GI 3 - Examine the Liver

Question 1

Explains procedure to patient, positions and drapes (re-drapes as needed).

Answer 1

Explain to patient:
“Today I am going to examine your liver. This will involve me looking at and touching your tummy. If at any point you feel uncomfortable or are in pain, please let me know.”
Position: supine w/ pillow under head and arms to their side
Drape: expose between the nipple line and symphysis pubis

Question 2

Inspects for and comments on systemic manifestation of liver disease: jaundice, palmer erythema, asterixis, ascites

Answer 2

Jaundice: increased bilirubin causing yellow sclera & skin
Palmer erythema: reddening of the palms at the thenar and hypothenar
Asterixis: tremor of the hand when the wrist is extended → hepatic encephalopathy (spectrum of neuropsychiatric abnormalities due to liver failure like cirrhosis)
Ascites: fluid buildup in the peritoneum → portal HTN

Question 3

Inspects the abdomen and comments on symmetry, visible peristalsis, striae, caput medusa

Answer 3

“I’m going to begin by observing the general appearance of my patient lying quietly. (Standing on the right of the patient; you should be bending down so that you can view the abdomen tangentially) I will be inspecting the surface contours, and movements of my patient’s abdomen, looking for bulges or peristalsis.

My patient’s abdomen appears (say what you see- symmetric, flat, rounded, protuberant, or scaphoid-markedly concave or hollow). There is no visible peristalsis (normally peristalsis is visible in very thin people). Visible peristalsis could suggest intestinal obstruction. (Color) I’m noting no bruises, erythema, or jaundice. No scars are visible which could be due to any trauma or past surgeries. I’m noting no striae *(stretch marks). *

Abnormally colored striae (pink-purple) are a hallmark of Cushing syndrome. I’m also noting no signs of engorged veins (a few small veins may be visible normally). Visibly engorged veins could suggest portal hypertension from cirrhosis (caput medusa) or inferior vena cava obstruction. Also, the umbilicus doesn’t appear everted. An everted umbilicus suggests a ventral hernia. There appears to be no bulging of the flanks* (full flanks are present).* If bulging of the flanks were present this could suggest ascites.”

Question 4

Percusses lever and identifies upper and lower border. Gives liver span in cm. Comments on findings

Answer 4

“Next, I’m going to percuss the liver. Are you in any pain now? Did you empty your bladder?”
“I’m going to measure the vertical span of liver dullness by first locating the midclavicular line on the right side. I’m going to percuss from below the umbilicus in an area of tympany above towards the lower edge of the liver thill I hear dullness. Can you place your hand here?”
“I’m going to percuss the upper edge of the liver starting from the upper costal margin midclavicular line in an area of lung resonance downward till I hear dullness. Can you place your hand here?”
“Next, I’ll measure in cm the distance between your two points, which is the vertical span of liver dullness. It is 10cm which is normal.”

The normal liver spans between 4 to 8cm in midsternal line and 6-12 cm in case of right midclavicular line. If the span of liver dullness > 12, it can be d/t Hepatomegaly. If < 6cm, can be due to small liver. If displaced, however is seen in COPD patients.

Question 5

Palpates lower border – starts in RIF, asks patient to inhale deeply, and describes liver findings i.e. nodularity, tenderness, consistency

Answer 5

With your left hand on the back of the patient* (used to stabilize)* start by palpating with your right hand just below the lower border of the liver.
- You want to start really low so not to miss an enlarged liver
- Ask the patient to take a deep breath and try to feel the edge of the liver as it comes down to meet your fingers
- If you feel it, ease up a bit to allow the liver to slip under your fingers to feel the anterior boarder

Findings:
Consistency/ tenderness: Normal liver has a soft smooth surface with a sharp edge and may be tender

Question 6

Checks for a Murphy sign and comment on findings. Describe the significance of a positive sign

Answer 6

Hook your left thumb or right fingers under the costal margin and ask the patient to inhale
- Pain on inspiration = Positive sign → inflammation of the gallbladder (cholecystitis)