It is heard in perisplenitis or perihepatitis due to microinfarction and inflammation.
Splenic rub is heard in the following conditions:
Chronic myeloid leukaemia
Abdominal girth should be measured at the level of umbilicus.
Periodic measurement is done to assess prognosis in ascites, paralytic ileus
Measure the distance between lower end of xiphisternum to umbilicus and from umbilicus to symphysis pubis.
Normally umbilicus is in mid position, it is displaced down in ascites, upper abdominal mass, displaced upwards in ovarian or pelvic tumors
Spinoumbilical measurement –It is the distance between umbilicus and anterior superior iliac spines. Normally they are equidistant. Shift of umbilicus to one side will occur in case of tumors that originating from the other side of the abdomen.
Normally the urinary bladder is not palpable. When there is retention of urine, a smooth firm regular oval shaped swelling will be palpated in the suprapubic region and its dome may sometimes reach as high as the umbilicus. The lateral and upper borders can be readily made out but it is not possible to feel its lower border In females.
However, the palpable bladder has to be differentiated from a gravid uterus, fibroid uterus and an ovarian cyst.
Gravid uterus: It is firmer, mobile side to side and vaginal signs are present.
Fibroid uterus: It is felt as a bosselated, firm swelling with different vaginal signs.
Ovarian cyst: It is eccentrically placed (left or right side).
When significant ascites is present, the abdominal masses may be difficult to feel by direct palpation.
Using the hand placed flat on the abdomen, mould the hand according to the shape of the abdomen, the fingers are flexed at the metacarpophalangeal joints so as to displace the underlying fluid.
This will enables the fingers to reach a mass covered in ascitic fluid.
This method should be used to palpate an enlarged liver or spleen with ascites.
Sudden displacement of liquid gives a tapping sensation over the surface of liver or spleen that is similar to patellar tap.
For eliciting this, place the hand flat on abdomen and make quick dipping movements.
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.
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.
Place your right palm over the liver or right hypochondrium and the left palm over the back, just opposite to the right palm.
You should stand on the right side of the patient.
Ask the patient to hold his breath after taking deep inspiration.
Look from the side and observe the separation of the hands along with expansile pulsation of
the liver.
The most common cause of pulsatile liver is CCF which produces functional tricuspid incompetence Hence, while examining the pulsatile liver, always look for engorged and pulsatile neck veins,and bipedal oedema for indirect evidence of CCF.
Lower Pole of right kidney is normally palpable.
Left kidney is usually not palpable unless either low in position or enlarged
Use bimanual technique to palpate the kidneys. Method of palpation of kidney
The patient lies flat on his back.
The examiner's left hand slides underneath the back to rest with the palm of the hand under the right loin.
The fingers remain free to flex at the metacarpophalangeal joints in the area of renal angle.
The examiners right hand is placed over the right upper quadrant.
Flexing the fingers of the Left hand can push the contents of the abdomen anteriorly.
Firm pressure is exerted by both hands at the height of inspiration to trap the palpable kidney between the two hands, otherwise it will prevent the descend of kidney by the diaphragm.
Assess the size, surface and consistency of the palpable kidney.
It is more often possible to feel a kidney by balloting.
In this case the renal angle is pressed sharply by the flexing fingers of the posterior hand.
The kidney can be felt to float upwards and strike the anterior hand. Left kidney is also palpated in the same manner.
Palpate the renal angle for tenderness.
Though kidney is retroperitoneal, it moves with respiration since it is related to the crus of the diaphragm posteriorly, the movement of the diaphragm is reflected to kidney producing restricted movement during respiration.
Causes of palpable kidney Unilateral palpable kidney
The spleen should enlarge more than 2 times to become palpable.
For Conventional palpation 2 handed technique is recommended
The patient is asked to lie in supine position
The left hand of examiner is placed posterolaterally over the left lower ribs.
The right hand of examiner is placed on the abdomen with finger tips directing to left hypochondrium.
Start palpating from the right iliac fossa towards left hypochondrium.
Don't start palpating too close to the costal margin, a large spleen will be missed.
As the Right hand is advanced closer to the left costal margin the left hand compresses firmly over the rib cage so as to enable a slightly enlarged soft spleen to be felt as it moves downwards at the end of inspiration.
If the spleen is not palpable in the supine position, the patient must be rolled onto the right side towards the examiner with the left hip and knee flexed and palpation repeated.Place the other hand posteriorly to support the lower rib cage and repeat the examination. Here one begins to palpate close to the Left costal margin
Alternatively, examine for spleen from patient's left side, curling the fingers of left hand beneath the costal,margin as the patient breathes deeply
Middletons maneuver for palpation of spleen
In this method the examiner stands on the left side of the patient facing the foot of the bed. The hooked fingers of the left hand are placed under the costal margin and with right hand pressure is exerted over the posterolateral aspect of the lower thorax. The patient is then asked to take a deep breath and spleen is felt at the end of deep inspiration
Note the following features if the spleen is palpable
Measure the enlargement from the tip of the 10th costal cartilage on the Left side towards the right iliac fossa. (10th rib is in line with the long axis of the spleen)
Movement with respiration - Well moving with respiration
Consistency - Soft / firm
Tenderness
Notch
Insinuation of the fingers between the mass and the costal margin is not possible.
Not bimanually palpable and upper border cannot be felt.
Grading of Splenic enlargement
Mild -1-2 cm
Moderate - 3-7 cm
Massive > 7 cm
Huge spleen can be bimanually palpable and becomes ballotable if ascites is present with splenomegaly.
Difference between spleen and left kidney
Features SpleenLateral kidney
Movement with respiration Well moving Restricted movement
Notch Absent Present
Insinuation of the fingers Not Possible possible
Between costal margin and the organ
Direction of enlargement Towards RIF Towards lumbar region
Splenic rub is heard in situations where the patient complains of acute pain in left upper quadrant of abdomen (often with radiation of pain to the tip of left shoulder) due to splenic infarction resulting in perisplenitis (with acute splenic tenderness)
It is produced in the following conditions like.
Subacute bacterial endocarditis
Chronic myeloid leukaemia.
Sickle cell anaemia.
After splenic puncture (eg. in diagnosis of chronic kala-azar).
Acute splenic tenderness indicates splenic infarction or abscess formation.
The characteristics of splenic rub are
It is a scratchy to-and-fro sound heard with respiration i.e. during movement of the spleen.
If the patient holds his breath, the rub stops.
The diaphragm of stethoscope should be placed over the spleen or left lower chest.
It should be always be differentiated from left sided pleural effussion(spleen is always tender in splenic rub
Treatment of splenic rub
Rest and analgesia.
Repeated splenic infarction may be an indication for splenectomy.
Always auscultate for spelnic rub over a hugely enlarged spleen.
Spleen may be mildly lender in acute malaria, infectious mononucleosis. SBE and enteric fever.
This test is done to differentiate between enlargement of stomach due to pyloric obstruction and acute dilatation of stomach
The diaphragm of stethoscope is placed over the epigastrium and scratch the upperpart of abdomen with a finger pen or pencil in a centrifugal fashion downwards and sideways
Note the change In character of the sound and mark the individual points with a pencil downwards and sideways.
The pencil marks are joined to get the outline of distended stomach which will cross the umbilicus In patient with pyloric stenosis.
This method is called ausculto scratch
In classical method of ausculto-percussion. a doctor percusses the stomach centrifugally in the direction away fro the stethoscope while the other doctor listens the change in character of the sound
Place the stethoscope on one side of the abdominal wall and keep it there minimally for one minute
until the bowel sounds are heard.
Usually the stethoscope is placed just to the right of the umbilicus.
Normal bowel sounds are intermittent low or medium-pitched gurgles mixed with occasional high-pitched tinkle.
Normal motility of the gut creates a characteristic gurgling sounds every 5-10 seconds that can be heard by unaided ear (Borborygmi).
Bowel sounds are increased in the following situations
In mechanical intestinal obstruction—Frequent loud low-pitched gurgles (borborygmi) are heard,often interspersed with high-pitched tinkles occuring in a rhythmic pattern with peristalsis. As a whole, the peristaltic sounds are exaggerated.
Increased bowel sounds with colicky pain is pathognomonic of small bowel obstruction,in between colicky pain, bowel is quiet and no sounds are audible.
Venous hum is synonymous with murmur heard in arteries. This may be called as venous murmur. It is produced as a result of enormous blood flow through the veins.
What are the common sites for venous hum ?
Sometimes, it is heard above either clavicle in a child and during pregnancy (physiological).
Commonly heard as a continuous humming sound over prominent veins seen in the epigastrium or
dilated veins seen around the umbilicus (pathological).
Pathological venous hum-It is often audible in hyperkinetic circulatory states eg. severe anaemia, thyrotoxicosis etc.
What are the characteristics of venous hum ?
Soft and low pitched.
Often continuous with early diastolic accentuation.
Best heard in sitting or erect position.
Best audible in inspiration.
Disappears on pressing the bell of stethoscope (so. place the bell lightly over a prominent vein),
and after Valsalva manoeuvre. It is accentuated by exercise.
Thrill may be associated with and disappear by application of light pressure.
Situation in which we search for abdominal venous hum ?
In the presence of dilated abdominal veins, we should search for venous hum.
The combination of dilated abdominal wall veins (caput medusae) and a venous hum at the umbilicus with normal liver is called Cruveilhier-Baumgarten syndrome. This syndrome may originate due to congenital patency of umbilical vein but more usually to a well-compensated cirrhosis.
Differential diagnosis of venous hum :
(A) In the epigastrium :
Arterial murmur of alcoholic hepatitis (heard over liver).
Arterial murmur heard over liver In hepatoma.
Continuous murmur produced due to coarctation of aorta.
The anatomical position of the spleen is behind and below the left 9th. 10th and 11th rib and its
long axis is lies along the direction of the left 10th rib
Its antero inferior end extends maximally upto the midaxiilary line
Postero-superior end lies 1-2 inches lateral to the T10 spine
The upper border of normal splenic dullness is present in left 9th rib and lor this reason the 8th ICS (space above the 9th rib) in left midaxillarv line is always resonant on percussion.
Nixon's method of percussion of spleen
The patient is asked to lie on the right side so that the spleen lies above the colon and stomach.
Percussion begins at the lower level of pulmonary resonance in the posterior axillary line and proceeds diagonally along a perpendicular line toward the lower mid anterior costal margin.
The upper border of dullness is normally 6-8 cm above the costal margin. Dullness greater than 8cm in an adult is considered as an indicator of splenic enlargement
Castell's method of percussion of spleen
Ask the patient to be in supine posture
Percuss the left axilla from above downwards along the midaxiilary line (keeping the patient s left hand on his head to expose the axilla).
Percussion in the lowest intercostal space in the anterior axillary (8th or 9th) produces a resonant note if the spleen is normal in size. This is true during expiration or full inspiration.
If the 8th ICS or spaces above are dull on percussion even on full inspiration it is expected that spleen has enlarged.
It is defined by tidal percussion usually situated in 5th Right intercostal space in mid clavicular line
It is a heavy percussion because the upper border of liver lies under cover of the right lung.
Upper and lower border of right lobe of liver can be mapped out.
Place the pleximetcr finger in the right 2nd ICS parallel to arbitrary upper border of liver and the line of percussion will be perpendicular to that border.
Start percussion from above downwards in the right chest along the right MCL.where the note will be resonant over lungs and work downwards vertically.
In normal liver, upper border is at 5th inter costal space where note is dull; This extends down to the lower border found at or just below right subcostal margin.
Percussion below the right costal margin is useful in hepatomegaly. Ask the patient to breathe in deeply as you percuss, lightly keeping the fingers parallel to the the margin. As the liver descends during inspiration, a change in note from resonance to dull signifies liver edge.
Percussion of the lower border of liver :
Start percussion from below upwards i.e. from right iliac fossa lo right hypochondrium along the right MCL.
Light percussion is done as it is a superficial organ.
Place the pleximeter finger parallel lo right subcostal margin and the line of percussion will be perpendicular to that margin.
Lower border of lung is found to lie in 6th rib. 8th rib and 10th rib in the MCL. midaxiilary and scapular line respectively.
How to assess the Liver span?
It is the measurement of liver size from the upper border to the lower border in the mid-clavicular line.
Normal liver span is 12.5 cm (12 - 15 cm)
Liver dullness is obliterated in following conditions
Severe emphysema
Right pneumothorax
Gas under the diaphragm [perforation of a viscus)
Shrunken liver Massive hepatic necrosis in fulminant hepatocellular failure , Advanced cirrhosis of liver.
Serial measurement of liver span is done to find out shrinkage or enlargement.
Normally the aorta is not readily palpable, but with regular practice it can be felt by deep palpation a little above and to the left of the umbilicus.
Palpation of the aorta is done by means of finger tips.
Press the extended fingers of both hands held side by side deeply into the abdominal wall to make out the left wall of aorta and its pulsation.
Remove both hands repeat the manoeuvre a few centimetres to the right.
In this way the pulsation and width of aorta can be detected.
The femoral artery is felt just below the inguinal ligament at the midpoint between the anterior superior iliac spine and pubic symphysis. Place the pulps of the Right index, middle and ring fingers over this site and palpate the wall of the vessel, strength and character of pulsation. Compare pulsation with the opposite femoral pulse.
Normally gallbladder is not palpable. When it is enlarged it is felt as a firm smooth globular swelling with distinct borders just lateral to the edge of the Right rectus near the tip of the 9th costal cartilage. It moves well with respiration. Causes of palpable gallbladder Enlarged gall bladder with jaundice
Carcinoma triad
Carcinoma head of pancreas
Carcinoma Ampulla of Vater
Carcinoma bile duct
Enlarged gallbladder without jaundice
Mucocoele of gallbladder
Cystic duct obstruction by stone
Carcinoma of gallbladder- Gallbladder is felt as a stony hard, irregular swelling.
Courvoisier’s Law
In cholelithiasis, the gallbladder is thickened, contracted and not palpable due to repeated cholecystitis. Gallbladder is distended and palpable in Ca head of pancreas.
Murphy’s Sign
Ask the patient to breath deeply and palpate for gallbladder, at the height of inspiration, breath is arrested with pain in acute cholecystitis,It is called Murphy's sign.
Causes of bilateral palpable kidney:
