites & Venous Patterns
- Examination of the Tongue
- Thyroid Exam
- Low Back Exam, Approach to
- Hip Region Exam, Approach to
- Knee Exam
- Shoulder Exam
- Deep Tendon Reflexes
- Pupillary Responses
- Involuntary Movements and Tremor Diagnosis
- Internal Capsule Stroke
- Dermatology Exam: Learning the Language
- Dermatology Exam: Nevi (Mole) Exam
- Dermatology Exam: Acne vs. Rosacea
- Bedside Ultrasound
- Rectal Exam