Palpation of

Viscera
----- liver
 palpate liver at
      To
midclavicular and
midsternal lines
Method: The right hand may be
held either parallel or
perpendicular to the long axis of
the patient. In the
midclavicular starting at the
anterior superior iliac crest,
examiner presses down firmly
and asks patient to inhale
deeply. This allows the liver to
move down to meet your
fingertips.
√ If you feel nothing, press up a
few centimeters toward the rib
cage and repeat the maneuver.
Do this continuously until you feel
the liver or reach the coastal
margin.
 √ Normally the liver is not
palpable, but sometimes the
examiner may feel the edge
of the normal liver at or
slightly below the right costal
margin.
√ When the liver is palpated,
a firm edge will strike the
fingers upon inspiration.
√ In the midsternal line, from
the level of the umbilicus, repeat
the above maneuvers to palpate
the liver.
√ Most doctors like to use
bimanual maneuvers to palpate
the liver. To do this, place the left
hand at right lower posterior chest
wall parallel to, or supporting
patient’s right 11-12th ribs or at
lower sternal area to limit the
chest respiration to make right
hand palpation more effective.
Note:
（ 1 ） When felt more than 2cm.
below the costal margin, however,
the organ should be considered
abnormally large.
 large right lobe of the liver,
which occasionally extends quite
far into the right flank.
√ Another exception is seen in
severe, chronic emphysema( 肺
气肿 ), in which the diaphragms
are depressed by the
overexpanded lung, displacing
the liver below the costal
margin.
In both instances the total mass
of the liver is within normal
limits.
（ 2 ） If you feel the liver, detect
the edge (sharp or round), tender or
not, hard or soft and repeat the
process laterally and medially to
define the contour. For masses
within the liver, describe the same
characteristics as above and listen
for a bruit over the mass.
        Size

√ Ordinarily the liver is not palpable,

or the liver can not be felt more than
2cm below the lower coastal margin,
and can not be felt more than upper
1/3 distance of the line from xiphoid
to umbilicus or more than 3cm
under the xiphoid.
√ Failure to feel the liver does not
mean that the liver is normal.
√ Measurement of the liver is done
in the midclavicular line and
midsternal line.
√ The quality of liver is classified into
three grades: softness( 质软 ),
toughness( 质韧 ), and hardness( 质
硬 ).
√ Normally the quality of liver is soft
and tender, just like the pouted( 撅嘴 )
lip.
√ In acute hepatitis or fatty liver( 脂肪
肝 ), the quality of liver is slightly tough.
In chronic hepatitis or blood stasis of
liver, liver is more tough and usually as
tough as apex nasi( 鼻尖 ).
√ In liver cirrhosis, the quality of liver is
hard. In liver carcinoma, the quality of
        Surface and edge
√ To observe whether the surface of
liver is smooth or not, whether there is
any node( 结节 ) or not, and whether
the edge is thin or thick and is regular
or irregular. The character of the
surface of the liver should be
described.
√ Sometimes large metastatic masses
may be present and palpable in the
liver.
√ In some persons with cirrhosis, the
anterior surface of the liver will have a
granular feel. This is easily felt in the
        Tenderness

Normally liver cannot be palpated as

tenderness unless the liver is
irritated by the liver chitonitis (that
is, inflammation of the diolame 包膜
of the liver) or pulled by the
enlargement of itself.
        Pulsation 搏动
√ Normally you cannot palpate any
pulsation of the liver.
√ If you palpate the pulsation of the
liver, you should pay attention to its
direction, that is, whether it is
unidirectional( 单向性 ) or expansile(
扩张性 ).
√ unidirectional pulsation is usually a
conductive one( 传导性搏动 ), caused
by the the conduction of the
pulsation of aorta abdominalis( 腹主
动脉 ).
√ If you put your hand on the sufface
of the liver, you will feel your hand is
pushed upward.
 √ expansile pulsation is the
pulsation of the liver per se and
usually found in tricuspid valve
insufficiency( 三尖瓣关闭不全 ).
 √ Because the contractive
pulsation of right ventricle
conducts to liver through right
atrium and then inferior vena
cava. If you put your hand on
the sufface of the liver, you will
have the opening-closing
sensation.
The positive Hepatojugular reflux
sign( 肝－颈静脉回流征 ): If you press
the liver, you will find the dilated
jugular vein becomes more bulged
or distended, as from the
enlargement of liver passive
congestion resulted from right
failure.
        Liver friction sensation 肝区摩擦
感
         Liver thrill 肝震颤
      To palpate spleen from
umbilicus to left costal margin
√ In examining for splenic
enlargement, the examiner
should stand at the patient’s
right side.
√ His left hand is placed over
the patient’s left
costovertebral angle,
exerting pressure to move
the spleen anteriorly. At the
same time his right hand is
worked gently under the
left anterior costal margin.
√ With the examiner’s hands
stationary in this position, the
patient is instructed to take a
deep breath.
√ If there is significant enlargement
of the spleen, it will be palpated as a
firm mass that slides out from under
the ribs, bumping against the finger
of the examiner’s right hand.
√ The spleen
normally
moves down
with
inspiration.
√ If splenic enlargement cannot
be felt by the technique just
described, the patient should
then be rolled slightly toward
the right so that the spleen may
fall anteriorly
√The examining hands are again
placed as described and the
procedure is repeated. Occasionally
a spleen that cannot be felt with the
patient in the supine position may
be palpated by this maneuver.
√ When the spleen can be felt, it
must be considered abnormal,
since the normal spleen is not
palpable.
Notes:
（ 1 ）           Starting from the
level of the umbilicus (or
below the percussed
dullness).
（ 2 ）  The maneuver is
similar to that used to
palpate the liver, but is more
subtle because the spleen is
more mobile and deeper
than the liver.
（ 3 ）   If the spleen is not
palpated, have the patient
roll on his right side and
repeat palpation.
（ 4 ） Measurement of the
spleen is the same as that of
the liver and is usually
expressed as centimeters
under the costal margin in
the midclavicular and under
the xiphoid process in the
midsternal lines.
（ 5 ）  A moderately or greatly
enlarged spleen is best described
by a drawing, especially the three
lines which are presented
schematically in the following
diagram . (NOTE: Severe
splenomegaly may cause rupture
when spleen is vigorously
palpated, so palpate gently and
carefully).
Line 1: The distance between
left costal border and the lower
edge of spleen along left
midclavicular line
Line 2: The distance between
the crossing point of left
midclavicular line and left
costal border and the
most remote point of the
spleen
Line 3: (when the spleen is
extremely large and exceeds the
anterior midline.) The distance
between the right border of the
spleen and the anterior midline.
If the spleen indeed exceeds the
anterior midline,
The mark “+” is used to indicate
“exceeding”, while “ – “ is used
to indicate “not exceeding”.
In clinical practice,
splenomegaly is classified
into three levels:
level 1 (slight enlargement 轻
度肿大 ):

During deep respiration, the

lower edge of
spleen is not more than 2cm
below the
costal border
level 2 (moderate
enlargement 中度肿大 ):

During deep respiration, the

lower edge of
spleen is more than 2cm below
the costal
border but above the umbilical
horizontal
line
level 3 (severe enlargement
高度肿大 ):

During deep respiration, the

lower edge of
Spleen is below the umbilical
horizontal
line or over anterior midline
      To palpate gall
bladder
Method: Put right hand below
the costal margin or lower
border of liver at
midclavicular line (grossly equal
to the lateral border of the right
rectus
muscles) and palpate deeply to
check for tenderness or bulging.
√ Under normal circumstances, the
gallbladder cannot be palpated.
 patient, the right upper
quadrant should always be
carefully palpated for a soft,
cystic mass, approximately 6 to
8 cm in diameter , which
appears to be attached to the
liver and moves with respiration.
This is an exceedingly valuable
sign in differentiating jaundice
caused by cancer of the head of
the pancreas or the common
bile duct from that caused by
 √ In the presence of tumor of the
common bile duct or head of the
pancreas, the wall of the gallbladder
is normal, and consequently the
organ is capable of distending to the
point that it is palpable. Such sign is
named Courvoisier sign.
√ If the obstruction is caused by
gallstones, the gallbladder wall
is inflamed, and this diseased
organ is not capable of
distention. Therefore, the
gallbladder will not become
palpable.
       To check for
Murphy’s sign..\..\教学相 关图片 \
腹部异 常体征 -Murphy氏征阳性 .rm
√ If pain is found in the gallbladder
area but gallbladder is not palpated ,
the examiner should put his left
hand on the lower lateral rib cage
with the 4 fingers stretching
superiorly and the thumb hooked
under the costal margin.
 √ Press down to the point of
gallbladder tenderness and ask
the patient to breathe deeply
and check to see whether the
patient stops breathing, changes
facial expression, or complaints
of pain.
 √ The sign indicates the
inflammation of gallbladder.
  abdominal
masses
Confused parts of body
with masses
The spine
Posterior sacral prominence
Stool
Transverse colon
Cecum
Muscle belly of rectus abdominis
 attention
A complete description of the mass
must be obtained during the
examination
Omission of any attrbute may lead to
erroneous conclusion
Mass i n a bd ome n
location
size
shape
consistency
Surface
tenderness
pulsatility
mobility
 location
Suggests the organ to be considered
For example:
mass in LUQ : spleen? Left kidney?
stomache? Colon?
 size
Pathologic process, extent and change
over time
 shape

Some organs have a characteristic

shape.
Kidney-horsebean
Spleen-fist
liver-triangle
 consistency
Carcinoma-stony hard
Lymphoma-rubbery
Abcess-soft and fluctuant
 Surface
Smooth suface—diffuse homogeneous
process
Nodular surface--metastases
 tenderness
Inflammatory process:infectious or
sterile
Distention of the capsule of viscus
ischemia
 pulsatility
Vascular: major arterial, aneurysmal
dialation of the aorta or one of its major
branches
Simulating aneurysms
Solid masses and tense cysts (transmit
normal aortic pulsations
 mobility
Suspended by long mesenteries
Movement with diaphragmatic
respiration: association with the liver or
spleen or mobile abdominal organ
 Fluid wa ve th ril l
( 液波震颤 )
With patient lying on his back, the
examiner’s left hand is placed
  against the patient’s right flank.
An assistant or the patient places
the ulnar edge of one hand lightly
against the middle of the abdomen
to prevent the transmission of any
wave through the tissues of the
abdominal wall.
The examiner’s right hand then
lightly taps the left flank of the
 Fluid wa ve th ril l

In the presence of a siguificant

amount of ascites, a wave will
be transmitted through the
fluid that will be felt against
the examiner’s left hand as a
sharp impulse. This finding is
present only when there is a
reasonably large amount of
fluid, usually 3000-4000 ml. So
the fluid wave thrill is not so
su ccussi on sp la sh 振
水音 ..\ ..\ 教学相关图片 \振水音 .rm
Succession splash is the
splash sound over the
upper abdomen.
It should be checked by
rocking the upper abdomen
to the left and right.
In normal patients this is
negative about 6-8 hours
Thanks for
Your Attention