What are the steps for a thorough physical examination of the liver?

Physical Examination of the Liver

A thorough physical examination of the liver should include inspection, palpation, percussion, and assessment for signs of chronic liver disease, with ultrasound confirmation when clinical findings are inconclusive or concerning.

Preparation and Patient Positioning

• Position the patient supine in a comfortable position with adequate exposure of the abdomen
• For palpation, have the patient place their right arm and hand gently behind their head in a comfortable position 1
• Ensure good lighting and a warm, quiet environment

Systematic Examination Approach

1. Inspection

• Observe the abdomen for distention, visible veins (suggestive of portal hypertension), or asymmetry
• Look for jaundice in the sclera and skin 1
• Note any visible masses or bulging in the right upper quadrant

2. Percussion

• Begin percussion at the right midclavicular line at a level below where lung resonance is heard
• Percuss downward until dullness is detected (upper border of liver)
• Continue percussion downward until tympany is heard (lower border of liver)
• Measure the total liver span in the midclavicular line (normal is approximately 6-12 cm) 2
• Note that percussion has limited accuracy in determining true liver size, with poor correlation to ultrasound measurements in healthy individuals (r=0.205) 3

3. Palpation

• Begin palpation in the right lower quadrant and move upward toward the right costal margin
• Use the flat of the hand with fingers extended and together
• Ask the patient to take a deep breath as you press inward and upward
• Note the following characteristics if the liver edge is palpable:
  • Location relative to costal margin (normally ≤1-2 cm below)
  • Consistency (soft, firm, or hard)
  • Surface (smooth or nodular)
  • Tenderness
  • Edge characteristics (sharp or rounded) 1

4. Special Techniques

• Hooking technique: Hook fingers under the right costal margin and ask patient to take a deep breath
• Scratch test: Place stethoscope over liver area and lightly scratch the skin - sound transmission increases over solid organs
• Auscultatory percussion: May improve detection of the liver below the costal margin compared to light percussion alone 4

Assessment for Signs of Chronic Liver Disease

Look for the following signs that may indicate chronic liver disease 1:

• Parotid enlargement
• Dupuytren's contracture
• Spider nevi
• Palmar erythema
• Gynecomastia
• Testicular atrophy
• Caput medusae (dilated periumbilical veins)
• Ascites
• Peripheral edema
• Hepatic encephalopathy

Interpretation of Findings

• A liver palpable more than 2 cm below the costal margin may suggest hepatomegaly 4
• Inability to palpate or percuss a significant area of dullness over the liver can indicate decreased liver volume due to massive hepatocyte loss 1
• An enlarged liver may be seen in viral hepatitis, malignant infiltration, congestive heart failure, or acute Budd-Chiari syndrome 1
• A nodular liver edge suggests cirrhosis
• A firm, hard consistency may indicate malignancy

Limitations and Pitfalls

• Physical examination of the liver has limited accuracy, especially for determining true liver size 3
• Inter-observer variability can be considerable 5
• Factors affecting accuracy include:
  • Patient body habitus
  • Abdominal wall thickness
  • Patient cooperation
  • Examiner experience
  • Presence of ascites or bowel gas

Correlation with Imaging

• When clinical findings are inconclusive or concerning, ultrasound confirmation is recommended 1
• A correction factor of approximately 1.6 can be applied to convert percussed liver span to expected transaxial ultrasound measurements 2
• Ultrasound provides more accurate assessment of liver size, surface characteristics, and internal architecture 3

When to Consider Additional Evaluation

Consider further evaluation with imaging and laboratory tests when:

• Liver span is abnormal
• Liver edge is nodular or irregular
• Liver consistency is abnormally firm or hard
• Signs of chronic liver disease are present
• Abnormal liver function tests are found 1

Remember that physical examination findings must be interpreted in the context of the patient's clinical presentation, laboratory results, and imaging studies for a comprehensive assessment of liver health.