Resonance below the fifth intercostal space suggests

hyperinflated lungs or occasionally the interposition of the

transverse colon between the liver and the diaphragm (Chilaiditi’s

sign).

In a patient with right upper quadrant pain, test for Murphy’s

sign (see Box 6.9); a positive modestly increases the probability

of acute cholecystitis. Palpable distension of the gallbladder is

rare and has a characteristic globular shape. It results from

either obstruction of the cystic duct, as in mucocoele or

empyema of the gallbladder, or obstruction of the common

bile duct with a patent cystic duct, as in pancreatic cancer. In

a jaundiced patient a palpable gallbladder is likely to be due to

extrahepatic obstruction, such as from pancreatic cancer or,

very rarely, gallstones (Courvoisier’s sign). In gallstone disease

the gallbladder may be tender but impalpable because of fibrosis

of the gallbladder wall.

Reproduced from Conn HO, Leevy CM, Vlahcevic ZR, et al. Comparison of

lactulose and neomycin in the treatment of chronic portal-systemic

encephalopathy. A double blind controlled trial. Gastroenterology 1977;

72(4):573, with permission from Elsevier Inc.

6.11 Grading of hepatic encephalopathy (West Haven)

Stage State of consciousness

0 No change in personality or behaviour

No asterixis (flapping tremor)

1 Impaired concentration and attention span

Sleep disturbance, slurred speech

Euphoria or depression

Asterixis present

2 Lethargy, drowsiness, apathy or aggression

Disorientation, inappropriate behaviour, slurred speech

3 Confusion and disorientation, bizarre behaviour

Drowsiness or stupor

Asterixis usually absent

4 Comatose with no response to voice commands

Minimal or absent response to painful stimuli

6.12 Differentiating a palpable spleen from the left kidney

Distinguishing feature Spleen Kidney

Mass is smooth and

regular in shape

More likely Polycystic kidneys

are bilateral irregular

masses

Mass descends in

inspiration

Yes, travels

superficially

and diagonally

Yes, moves deeply

and vertically

Ability to feel deep to

the mass

Yes No

Palpable notch on the

medial surface

Yes No

Bilateral masses

palpable

No Sometimes, e.g.

polycystic kidneys

Percussion resonant

over the mass

No Sometimes

Mass extends beyond

the midline

Sometimes No (except with

horseshoe kidney)

Fig. 6.16 Palpation of the spleen. A Initial palpation for the splenic edge moving diagonally from the umbilicus to the left hypochondrium. B If the

spleen is impalpable by the method shown in A, use your left hand to pull the ribcage forward and elevate the spleen, making it more likely to be palpable

by your right hand.

The physical examination • 109

6

• Keep your finger on the site of dullness in the flank and

ask the patient to turn on to their opposite side.

• Pause for 10 seconds to allow any ascites to gravitate,

then percuss again. If the area of dullness is now

resonant, shifting dullness is present, indicating ascites.

Fluid thrill

• If the abdomen is tensely distended and you are uncertain

whether ascites is present, feel for a fluid thrill.

• Place the palm of your left hand flat against the left side of

the patient’s abdomen and flick a finger of your right hand

against the right side of the abdomen.

• If you feel a ripple against your left hand, ask an assistant

or the patient to place the edge of their hand on the

midline of the abdomen (Fig. 6.18). This prevents

transmission of the impulse via the skin rather than

through the ascites. If you still feel a ripple against your left

hand, a fluid thrill is present (detected only in gross

ascites).

Causes of ascites are shown in Box 6.14.

Auscultation

Examination sequence

• With the patient supine, place your stethoscope diaphragm

to the right of the umbilicus and do not move it.

• Listen for up to 2 minutes before concluding that bowel

sounds are absent.

• Listen above the umbilicus over the aorta for arterial bruits.

6.13 Causes of splenomegaly

Haematological disorders

• Lymphoma and lymphatic

leukaemias

• Myeloproliferative diseases,

polycythaemia rubra vera and

myelofibrosis

• Haemolytic anaemia,

congenital spherocytosis

Portal hypertension

Infections

• Glandular fever

• Malaria, kala-azar

(leishmaniasis)

• Bacterial endocarditis

• Brucellosis, tuberculosis,

salmonellosis

Rheumatological conditions

• Rheumatoid arthritis (Felty’s

syndrome)

• Systemic lupus erythematosus

Rarities

• Sarcoidosis

• Amyloidosis

• Glycogen storage disorders

ribs and pulling the ribcage forward (Fig. 6.16B), or ask

the patient to roll towards you and on to their right side

and repeat the above.