Palpation during inspiration

The liver, gallbladder, spleen and kidneys should be examined in turn during deep inspiration. The key to success is to keep the examining hand still and wait for the organ to descend. One common error is to begin palpation of the liver too close to the costal margin, thereby missing the liver edge.

Examination sequence

Liver

□ Place the hand flat on the abdomen with the lingers pointing upwards and position the sensing fingers (index and middle) lateral to the rectus muscle so that the fingertips lie on a line parallel to lhe expected liver edge (Fig. 5.11). Start palpation from the transumbilical plane,

□ Press the hand firmly inwards and upwards and keep it steady while the patient lakes a deep breath through the mouth.

□ At the height of inspiration, release the inward pressure on the hand while maintaining the upward pressure. With this movement, the tips of the fingers should slip over the edge of a palpable liver.

□ Note whether the edge is sharp as is normal, or whether it is rounded, firm, irregular or tender.

□ Trace lhe surface and edge of a palpable liver across the abdomen and examine it for irregularities using the fingertips, keeping them steady in a new position each time the patient takes a deep breath. Irregularities may be felt as the liver slides under the fingertips with each inspiration.

Gall bladder

□ Place the examining fingers over the gall bladder area and ask Lhe patient to take a deep breath. Inspiration may be sharply arrested with tensing of the abdominal muscles because of a sudden accentuation of pain suggesting acute cholecystitis (Murphy's sign).

Murphy Sign AbdomenAbdominal PalpationAbdominal Exam Palpation

Fig, 5.10 The use of diagrams in case recording. H] An abdominal mass and enlarged liver in a patient with gastric carcinoma and hepatic metastases. !H Splenomegaly and lymphadenopathy in a patient with Hodgkin's lymphoma. 0 Tumour arising from the pelvis. This couifl be a bladder, uterine or ovarian swelling,

Lymphoma Abdomen

Spleen

□ Place the examining hand on the anterior abdominal wall with the fingertips well below the left costal margin, pressing inwards and upwards (Fig. 5.12A).

□ Ask the patient to breathe in deeply. If the spleen is significantly enlarged, it will bump against the fingertips.

□ At the height of inspiration, release the pressure on the examining hand so that the fingertips slip over the lower pole of the spleen, confirming its presence and surface characteristics.

Spleen Palpation

□ If the spleen is not palpable, move the examining hand upwards after each inspiration until the fingertips are under the costal margin.

□ Repeat this process along the entire rib margin as the position of the enlarging splenic tip is variable.

□ If still no! palpable, position the patient in the right lateral position with the left hip and knee flexed, and repeat the examination.

□ Alternatively, examine the patient from the left side, curling the fingers of the examining hand under the left costal margin as the patient breathes in deeply (Fig. 5.12B).

Kidneys

□ Use a bimanual technique to palpate the kidneys.

□ Place one hand posteriorly below the lower rib cage and the other over the upper quadrant.

□ Push the two hands together firmly bul gently as the patient breathes out.

□ Feel for the lower pole moving down between the hands as the patient breathes in deeply.

□ Push the kidney back and forwards between the two hands - this is known as ballotling. It helps to confirm that the structure being palpated is the kidney.

□ Assess the size, surface and consistency of a palpable kidney.

□ Examine the left kidney from either side (Fig. 5.13). Abnormal findings

Common causes of hepatomegaly in adults in Britain arc-

show n in Table 5.27. Physical signs that may occur in hepatobiliary disorders arc illustrated in Figure 5.14.

Courvoisier Sign Physical ExamKidney PalpationPalper Bimanuel Rein
Fig. 5.13 Palpation of the left kidney. H From the same side and 0 from the opposite side.

TABLE 5.27 Important causes of palpable enlargement of the liver and/or spleen

Hepatomegaly

Splenomegaly

Hepatosplenomegaly

Congestive cardiac failure

Leukaemia

Infectious mononucleosis

Fatty infiltration, e.g. alcoholic liver disease

Haemolytic anaemia

Myelofibrosis

Congenital Riedei's lobe

Portal hypertension

Polycythaemia rubra vera

Viral hepatitis

Rheumatoid arthritis, systemic lupus erythematosus

Hepatic cirrhosis

Malignancy (primary or secondary)

Infections, e.g. malaria, subacute bacterial endocarditis

Lymphoma

Amyloidosis, sarcoidosis

Gallstones are common with advancing years, especially in women and may result in acute cholecystitis, with tenderness overlying the gall bladder below the right costal margin in the mid-clavicular line. A palpable gall bladder is an abnormal finding and denotes enlargement. In the absence of jaundice, it is due to obstruction of the cystic duct leading to mucocele or empyema. Obstruction of the common bile duct produces jaundice; if the gall bladder is also enlarged, the obstruction is usually due to causes other than gallstones, such as carcinoma of the pancreas, since in cholelithiasis the gall bladder wall is diseased and thickened and cannot enlarge (Courvoisier's law).

A palpable spleen is always pathological and a spleen which remains palpable during expiration is grossly enlarged. Important causes of splenomegaly are shown in Table 5.27. Splenomegaly may be mistaken for an enlarged kidney; some features helpful in making this distinction are shown in Table 5.28.

Owing to the varying thickness of the abdomen, kidney enlargement is difficult for the inexperienced to assess unless there is gross enlargement. Irregularity of the surface or an abnormally hard consistency is more easily appreciated.

When the liver is readily palpable, it may he difficult to decide whether the right kidney can also be fell, and the opposite is also the case. This is particularly true in polycystic disease of the kidneys especially in those patients who also have associated cystic disease of the liver.

Tenderness of the kidney is often greatest posteriorly and may be elicited by gently tapping the renal angle using a fist, with the patient silting forward. Enlargement of one kidney is often the result of compensatory hypertrophy due to renal agenesis, hypoplasia or atrophy affecting the other kidney; alternatively, it may suggest the presence of a renal tumour or hydronephrosis. Enlargement of both kidneys may occur in polycystic disease and amyloidosis.

Rarely, the two kidneys are joined at their lower poles and may be palpable straddling the midline ('horseshoe kidney').

Other important causes of a palpable abdominal mass are given in Table 5.29.

Many patients with renal disease have small kidneys which arc naturally non-palpable. Indeed, the possibility of chronic renal failure is more frequently suggested from the history than from the clinical examination as the signs are usually only present at an advanced stage (Fig. 5.15).

Bimanual Palpation Technique
disease.

TABLE 5.28 Checklist to differentiate palpable spleen from left kidney

Distinguishing feature

Spleen

Kidney

Mass is smooth and regular In shape

More likely

Polycystic kidneys are bilateral. Irregular masses

Mass descends In inspiration

Yes, moves superficially and diagonally

Yes, moves deeply and vertically

Able to feel deep to the mass

Yes

No

Able to Insert fingers superficial to mass

No

Yes

Palpable notch on the medial surface

Yes, If very enlarged

No

Bilateral masses palpable

No

Sometimes (e.g. polycystic kidneys}

Percussion resonant over the mass

No

Sometimes

Mass extends beyond the midline

Sometimes

No (except with horseshoe kidney)

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Responses

  • CONCORDIO
    How to keep hand steady in liver examination?
    5 years ago
  • paul johnston
    Is the gallbladder palpable?
    5 years ago
  • niklas
    Is the liver palpable on inspiration?
    5 years ago
  • adiam
    Is an enlarged liver on deep palpation tender?
    4 years ago
  • sara
    When palpating the abdomen, you should note whether the liver is enlarged in the?
    4 years ago
  • catone
    How far should the liver extend below the costal margin during inspiration?
    4 years ago
  • thomas
    When to palpate liver inspiration or expiration?
    3 years ago
  • Kaarle Lindfors
    Do you palpate liver on inspiration or experiation?
    2 years ago
  • jakob
    Why spleen is palpable during inspiration and kidney during expiration?
    2 years ago
  • elizabeth
    How far should liver be felt below costal margin?
    2 years ago
  • Jacqueline Frank
    Is the hand pressed during inspiration in liver palpation?
    2 years ago
  • Sven
    Is it normal to feel the liver on deep palpation?
    1 year ago
  • kaija
    How to assess the liver by palpation?
    1 year ago
  • Berardo Iadanza
    Is the edge of the liver felt during inspiration or expiration?
    1 year ago
  • mohammad
    Why abdominal palpation during inspiration?
    11 months ago
  • ruaraidh
    What happens to liver position on inspiration?
    6 months ago
  • KEKE R
    How far up in the abdomin should the liver be?
    6 months ago
  • polo
    When to palpate organs relative to breathing?
    5 months ago
  • gustavo
    Is the spleen palpated bimanually?
    2 months ago
  • Mikki
    How to palpate spleen?
    29 days ago
  • brunilde
    Why to deep inspiration palpation?
    2 days ago

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