During palpation of abdomen one must follow the following rules are followed :
- Always stand on the right side of the patient because mostly people are right-handed.
- Ask the patient to flex the thighs to relax the abdominal musculature.
- Turn the patients head to the left so that patient cannot breathe on your face.
- Ask the patient to breathe deeply but regularly with open mouth.
- The hands of the the patient will be by the side of his/her trunk this is to relax the abdomen
- The patient should lie comfortably on his back, on a firm mattress with the head supporting pillow.
- There should be good light for the purpose of examination.
- In the winter season, the the examiner should be made warm his hands by rubbing together vigorously.
There are three techniques for palpation of liver .Most of the clinicians are well conversant with the conventional method
Exposure of abdomen (for palpation) :
- Above — The xiphisternum.
- Below — Just above the inguinal ligament.
- Exposure of abdomen from the xiphisternum to upper thigh (in males), or to Just above the inguinal lieament (in females) is usually carried out in inspection of abdomen.
The satisfactory position of the hands can usually be achieved if the examiner sits on the edge of the bed or kneels beside it.
Conventional method of palpation of liver
- The flat of one or both hands should be placed on the abdomen lateral to the rectus muscle, with the tips of the fingers pointing upwards. The hand is placed parallel to the arbitrary lower border of liver (or the right subcostal margin lateral to the right rectus abdominis muscle.
- At the height of inspiration press firmly inwards and upwards when the radial border of the right index finger will slip over the lower border of the liver, if that is palpable.
- The hands should be kept steady while on inspiration and advanced upwards during expiration by 1 or 2 cm higher level on the anterior abdominal wall. In this way go on palpating upwards in search of the liver Now palpate the epigastrium for the left lobe of liver.
- To avoid overlooking gross enlargement, it is advisable to palpate from Right iliac fossa,gradually upwards. By this upward movement, the tip of the fingers will slip over the edge of a palpable liver.
Preferred method (according to few clinicians)
- Place both your hands side by side on the anterior abdominal wall in the right hypochondriac just lateral to the right rectus abdominis muscle with the fingers pointing upwards.
- If any reistance is felt move the hands further downwards until the resistance disappears.
- The patient is asked to inspire deeply and at the height of inspiration press the fingers upwards and inwards.
- This manoeuvre is repeated from lateral to medial side in search of the lower border of liver.When the hand is moved downwards, the loss of resistance demarcates the lower border of liver.
Alternative method (according to few clinicians)
- The right hand of examiner is placed flat in the right iliac fossa with the fingers directing upwards, laleral to the right rectus abdominis muscle.
- At the height of inspiration, the hand is pressed firmly inwards and upwards.
- With the inspiration the tips of the fingers will slip over the edge of the liver if it is palpable
- The left hand may be placed in the lower part of right chest wall posteriorly.
Dipping method is applied in the presence of ascites.
Points to note in palpable liver
- Degree of enlargement -This is expressed by centimetres/inches or in number of lingers placed between the lower costal margin and the lower border of the palpable liver at right midclavicular lineMCL.Measurement is taken during natural expiration.
- Consistency — Soft, firm or hard.
- Tenderness — Tender or non-tender.
- Surface— Smooth or irregular ,if irregular finely irregular or coarsely irregular.
- Margin or border—Sharp or rounded. Usually a soft liver has roundedmargin. firm or hard liver has a sharp margin. The margin may be irregular in cirrhosis of liver.
- Movement with respiration—Liver always moves 1 to 3 cm downwards with deep inspiration.
- Left lobe enlarged or not.
- Pulsation—Pulsatile liver link
- Upper border of liver dullness
- Percuss the right side of chest from above downwards along the right MCL. Normally the upper border of liver dullness in found in right 5th ICS at right MCL.
- Palpable hepatic rub.
- Place the stethoscope over the liver and auscultate carefully for any hepatic bruit or hepatic rub.
Right lobe of the liver is palpated by keeping the hand lateral to the right rectus abdominis muscle while the left lobe is examined in the midline.
Reidle's lobe of liver
It is a congenital variant of Right lobe, a tongue like projection from the inferior surface of the Right lobe. It can be palpated and confused with an enlarged gallbladder or Right kidney.
