palpation

• Ensure that your hands are warm. If the patient is in a low bed, sit on, or kneel beside, the
bed on the patient's right side.
• → Ask the patient to place his arms alongside his body to help relax the abdominal wall.
Placing a pillow under the patient's knees may also help by allowing flexion of the hips
(Fig. 5.11).
• → Ask the patient to show you where he feels pain before you start, and to report any
tenderness as you examine him.
• → Begin with gentle superficial examination of the whole abdomen. If the patient has
abdominal pain, start away from the site of maximal pain and move in a systematic
manner through the nine regions of the abdomen.
• → Use your right hand, keeping it flat and in contact with the abdominal wall, and avoid
using your finger tips. As you palpate, watch the patient's face for any sign of discomfort.
• → Palpate lightly in each region in turn, then repeat this palpating deeply.
• → Test muscle tone by light dipping movements with your fingers.

Hepatomegaly.
Hepatic enlargement can result from chronic parenchymal liver disease from any cause.
Although the liver is enlarged in early cirrhosis, it is often shrunken in end-stage cirrhosis. Fatty
liver (hepatic steatosis) from alcohol or other causes can cause marked hepatomegaly. Hepatic
enlargement due to metastatic tumour deposits is hard and irregular. An enlarged left lobe may
be felt in the epigastrium or even the left hypochondrium. Hepatocellular cancer sometimes
causes an audible bruit which can also rarely be heard in alcoholic hepatitis. In right heart failure,
the liver is usually soft and may be tender. A pulsatile liver indicates tricuspid incompetence.
→ Examination sequence
• → Start palpating in the right iliac fossa. If you start in the right
hypochondrium, you may already be above the lower border of a
massively enlarged liver.
• → Use either the radial border of your right hand, i.e. the outside edge
of the forefinger, or the finger pads; in both cases keep your hand flat
on the abdomen (Fig. 5.12). Do not dig in with your finger tips as you
may get a false impression of the liver edge.
• → Keep your hand stationary and ask the patient to take a deep breath
in. Try to feel the edge of the enlarged liver as it moves downwards
on inspiration.
• → Move your hand progressively further up the abdomen a
centimetre or so at a time repeating the request to breathe in until you
reach the costal margin or detect the edge.
• → If you feel the liver edge, work out if it is enlarged or displaced
downwards as occurs in patients with hyperinflated lungs from
emphysema. The liver is dull to percussion whereas the lung is
resonant, so locate the upper border of the liver by percussing over the
right lateral chest wall. The lower three to four ribs are normally dull
to percussion. A reduced area of dullness suggests emphysema, a
shrunken liver (as occurs in end-stage cirrhosis), or occasionally
 interposition of the transverse colon between the liver and the
diaphragm.

• → Measure the distance below the costal margin in centimetres in the

midclavicular line.
The aim is to feel if the lower border of the liver is palpable. If you detect the liver edge,
describe:

• size, e.g. in cm below the costal margin

• surface - smooth or irregular
• edge - smooth or irregular
• consistency - soft or hard
• if it is tender
• if it is pulsatile
• whether there is an audible bruit.

The gall bladder may be palpable in the right hypochondrium if it is swollen (Fig. 5.13A). It has
a characteristic globular feel, and, unlike the liver, you can palpate above it. It becomes swollen
due to obstruction either of the cystic duct (resulting in a mucocele of the gall bladder) or of the
common bile duct if the cystic duct is patent, as in pancreatic cancer. A gall bladder with
gallstone disease is not palpable because it becomes thickened and contracted. If the gall bladder
is palpable in a jaundiced patient the obstruction is not due to gallstones but is likely to be
pancreatic cancer or distal cholangiocarcinoma (Courvoisier's law).

Splenomegaly refers to enlargement of the spleen. The term hypersplenism refers to the
pancytopenia (low platelet, white cell count and haemoglobin) found in patients with chronic
splenic enlargement. This is due to increased destruction of circulating blood cells.
Haematological disorders causing splenomegaly commonly, but not invariably, also cause
enlargement of the liver. Haemolytic anaemia causes mild splenomegaly without hepatomegaly.
Portal hypertension is usually due to cirrhosis, when the liver may or may not be enlarged.
The spleen has to increase in size threefold to be palpable, so a palpable splenic edge always
indicates splenomegaly. Causes of splenomegaly are listed in Table 5.21. The spleen enlarges
from under the left costal margin down and medially towards the right iliac fossa (Fig. 5.13B). If
the spleen is significantly enlarged, a characteristic notch may be palpable midway along its
leading edge.
→ Examination sequence
→ With your right hand start in the right iliac fossa and ask the patient to
breathe in deeply as you press posteriorly and caudally for 1-2 centimetres
(Fig. 5.14A). Try to detect the spleen as it moves down against your fingers.
→ Move your hand diagonally upwards and across the abdomen 1-2
centimetres at a time into the left hypochondrium repeating this manoeuvre.
→ Feel the costal margin along its length as the position of the spleen tip is
variable.
• → If you cannot feel the splenic edge, ask the patient to roll towards
 you onto the right side and repeat the above.
• → Palpate with your right hand while using your left hand to press
forward on the patient's left lower ribs from behind (Fig. 5.14B).

• → Feel along the left costal margin.