Makindo Medical Notes

Overview of Liver Examination

The liver examination is a crucial part of the abdominal examination, used to assess the size, consistency, and tenderness of the liver. This examination can help detect liver enlargement (hepatomegaly), liver masses, or tenderness that may indicate underlying liver disease.

Preparation

• Ensure privacy and obtain consent from the patient.
• Explain the procedure to the patient and answer any questions they may have.
• Ensure the patient is comfortably positioned, lying supine with their arms at their sides.

Inspection

• Observe the abdomen for any visible masses or distention.
• Look for signs of liver disease such as jaundice, spider naevi, or ascites.

Palpation

• Stand on the right side of the patient.
  • Start palpation in the right iliac fossa and move upwards towards the right costal margin.
  • Ask the patient to take a deep breath in, and with each breath, advance your hands closer to the right upper quadrant.
  • Feel for the liver edge as it descends on inspiration.
  • Assess the liver edge for texture (smooth or irregular), tenderness, and consistency (soft or hard).

Percussion

• Percuss the liver span:
  • Begin percussion at the level of the right midclavicular line, starting in the lung field where resonance is heard.
  • Move downwards until dullness is detected, marking the upper border of the liver.
  • Percuss upwards from the right iliac fossa in the midclavicular line until dullness is detected, marking the lower border of the liver.
  • Measure the distance between these two points to determine the liver span. Normal liver span is approximately 6-12 cm in the midclavicular line.

Auscultation

• Listen for bruits over the liver, which may indicate vascular abnormalities such as hepatic artery aneurysm or arteriovenous malformation.
• Auscultate for friction rubs that may suggest peritoneal inflammation over the liver (e.g., perihepatitis).

Common Findings

• Normal:
  • The liver edge is not palpable or is felt just below the right costal margin, with a smooth and soft texture.
  • Percussion reveals a liver span of 6-12 cm in the midclavicular line.
• Abnormal:
  • Hepatomegaly: The liver is palpable more than 2 cm below the costal margin.
  • Nodular or Irregular Liver Edge: May suggest cirrhosis or liver tumours.
  • Tenderness: May indicate hepatitis, liver abscess, or congestion due to heart failure.
  • Bruits or Friction Rubs: Indicate vascular abnormalities or peritoneal inflammation.

Documentation

• Record your findings in the patient's medical record, including:
  • Size of the liver (in cm below the costal margin and liver span).
  • Texture, consistency, and tenderness of the liver edge.
  • Presence of any bruits or friction rubs.
  • Any associated findings, such as jaundice or ascites.

Patient Education

• Explain the significance of your findings to the patient in understandable terms.
• Discuss any further investigations or referrals that may be needed based on your findings.
• Advise on any specific symptoms to watch for and when to seek further medical attention.

Summary

A thorough liver examination involves inspection, palpation, percussion, and auscultation to assess for hepatomegaly or other abnormalities. Accurate documentation and patient education are crucial for effective diagnosis and management.

Interpretation

• Hard irregular and non-tender - cancer
• Smooth firm non-tender - cirrhosis or lymphoma
• Smooth tender enlarged - CCF, Alcohol, hepatitis
• Pulsatile - Tricuspid regurgitation
• Hepatomegaly: Some causes - Metastases, Cirrhosis, CCF, Lymphoma