Liver Palpation Technique
Palpation of the liver is best completed while feeling the liver edge during inspiration. 1
Optimal Respiratory Timing for Liver Palpation
The liver physically moves during the respiratory cycle, and this movement is critical to successful palpation. 1 During inspiration, the diaphragm descends and pushes the liver downward and anteriorly, bringing the liver edge closer to the examining hand and making it more accessible for palpation. 1
Key Technical Points:
The patient should be positioned supine with the right arm comfortably placed behind the head to optimize exposure of the right upper quadrant 1
Palpation should be performed during inspiration when the liver descends and the edge becomes palpable beneath the costal margin 1
The examiner should place their hand below the anticipated liver edge and ask the patient to take a deep breath, feeling for the liver edge as it descends during inspiration 1
Important Distinction: Biopsy vs. Physical Examination
It is crucial to distinguish between liver palpation (physical examination) and liver biopsy technique, as they use opposite respiratory phases:
For physical examination/palpation: Perform during inspiration to bring the liver edge down to the examining hand 1
For liver biopsy: The needle insertion occurs during expiration (breath-hold at end-expiration) to reduce risk of pneumothorax and prevent liver laceration from respiratory movement 1
Proper Sequence of Abdominal Examination
Palpation should occur AFTER both inspection and percussion, following the standard IAPP sequence (Inspection, Auscultation, Percussion, Palpation). 2 This sequence is recommended because:
- Palpation can potentially alter bowel sounds if performed before auscultation 2
- Percussion helps identify the liver borders before attempting palpation 2
- Light palpation should precede deep palpation to detect areas of tenderness 2
Common Pitfalls to Avoid:
- Palpating during expiration will cause the liver to ascend away from the examining hand, making the edge difficult or impossible to feel 1
- Failing to position the patient properly with the right arm behind the head limits access to the liver 1
- Palpating tender areas first may increase patient discomfort and guarding, limiting the examination 2
- Applying excessive pressure initially before establishing baseline tenderness can compromise the examination 2