In a jaundiced patient, spider naevi, palmar erythema and

ascites all strongly suggest chronic liver disease rather than

obstructive jaundice.

Abdominal examination

Examine the patient in good light and warm surroundings,

positioned comfortably supine with the head resting on only

one or two pillows to relax the abdominal wall muscles. Use extra

pillows to support a patient with kyphosis or breathlessness.

Inspection

Examination sequence

• Look at the teeth, tongue and buccal mucosa; check for

mouth ulcers.

• Note any smell, including alcohol, fetor hepaticus, uraemia,

melaena or ketones.

• Expose the abdomen from the xiphisternum to the

symphysis pubis, leaving the chest and legs covered.

The normal abdomen is flat or slightly scaphoid and symmetrical.

At rest, respiration is principally diaphragmatic; the abdominal wall

moves out and the liver, spleen and kidneys move downwards

during inspiration. The umbilicus is usually inverted.

Skin

In older patients, seborrhoeic warts, ranging from pink to brown

or black, and haemangiomas (Campbell de Morgan spots) are

common and normal, but note any striae, bruising or scratch

marks.

Visible veins

Abnormally prominent veins on the abdominal wall suggest portal

hypertension or vena cava obstruction. In portal hypertension,

recanalisation of the umbilical vein along the falciform ligament

produces distended veins that drain away from the umbilicus:

the ‘caput medusae’. The umbilicus may appear bluish and

distended due to an umbilical varix. In contrast, an umbilical

hernia is a distended and everted umbilicus that does not appear

vascular and may have a palpable cough impulse. Dilated tortuous

veins with blood flow superiorly are collateral veins caused by

obstruction of the inferior vena cava. Rarely, superior vena cava

obstruction gives rise to similarly distended abdominal veins, but

these all flow inferiorly.

Abdominal swelling

Diffuse abdominal swelling could be due to ascites or intestinal

obstruction. If localised, it could be caused by urinary retention,

a mass or an enlarged organ such as the liver. In obesity, the

umbilicus is usually sunken; in ascites, it is flat or, more commonly,

everted. Look tangentially across the abdomen and from the

foot of the bed for any asymmetry suggesting a localised mass.

Abdominal scars and stomas

Note any surgical scars or stomas and clarify what operations

have been undertaken (Figs 6.10 and 6.11). A small infraumbilical

incision usually indicates a previous laparoscopy. Puncture scars

from laparoscopic surgical ports may be visible. An incisional

hernia at the site of a scar is palpable as a defect in the abdominal

• Inspect the mouth, throat and tongue.

• Ask the patient to look down and retract the upper eyelid

to expose the sclera; look to see if it is yellow in natural

light (see Fig. 6.8).

• Examine the cervical, axillary and inguinal lymph

nodes (p. 33).

Striae indicate rapid weight gain, previous pregnancy or, rarely,

Cushing’s syndrome. Loose skin folds signify recent weight loss.

Stigmata of iron deficiency include angular cheilitis (painful

cracks at the corners of the mouth) and atrophic glossitis (pale,

smooth tongue). The tongue has a beefy, raw appearance in

folate and vitamin B12 deficiency. Mouth and throat aphthous

ulcers are common in coeliac and inflammatory bowel disease

(see Fig. 6.3B).

Gastric and pancreatic cancer may spread to cause enlargement

of the left supraclavicular lymph nodes (Troisier’s sign). More

widespread lymphadenopathy with hepatosplenomegaly suggests

lymphoma.

Liver disease

Do not confuse the diffuse yellow sclerae of jaundice with small,

yellowish fat pads (pingueculae) sometimes seen at the periphery

of the sclerae.

Certain signs (stigmata) suggest chronic liver disease (see

Fig. 6.9):

• Palmar erythema and spider naevi are caused by excess

oestrogen associated with reduced hepatic breakdown of

sex steroids. Spider naevi are isolated telangiectasias that

characteristically fill from a central vessel and are found in

the distribution of the superior vena cava (upper trunk,

arms and face). Women may have up to five spider naevi

in health; palmar erythema and numerous spider naevi are

normal during pregnancy. In men, these signs suggest

chronic liver disease.

• Gynaecomastia (breast enlargement in males), with loss of

body hair and testicular atrophy, may occur due to

reduced breakdown of oestrogens.

• Leuconychia, caused by hypoalbuminaemia, may also

occur in protein calorie malnutrition (kwashiorkor),

malabsorption due to protein-losing enteropathy, as in

coeliac disease, or heavy and prolonged proteinuria

(nephrotic syndrome).

• Finger clubbing is found in liver cirrhosis, inflammatory

bowel disease and malabsorption syndromes.

Other signs that may be associated with liver disease include:

• Dupuytren’s contracture of the palmar fascia (see Fig. 3.5):

linked with alcohol-related chronic liver disease

• bilateral parotid swelling due to sialoadenosis: may be a

feature of chronic alcohol abuse.

Signs that suggest liver failure include:

• asterixis, a coarse flapping tremor when the arms are

outstretched and hands dorsiflexed, which occurs with

hepatic encephalopathy

• fetor hepaticus, a distinctive ‘mousy’ odour of dimethyl

sulphide on the breath, which is evidence of portosystemic

shunting (with or without encephalopathy)

• altered mental state, varying from drowsiness with the

day/night pattern reversed, through confusion and

disorientation, to unresponsive coma

• jaundice

• ascites

The physical examination • 105

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