How is the liver assessed in an abdominal exam?

Answer

The span of the liver, for example, should be measured in the right midclavicular line. Presence of splenomegaly begins with gentle palpation from the umbilicus in an upward diagonal direction into the left upper quadrant. Support of the flank on the left may support and aid in projection of the spleen toward the examiners fingers. Enlarged or cystic kidneys may also be palpated with this maneuver.^[1]It should be noted if the spleen, the liver, or both cross the midline.

Percussion of intercostals spaces is required to determine the cephalad border of the liver and of the spleen and thus to unequivocally establish the presence of organomegaly. Percussion is performed by tapping on the examiner’s hand with the second digit of the other hand. It may be an invaluable maneuver to determine size. The caregiver should be able to distinguish between hyperinflation of the lungs (as seen in asthma or cystic fibrosis or any obstructive pulmonary disease) from true hepatosplenomegaly. If the latter is present, the examiner should attempt to determine if the enlarged organs are firm and/or heterogeneous from an infiltrative process or have a normal consistency from congestion (see Table 2 in Preparation).

If determining the size of the liver is difficult, the scratch test may provide additional information. The diaphragm of the stethoscope is held over the liver, and the examiner listens for change in the quality of sound as the opposite hand gently scratches the abdomen moving in a semicircle around the stethoscope.^[1]

Table 2. Correlation of Physical Findings With Diagnostic Possibilities (Open Table in a new window)

Physical Finding	Disease Process to Consider
Epigastric tenderness	Acid peptic disease (GER, gastritis, PUD)
Discomfort with minimal movement	Peritonitis
Distension with fullness left lower quadrant	constipation
Diffuse tenderness with increased tympany	IBS vs small bowel obstruction
Tenderness at McBurney's point	Appendicitis
Tenderness medial to McBurney's point	Meckels diverticulum
Increased tenderness with inspiration in RUQ (Murphy sign)	Gallbladder pathology
Pain with lifting extended right leg against resistance (Psoas sign)	Retrocecal appendicitis or other retroperitoneal irritation (abscess of Crohn disease, pancreatitis, pyelonephritis)
Bulging flanks	Ascites or obesity
Shifting dullness	Ascites
Pain with deep knee squats	Retrocecal appendicitis
"Hepatosplenomegaly" with cephalad borders at lower ribs	Hyperinflation as seen in obstructive pulmonary disease
Hepatomegaly or hepatosplenomegaly with jaundice and/or caput medusae	Cirrhosis with portal hypertension
Hepatomegaly or hepatosplenomegaly without jaundice and normal consistency of enlarged organs	Congestion secondary to heart failure
Hepatomegaly or hepatosplenomegaly without jaundice and firm consistency of enlarged organs	Storage or Infiltrative disease process including leukemia and other neoplasia
Firm hepatomegaly without splenomegaly or jaundice, especially with increased blood pressure	Congenital hepatic fibrosis
Jaundice with liver tenderness, and/or enlargement	Hepatitis
Jaundice with normal liver findings	Gilbert syndrome, hemolytic process, metabolic disease, early hepatitis
Pain relieved by sitting up	Pancreatitis, retroperitoneal pathology
Periumbilical bruising and edema (Cullen's sign)	Hemorrhagic pancreatitis
Bruising of flanks (Grey Turner sign)	Hemorrhagic pancreatic, renal hemorrhage
Isolated splenomegaly	Splenic trauma, extra-hepatic portal hypertension, splenic sequestration, hemolytic diseases, certain storage diseases

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Swartz, MH. Textbook of Physical Diagnosis: History and Examination. wb saunders; 2002.
Sir Zachary Cope, revised by William Silen. Cope's early Diagnosis of the Acute Abdomen. 15. New York: Oxford University Press; 1979. 32-49.
Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, et al. Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018. JAMA Pediatr. 2020 Sep 1. 174 (9):e202209. [Medline].
Schacherer N, Miller J, Petronis K. Pediatric blunt abdominal trauma in the emergency department: evidence-based management techniques. Pediatr Emerg Med Pract. 2014 Oct. 11 (10):1-23; quiz 23-4. [Medline].
Streck CJ, Vogel AM, Zhang J, Huang EY, Santore MT, Tsao K, et al. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg. 2017 Apr. 224 (4):449-458.e3. [Medline].
Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes.
Dinh VA, Frederick J, Bartos R, Shankel TM, Werner L. Effects of ultrasound implementation on physical examination learning and teaching during the first year of medical education. J Ultrasound Med. 2015 Jan. 34 (1):43-50. [Medline].
Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does This Child have Appendicits?. JAMA. 2007. 298:438-51.
Mahajan L, Wyllie R. Chronic Abdominal Pain of childhood and Adolescence. Wyllie R, Hyams J. Pediatric gastrointestinal Disease: Pathophysiology, diagnosis, management. second. Philadelphia Pa: W.B Saunders; 1999. 4.
Matin J, Alpern E. Abdominal Pain in Children. Mills AM, Dean AJ. Emergency Medicine clinics of North America. Elsevier; 2011. 29: 401-428.
Ross A, LeLeiko NS. Acute abdominal pain. Pediatr Rev. 2010 Apr. 31(4):135-44; quiz 144. [Medline].
McNamara R, Dean AJ. Approach to Acute Abdominal Pain. Mills AM, Dean AJ. Emergency Medicine Clinics of North America. Elsevier; 2011. 29: 159-173.
Lowe M, Woolridge D. Normal Newborn Exam, or is it?. Emergency Medicine Clinics of North America. 2007. 29: 921-946.
Geifer MJ, Murray KF, Colletti RB. Pathophysiology, diagnosis, and management of pediatric ascites. j Pediatr Gastroenterol Nutr. May 2011. 52:503-13.
White MC, Langer JC, Don S, DeBaun MR. Sensitivity and cost minimization analysis of radiology versus olive palpation for the diagnosis of hypertrophic pyloric stenosis. J Pediatr Surg. 1998 Jun. 33(6):913-7. [Medline].
Copeland DR, Cosper GH, McMahon LE, et al. Return of the surgeon in the diagnosis of pyloric stenosis. J Pediatr Surg. 2009 Jun. 44(6):1189-92; discussion 1192. [Medline].
Adelgais KM, Kuppermann N, Kooistra J, Garcia M, Monroe DJ, Mahajan P, et al. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014 Dec. 165 (6):1230-1235.e5. [Medline].
Rostas J, Cason B, Simmons J, Frotan MA, Brevard SB, Gonzalez RP. The validity of abdominal examination in blunt trauma patients with distracting injuries. J Trauma Acute Care Surg. 2015 Jun. 78 (6):1095-100 ; discussion 1100 - 1. [Medline].

Media Gallery

Abdominal palpation of a boy.
Abdominal auscultation.
Abdominal auscultation.
Percussion over the liver.
Abdominal wall findings from a handlebar injury.
Abdominal wall findings in a passenger who was restrained with only a lap belt during a motor vehicle accident.
Location of McBurney point illustrated on the abdomen of a male subject.
Abdominal quadrants.
Grey Turner sign. This 40-year-old woman complained of worsening epigastric pain of five days' duration. On examination, she had hypotension, a board-like abdomen, and extensive ecchymoses over her right loin.
Acute pancreatitis with Cullen sign.
A person with jaundice due to hepatic failure.

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Table 2. Correlation of Physical Findings With Diagnostic Possibilities

Table 2. Correlation of Physical Findings With Diagnostic Possibilities

Physical Finding	Disease Process to Consider
Epigastric tenderness	Acid peptic disease (GER, gastritis, PUD)
Discomfort with minimal movement	Peritonitis
Distension with fullness left lower quadrant	constipation
Diffuse tenderness with increased tympany	IBS vs small bowel obstruction
Tenderness at McBurney's point	Appendicitis
Tenderness medial to McBurney's point	Meckels diverticulum
Increased tenderness with inspiration in RUQ (Murphy sign)	Gallbladder pathology
Pain with lifting extended right leg against resistance (Psoas sign)	Retrocecal appendicitis or other retroperitoneal irritation (abscess of Crohn disease, pancreatitis, pyelonephritis)
Bulging flanks	Ascites or obesity
Shifting dullness	Ascites
Pain with deep knee squats	Retrocecal appendicitis
"Hepatosplenomegaly" with cephalad borders at lower ribs	Hyperinflation as seen in obstructive pulmonary disease
Hepatomegaly or hepatosplenomegaly with jaundice and/or caput medusae	Cirrhosis with portal hypertension
Hepatomegaly or hepatosplenomegaly without jaundice and normal consistency of enlarged organs	Congestion secondary to heart failure
Hepatomegaly or hepatosplenomegaly without jaundice and firm consistency of enlarged organs	Storage or Infiltrative disease process including leukemia and other neoplasia
Firm hepatomegaly without splenomegaly or jaundice, especially with increased blood pressure	Congenital hepatic fibrosis
Jaundice with liver tenderness, and/or enlargement	Hepatitis
Jaundice with normal liver findings	Gilbert syndrome, hemolytic process, metabolic disease, early hepatitis
Pain relieved by sitting up	Pancreatitis, retroperitoneal pathology
Periumbilical bruising and edema (Cullen's sign)	Hemorrhagic pancreatitis
Bruising of flanks (Grey Turner sign)	Hemorrhagic pancreatic, renal hemorrhage
Isolated splenomegaly	Splenic trauma, extra-hepatic portal hypertension, splenic sequestration, hemolytic diseases, certain storage diseases

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