Abdominal Palpation
July 1st, 2020
Overview
Right ventricular failure may manifest as hepatomegaly, splenomegaly and ascites; demonstrating these findings can help to clinch the clinical diagnosis. An important target for palpation in the cardiovascular examination is also the abdominal aorta, as an undiagnosed aneurysm may be fatal in the future.
Pulsatile Abdominal Mass
The presence of a pulsatile abdominal mass is suggestive of an abdominal aortic aneurysm.
How to Assess
- Place the hands on either side of the midline and identify the outermost margin of the aorta, feeling for a pulsatile mass.
Hepatomegaly
Apply gentle pressure to the right lower quadrant with the palpating hand parallel to the edge of the liver. Ask the patient to take a slow breath in to bring the liver edge toward the fingertips. Move the hand 2cm superiorly each time the patient breathes out and repeat until the lower edge of the liver is palpable.
Scratch Test for Lower Liver Edge
- Place the stethoscope over the liver just above the costal margin. Gently scratch the lower abdomen in the midclavicular line and slowly move up. Once the finger scratches over the lower liver edge the sound will be transmitted to the stethoscope.
Percussion of Upper Liver Edge
- Percuss down the midclavicular line from the level of the third rib, with the struck finger held horizontal to the ribs. Once the top edge of the liver is percussed the percussion note will become dull.
Interpretation
- Measure the liver size by estimating the location of the upper and lower liver edges. Hepatomegaly is present if the liver span is greater than 15cm.
Causes of Hepatomegaly
- Congestion - congestive cardiac failure, hepatic vein thrombosis, cirrhosis
- Hepatitis - alcoholic, fatty, viral, drug-induced
- Metabolic liver disease - amyloidosis, haemochromatosis, Wilson's disease
- Cancers - liver, stomach, pancreas, lung, colorectal, melanoma
- Infection - bacterial, viral, parasitic
- Haematological - leukaemia / Hodgkin lymphoma
Splenomegaly
How to Elicit
- Apply gentle pressure to the right lower quadrant. Ask the patient to take a deep breath in. Move the hand superiorly and medially each time the patient breathes out and repeat until the left costal margin is reached. Repeat with the patient in the right lateral decubitus position.
Splenomegaly is present if the spleen is palpable.
Causes of Splenomegaly
- Congestion - congestive cardiac failure, portal vein thrombosis, cirrhosis
- Infection - bacterial / viral / parasitic
- Inflammation - SLE, IBD, rheumatoid arthritis
- Haematological - leukaemia / lymphoma, thalassaemia, sickle cell disease
- Cancers - splenic tumours, metastases
Massive splenomegaly is uncommon and occurs in the setting of CML, myelofibrosis, certain lymphomas, malaria and leichmaniasis.
Ascites
Shifting Dullness
- Percuss the patient's abdomen from the umbilicus to the left flank, noting where the percussion note changes from resonant to dull. Ask the patient to roll over to their left side and repeat percussion. If ascites is present the area of resonance will move at least 3cm medially.
Fluid Wave
- Ask the patient or an assistant to apply pressure using the ulnar surface of their hand to the midline of the abdomen. Place the fingertips of one hand along the left flank and with the other hand firmly palpate the opposite flank. Ascites is present if a fluid wave is felt on the opposite side of the abdomen.
Causes of Ascites
- Liver cirrhosis
- Heart failure
- Constrictive pericarditis
- Peritonitis - tuberculous, neoplasmic, bacterial
- Hypoalbuminaemia - nephrotic syndrome, malnutrition
- Pancreatitis
- Cancer - liver, stomach, pancreas, adrenals, gut
- Thrombosis - portal vein, mesenteric vessels
- Ovarian disease
- Hypothyroidism
- Peritoneal dialysis
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