Examination of the liver and gall bladder

Examination of the Liver
The liver is a large, solid organ that normally lies completely under the right costal arch. There is some variation in form (see anatomy textbooks). There are many liver disorders, and many disorders that may involve the liver. Therefore, specific attention should be granted to the liver during each physical examination, and especially during each abdominal examination.

Procedure

Inspection
If a hepatic disorder is suspected, the following targeted assessments should be carried out during inspection:

  • colour of skin and mucous membranes (jaundice, palmar erythema);
  • itching (pruritus);
  • spider angioma;
  • distended veins surrounding the navel (caput Medusae);
  • haemorrhoids.

Percussion

  • Percuss along the midclavicular line starting at the nipple (or, for women, as high as possible under the right breast) and moving in a caudal direction, keeping the pleximeter finger parallel to the ribs [figure 23]

Figure 23: Midclavicular line

  • The point at which a change in the resonant percussion tone first occurs (the border of relative liver dullness) indicates the upper border of the liver.
  • Have the patient breathe in deeply once and check whether this border shifts.
  • Then percuss further in a caudal direction [figure 24]. The sound is dull when percussing over the liver

Figure 24

  • The point at which the liver dullness changes to the tympanic tone of the abdomen marks the lower border of the liver.
  • If uncertain, repeat percussion while moving in a cranial direction.
  • Determine the size of the liver
    The upper border of the liver on the midclavicular line is normally found in the 4th or 5th intercostal space. The actual lower border of the liver is generally lower than that found by percussion, because the lower portion of the liver is too thin to cause any dullness. The lower border can be determined more accurately by palpation. However, the normal liver is often impalpable. The distance between the upper and lower border of dullness on percussion along the midclavicular line (the liver span) is usually 6-12 cm.
    This liver span can be smaller if the transverse colon is filled with air and is located between the abdominal wall and the liver (colonic interposition).
    If both the upper and lower borders are in a lower position than normal, then the patient may have a low-lying liver (ptosis).
    If the upper border is higher than normal, determine whether there is a disorder in the right side of the thorax.
    If there is no liver dullness, the patient may have pneumoperitoneum (air in the abdominal cavity).
    Pain upon percussion just under the right costal arch suggests gall bladder inflammation (cholecystitis) [figure 25].

Figure 25

Palpation

  • Sit to the right of the patient.
  • Lay your left hand flat on the right lumbar region parallel to the costal arch.
    If necessary, this hand can be used to exert upward pressure to raise and hold the right side of the thorax in a slightly higher position, which can facilitate palpation.
  • Carefully lay the right hand flat on the upper right abdomen with the fingers parallel to the costal arch and with the index finger below the lower border of the liver, which has previously been determined by percussion [figure 26]. The fingertips are lateral to the rectus abdominis muscle. Generally use the radial side of the right index finger to palpate.

Figure 26

  • Ask the patient to breathe in calmly and deeply through the mouth.
    During inspiration, the liver is displaced caudally by the contracting diaphragm.
  • While the patient is inhaling, make a careful gliding motion with the right hand in the cranial direction.
  • If the border of the liver is not felt, repeat this process after repositioning the palpating hand slightly in the cranial direction. Repeat this process until you reach the right costal arch.
    This procedure can also be performed by placing the right hand on the upper right abdomen so that that the fingertips point in the direction of the costal arch [figure 27]

Figure 27

Focus points

  • Palpate carefully. Rough palpation increases the chance of active muscle contraction.
  • If the abdomen is very tense, the patient can be asked to bend the legs slightly.
  • If the edge of the liver is palpable, you will feel it first against the finger before it slides under.
  • If the edge of the liver is palpable, determine the shape of the underside of the liver by following the edge in both the medial and lateral directions, using the technique described above [figure 28].

figure 28

  • If the liver is palpable, determine the following:
    • distance between the right costal arch and the lower border of the liver;
      under normal conditions, this is no greater than 2 centimetres
    • consistency of the lower border of the liver;
      normally soft, but can be slightly to very firm under pathological conditions
    • surface of the lower edge of the liver;
      normally sharp and smooth, but can be blunt and irregular with pathology
    • liver palpation tenderness;
      normally not tender on palpation
    • surface of the liver (as far as it is palpable).
      generally smooth, but can be irregular and bumpy under pathological conditions
  • Always interpret the results in the context of those found during percussion.
  • If the patient feels pain when breathing in deeply during palpation of the liver or if the pain suddenly increases and the patient catches their breath, this is referred to as a positive Murphy’s sign. This phenomenon indicates gall bladder inflammation (cholecystitis).
  • If a spherical mass is found below the edge of the liver, it may be an enlarged gall bladder [figure 29].

figure 29

Examination of the Gall blader

It can be difficult to differentiate between an enlarged liver lobe, an enlarged gall bladder, and infiltrate.

  • Distinction is possible based on the following findings
    • a swollen gall bladder has a spherical, clearly defined end; as you move cranially, the gall bladder can no longer be demarcated; an enlarged liver lobe cannot be distinguished from the liver boundary;
    • in some cases, the liver boundary can be followed over the swollen gall bladder; 
    • in some cases it is even possible to roll the affected gall bladder between the palpating fingers.
      The gall bladder is normally impalpable. A palpable gall bladder therefore always indicates pathology.
  • If an enlarged but painless gall bladder is felt in a jaundiced patient, this is referred to as a positive Courvoisier’s sign.
    In this case, there is a high probability that the biliary duct (ductus choledochus) is obstructed by a malignancy.
  • If the resistance is painful upon palpation, it may indicate an acute obstruction (e.g. gallstones) or infiltrate (cholecystitis).