Visible peristalsis

Fig. 6.12 Palpable abnormalities in the abdomen.

6.9 Specific signs in the ‘acute abdomen’

Sign Disease associations Examination

Murphy’s Acute cholecystitis:

Sensitivity 50–97%

Specificity 50–80%

As the patient takes a deep breath in, gently palpate in the right upper

quadrant of the abdomen; the acutely inflamed gallbladder contacts the

examining fingers, evoking pain with the arrest of inspiration

Rovsing’s Acute appendicitis:

Sensitivity 20–70%

Specificity 40–96%

Palpation in the left iliac fossa produces pain in the right iliac fossa

Iliopsoas Retroileal appendicitis, iliopsoas abscess,

perinephric abscess

Ask the patient to flex their thigh against the resistance of your hand; a painful

response indicates an inflammatory process involving the right psoas muscle

Grey Turner’s

and Cullen’s

Haemorrhagic pancreatitis, aortic rupture and

ruptured ectopic pregnancy (see Fig. 6.25)

Bleeding into the falciform ligament; bruising develops around the umbilicus

(Cullen) or in the loins (Grey Turner)

Aorta

Liver edge

Lower pole of

right kidney

Hard faeces

Rectus abdominis

and its tendinous

insertions

Normal colon Small lymph

nodes Distended

bladder

Fig. 6.13 Palpable masses that may be physiological rather than

pathological.

close to the costal margin, missing the edge of the liver or

spleen.

Hepatomegaly

Examination sequence

• Place your hand flat on the skin of the right iliac fossa.

• Point your fingers upwards and your index and middle

fingers lateral to the rectus muscle, so that your fingertips

lie parallel to the rectus sheath (Fig. 6.14). Keep your hand

stationary.

• Ask the patient to breathe in deeply through the mouth.

• Feel for the liver edge as it descends on inspiration.

• Move your hand progressively up the abdomen,

1 cm at a time, between each breath the patient

takes, until you reach the costal margin or detect the

liver edge.

The physical examination • 107

6

• the lower pole of the right kidney in the right flank

• faecal scybala (hardened masses of faeces) in the sigmoid

colon in the left iliac fossa

• a full bladder arising out of the pelvis in the suprapubic

region.

The normal liver is identified as an area of dullness to percussion

over the right anterior chest between the fifth rib and the costal

margin.

The liver may be enlarged (Fig. 6.15A) or displaced downwards

by hyperinflated lungs.

Hepatic enlargement can result from chronic parenchymal

liver disease from any cause (Box 6.10). The liver is enlarged in

early cirrhosis but often shrunken in advanced cirrhosis. Fatty

liver (hepatic steatosis) can cause marked hepatomegaly. Hepatic

enlargement due to metastatic tumour is hard and irregular. An

enlarged left lobe may be felt in the epigastrium or even the left

hypochondrium. In right heart failure the congested liver is usually

soft and tender; a pulsatile liver indicates tricuspid regurgitation.

A bruit over the liver may be heard in acute alcoholic hepatitis,

hepatocellular cancer and arteriovenous malformation. The most

• If you feel a liver edge, describe:

• size

• surface: smooth or irregular

• edge: smooth or irregular; define the medial border

• consistency: soft or hard

• tenderness

• pulsatility.

• To examine for gallbladder tenderness, ask the patient to

breathe in deeply, then gently palpate the right upper

quadrant in the mid-clavicular line.

Percussion

Examination sequence

• Ask the patient to hold their breath in full expiration.

• Percuss downwards from the right fifth intercostal space in

the mid-clavicular line, listening for dullness indicating the

upper border of the liver.

• Measure the distance in centimetres below the costal

margin in the mid-clavicular line or from the upper border

of dullness to the palpable liver edge.

In the normal abdomen, you may feel:

• the liver edge below the right costal margin

• the aorta as a pulsatile swelling above the umbilicus

Fig. 6.14 Palpation of the liver.

6.10 Causes of hepatomegaly

Chronic parenchymal liver disease

• Alcoholic liver disease

• Hepatic steatosis

• Autoimmune hepatitis

• Viral hepatitis

• Primary biliary cirrhosis

Malignancy

• Primary hepatocellular cancer • Secondary metastatic cancer

Right heart failure

Haematological disorders

• Lymphoma

• Leukaemia

• Myelofibrosis

• Polycythaemia

Rarities

• Amyloidosis

• Budd–Chiari syndrome

• Sarcoidosis

• Glycogen storage disorders

Costal margin

Liver edge Costal margin

Tip enlargement

Moderate enlargement

Marked enlargement

Mild enlargement

Moderate

enlargement

Marked

enlargement

A B

Fig. 6.15 Patterns of progressive enlargement of liver and of spleen. A Direction of enlargement of the liver. B Direction of enlargement of the

spleen. The spleen moves downwards and medially during inspiration.

108 • The gastrointestinal system

Splenomegaly

The spleen has to enlarge threefold before it becomes palpable,

so a palpable spleen always indicates splenomegaly. It enlarges

from under the left costal margin down and medially towards the

umbilicus (Fig. 6.15B). A characteristic notch may be palpable

midway along its leading edge, helping differentiate it from an

enlarged left kidney (Box 6.12).

Examination sequence

• Place your hand over the patient’s umbilicus. With your

hand stationary, ask the patient to inhale deeply through

the mouth.

• Feel for the splenic edge as it descends on inspiration.

• Move your hand diagonally upwards towards the left

hypochondrium (Fig. 6.16A), 1 cm at a time between each

breath the patient takes.

• Feel the costal margin along its length, as the position of

the spleen tip is variable.

• If you cannot feel the splenic edge, palpate with your right

hand, placing your left hand behind the patient’s left lower

common reason for an audible bruit over the liver, however, is

a transmitted heart murmur. Liver failure produces additional

symptoms of encephalopathy, which can be graded (Box 6.11).