Gastro Exam

Palpation of the Spleen



  • Splenomegaly is present if the spleen is palpable. This may be a sign of portal hypertension due to liver, vascular or pulmonary disease; splenomegaly also occurs with certain infections and haematologic malignancies.
    • 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.
    • Causes of Splenomegaly

    • Congestion - congestive cardiac failure, portal vein thrombosis, cirrhosis
    • Infection - bacterial, viral, parasitic
    • Inflammation - SLE, IBD, rheumatoid arthritis
    • Haematological - leukaemia / lymphoma, thalassaemia
    • Cancers - splenic tumours, metastases
  • Massive splenomegaly is uncommon and occurs in the setting of CML, myelofibrosis, certain lymphomas, malaria and leichmaniasis.
Want more info like this?
  • Your electronic clinical medicine handbook
  • Guides to help pass your exams
  • Tools every medical student needs
  • Quick diagrams to have the answers, fast
  • Quizzes to test your knowledge


 Adams PC, Barton JC. Haemochromatosis. The Lancet. 2007;370:1855-1860. Ahmed R, McNamara S, Gandevia S, Halmagyi GM. Paradoxical abdominal wall movement in bilateral diaphragmatic paralysis. Practical neurology. 2012;12:184. Allen K. Hereditary Haemochromatosis: Diagnosis and Management. Australian Family Physician. 2010;39:938-941. Al?Himdani S, Ud?Din S, Gilmore S, Bayat A. Striae distensae: a comprehensive review and evidence?based evaluation of prophylaxis and treatment. British Journal of Dermatology. 2014;170:527-547. Appasani S, Kochhar S, Nagi B, Gupta V, Kochhar R. Benign gastric outlet obstruction--spectrum and management. Tropical gastroenterology : official journal of the Digestive Diseases Foundation. 2011;32:259. Baid H. A critical review of auscultating bowel sounds. British Journal of Nursing. 2009 Oct; 18(18): 1125-1129. Beech N, Goh R, Lynham A. Management of dental infections by medical practitioners. Australian Family Physician. 2014;43:289-291. Belabbes S, Lamsiah T, Zainoun B, Choho A, Drissi M. Trichobezoar: Unusual cause of epigastric mass. Indian Journal of Gastroenterology. 2015;34:277-278. Besur SV, Tadakamalla A, Talluri SK. Pyoderma gangrenosum. QJM : monthly journal of the Association of Physicians. 2012;105:1219-1220.
Blaker P, Wilkinson M. Chronic constipation: diagnosis and current treatment options. Prescriber. 2010;21:30-45.
 Brown RB. Benign prostatomegaly, carcinoma and prostatitis. Australian family physician. 1986;15:1551, 1553. Bull-Henry K, Al-Kawas FH. Evaluation of occult gastrointestinal bleeding. American family physician. 2013;87:430. Byrd JA, Bruce AJ, Rogers 3, Roy S. Glossitis and other tongue disorders. Dermatologic clinics. 2003;21:123. Callewaert B, Malfait F, Loeys B, De Paepe A. Ehlers-Danlos syndromes and Marfan syndrome. Best Practice & Research Clinical Rheumatology. 2008;22:165-189. Carlson HE. Approach to the patient with gynecomastia. The Journal of clinical endocrinology and metabolism. 2011;96:15-21. Castell DO, Frank BB. Abdominal examination: role of percussion and auscultation. Postgrad Med. 1977 Dec; 62(6): 131-4. Chakma SM, Singh RL, Parmekar MV, et al. Spectrum of perforation peritonitis. Journal of clinical and diagnostic research : JCDR. 2013;7:2518.
Chicken W, Davidson T. Gynaecomastia: assessment and management. Trends in Urology & Men's Health. 2013;4:17-20.
 Clinical anatomy and the physical examination Part I: Thorax, abdomen, perineum, and pelvis. Clinical anatomy 2001; 14 (5): 332.
Darby I. Drugs and gingival bleeding. Australian Prescriber. 2006;29:154.
 Davey WW. Rovsing's Sign. The British Medical Journal. 1956;2:28-30.
David M, Pelberg J, Kuntz C. Grey Turner's sign. QJM : monthly journal of the Association of Physicians. 2013;2012;106:481.
Detry O, De Roover A. Spider Angiomas. The New England Journal of Medicine. 2009;360:280-280.
 Devani A, Barankin B. Dermacase. Angular cheilitis. Canadian family physician Médecin de famille canadien. 2007;53:1011, 1022. Douglass AB, Douglass JM. Common dental emergencies. American family physician. 2003;67:511. Eipper DF, Gifford RW, Stewart BH, Alfidi RJ, McCormack LJ, Vidt DG. Abdominal bruits in renovascular hypertension. The American Journal of Cardiology. 1976;37:48-52. Erickson K, Donovan TE, Swift EJ. Dental Erosion. Journal of Esthetic and Restorative Dentistry. 2013;25:212-212. Fargo MV, Latimer KM. Evaluation and management of common anorectal conditions. American family physician. 2012;85:624. Franckowiak JJ, Jackman RJ. The etiology of pilonidal sinus. Diseases of the colon and rectum. 1962;5:28-36. Franklin GA, Richardson JD, Brown AL, et al. Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries. The American surgeon. 2007;73:611. Gendreau L, Loewy ZG. Epidemiology and Etiology of Denture Stomatitis. Journal of Prosthodontics. 2011;20:251-260. Ghasemi A, Gorouhi F, Rashighi?Firoozabadi M, Jafarian S, Firooz A. Striae gravidarum: associated factors. Journal of the European Academy of Dermatology and Venereology. 2007;21:743-746. Ghosn SH, Kibbi A. Cutaneous manifestations of liver diseases. Clinics in Dermatology. 2008;26:274-282.
Gilliland PF, Deller JJ, Hall R. A Bruit Due to Renal-Artery Stenosis: Value of Auscultation in the Diagnosis of Renal Hypertension. The New England Journal of Medicine. 1961;264:659-660.
 Glancy DG. Intestinal obstruction. Surgery (Oxford). 2014;32:204-211. Grover CA, Sternbach G. Charles McBurney: McBurney's point. The Journal of emergency medicine. 2012;42:578. Gupta K, Dhawan A, Abel C, Talley N, Attia J. A Re-evaluation of the scratch test for locating the liver edge. BMC Gastroenterology. 2013; 13: 35. Gupta SK, Gupta R, Singh G, Gupta S. Perforation Peritonitis:A Two Year Experience. JK Science. 2010;12:141-144. Gupta T, Kansal NK. Medical image. A benign glossal lesion. The New Zealand Medical Journal (Online). 2014;127. Haresaku S, Hanioka T, Tsutsui A, Watanabe T. Association of lip pigmentation with smoking and gingival melanin pigmentation. Oral Diseases. Harris S. Cullen's sign revisited. Am J Med. 2008;121:682-683. Hazin R, Tarek I. Abu-Rajab Tamimi, Abuzetun JY, Zein NN. Recognizing and treating cutaneous signs of liver disease. Cleveland Clinic Journal of Medicine. 2009;76:599-606. Hibberts F, Bushell C. Physical assessment in gastroenterology: abdominal examination. Gastrointestinal Nursing. 2007 Sep; 5(7): 24-30. Hol L, van Leerdam ME, van Ballegooijen M, et al. Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy. Gut. 2010;59:62. Huang BL, Chandra S, Shih DQ. Skin manifestations of inflammatory bowel disease. Frontiers in physiology. 2012;3:13. Jaka H, Mchembe MD, Rambau PF, Chalya PL. Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases. BMC surgery. 2013;13:41-41. Jones JT. Pigmentation of lips and buccal mucosa associated with intestinal polyposis. South African medical journal. 1953;27:930. Kamath N, Bhatia S, Singh H, Shetty A, Shetty S. Hereditary hemorrhagic telangiectasia. North American journal of medical sciences. 2015;7:125-128. Kawar N, Gajendrareddy PK, Hart TC, Nouneh R, Maniar N, Alrayyes S. Periodontal Disease for the Primary Care Physician. Disease-a-Month. 2011;57:174-183. Korber A, Dissemond J. Black Hairy Tongue. The New England Journal of Medicine. 2006;354:67-67. Kuehn HG, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and anal findings. International journal of medical sciences. 2009;6:77-84. Kundu N, Abouhassan W, Ibikunle C. Perianal mass. Eplasty. 2011;11:ic7. Laugier P, Hunziker N, Olmos L. Essential melanic pigmentation of the mouth and the lips. Annales de dermatologie et de vénéréologie. 1977;104:181. Lenane P, Powell F. Oral pigmentation. Journal of the European Academy of Dermatology and Venereology. 2000;14:448-465. Lourenco SV, Silva MAM, Nico MMS. An ulcer on the lip. Clinical & Experimental Dermatology. 2005;30:199-200. Lund JN, Scholefield JH. Internal sphincter spasm in anal fissure. The British journal of surgery. 1997;84:1723-1724. Magalhães AC, Wiegand A, Young A, Schlueter N. Dental erosion. International journal of dentistry. 2012;2012:356021. Mandel L. Salivary Gland Disorders. Dental Clinics of North America. 2011;55:121-140. Mantas AM, Wells J, Trotter J. Kayser-Fleischer rings of acute Wilson's disease. Proceedings (Baylor University. Medical Center). 2013;26:166-167. Masferrer E, Jucgla A. Geographic Tongue. New England Journal of Medicine. 2009;361:e44. Masha L, Bernard S. Grey Turner's sign suggesting retroperitoneal haemorrhage. Lancet (London, England). 2014;383:1920. McGirt LY, Martins CR. Dermatologic Diagnoses in the Perianal Area. Clinics in Colon and Rectal Surgery. 2004;17:241-245. Mowat C, Stanley AJ. Review article: spontaneous bacterial peritonitis--diagnosis, treatment and prevention. Alimentary pharmacology & therapeutics. 2001;15:1851.
Musana K, Yale SH. John Benjamin Murphy (1857 - 1916). Clinical medicine & research. 2005;3:110-112.
 Musana KA, Yale SH. Murphy's Sign. Clin Med Res. 2005 Aug; 3(3): 132.
Mushtaq F, Tudor G, El-Hadi S. Rectal bleeding in children – causes and investigations. Paediatrics and Child Health. 2014;24:491-500.
 Narula HS, Carlson HE. Gynaecomastia--pathophysiology, diagnosis and treatment. Nature reviews. Endocrinology. 2014;10:684-698. Nautiyal A. Liver palms (palmar erythema). Am J Med. 2010;123:596-597. Nguyen DH, Martin JT. Common dental infections in the primary care setting. American Family Physician. 2008;77:797.
Niederau C, Lange S, Frühauf M, Thiel A. Cutaneous signs of liver disease: value for prognosis of severe fibrosis and cirrhosis. Zeitschrift für Gastroenterologie. 2006;43:P220.
 Niewoehner CB, Schorer AE. Gynaecomastia and Breast Cancer in Men. BMJ: British Medical Journal. 2008;336:709-713. Parikh K, Ali MA, Wong RCK. Unusual Causes of Upper Gastrointestinal Bleeding. Gastrointestinal endoscopy clinics of North America. 2015;25:583-605. Parikh RP, Upadhyay KJ. Cullen's sign for acute haemorrhagic pancreatitis. The Indian journal of medical research. 2013;137:1210-1210. Perera GA. A Note on Palmar Erythema (So-Called Liver Palms). JAMA. 1942; 119: 1417-1418. Perlman SL, Boder Deceased E, Sedgewick RP, Gatti RA. Ataxia-telangiectasia. Handbook of clinical neurology. 2012;103:307. Pfenninger JL, Zainea GG. Common anorectal conditions: Part I. Symptoms and complaints. American family physician. 2001;63:2391. Pines J, Uscher Pines L, Hall A, Hunter J, Srinivasan R, Ghaemmaghami C. The interrater variation of ED abdominal examination findings in patients with acute abdominal pain. Am J Emerg Med. 2005 Jul; 23(4): 483-7. Potter MA, Bartolo DCC. Proctalgia fugax. European Journal of Gastroenterology & Hepatology. 2001;13:1289-1290. Prosenz J, Hirtler L. Rovsing sign revisited-effects of an erroneous translation on medical teaching and research. Journal of surgical education. 2014;71:738. Rahbour G, Ullah MR, Yassin N, Thomas GP. Cullen's sign - Case report with a review of the literature. International Journal of Surgery Case Reports. 2012;3:143-146. Raina S, Jaryal A. Dupuytren's contracture. The Indian journal of medical research. 2012;136:502. Reamy B. Common tongue conditions in primary care. Am Fam Physician. 2010;81:627. Reese GE, von Roon AC, Tekkis PP. Haemorrhoids. BMJ clinical evidence. 2009;2009. Reunala T. Dermatitis herpetiformis: Coeliac disease of the skin. Annals of Medicine. 1998;30:416-418. Schrag A, Schott JM. Kayser-Fleischer Rings in Wilson's Disease. The New England Journal of Medicine. 2012;366. Schumaker HB. The Diagnosis of Coarctation of the Aorta with Particular Reference to the Importance of Absent or Diminished Abdominal Aortic Pulsation. Annals of Surgery. 1952 Jan; 135(1): 111-113. Scully C, Shotts R. ABC Of Oral Health: Mouth Ulcers And Other Causes Of Orofacial Soreness And Pain. BMJ: British Medical Journal. 2000;321:162-165. Seo AY, Kim N, Oh DH. Abdominal Bloating: Pathophysiology and Treatment. J Neurogastroenterol Motil. 2013 Oct; 19(4): 433-453, Seupaul RA, Collins R. Physical Examination of the Liver. Annals of Emergency Medicine. 2001; 45(5): 553-555. Shafer N. A new method of abdominal examination: preliminary report. Curr Ther Res Clin Exp. 1967 Feb; 9(2): 82-4. Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatologic therapy. 2010;23:230-242. Shenenberger D, Barlow T. Photo quiz. Ulcer on lower lip of deployed serviceman. Ecthyma. American family physician. 2011;83:601.
Sherlock KE, Turner W, Elsayed S, et al. The Evaluation of Digital Rectal Examination for Assessment of Anal Tone. Global Spine Journal. 2012;2:P104.
 Sheth TN, Choudry NK, Bowes M, Detsky AS. The Relation of Conjunctival Pallor to the Presence of Anaemia. J Gen Intern Med. Feb 1997; 12(2): 102-106. Shimazaki Y, Soh I, Saito T, et al. Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. Journal of dental research. 2001;80:340-345. Shimizu T, Tokuda Y. Visible intestinal peristalsis. BMJ case reports. 2013;2013:bcr2013201748-bcr2013201748. Shovlin CL. Hereditary haemorrhagic telangiectasia: Pathophysiology, diagnosis and treatment. Blood Reviews. 2010;24:203-219. Singh A, Verma R, Murari A, Agrawal A. Oral candidiasis: An overview. Journal of Oral and Maxillofacial Pathology. 2014;18:81-85. Singh G. Nails in systemic disease. Indian journal of dermatology, venereology and leprology. 2011;77:646-651.
Skinner N, Junker JA, Flake D. What is angular cheilitis and how is it treated?. Journal of Family Practice. 2005;54:470.
 Sood A, Paik A, Lee E. Dupuytren's Contracture. Eplasty. 2013;13:ic1. Sugerman DT. Anal Fissure. JAMA. 2014;311:1171-1171. Sundriyal D, Kumar N, Dubey SK, Walia M. Virchow's node. Case Reports. 2013 Sep 12;2013:bcr2013200749. Tack J, Müller?Lissner S, Stanghellini V, et al. Diagnosis and treatment of chronic constipation – a European perspective. Neurogastroenterology & Motility. 2011;23:697-710. Tingle LE, Molina D, Calvert CW. Acute pericarditis. Am Fam Physician. 2007 Nov 15;76(10):1509-14. toopler ET, Kuperstein AS. Glossitis secondary to vitamin B12 deficiency anemia. Canadian Medical Association journal. 2013;185:E582-E582. Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytren's Contracture Unfolded. BMJ: British Medical Journal. 2006;332:397-400. Tripathi RC, Sidrys LA. 'Conjunctival Icterus,' Not 'Scleral Icterus'. JAMA. 1979;242:2558-2558. Van Meegdenburg MM, Heineman E, Broens PMA. Pudendal Neuropathy Alone Results in Urge Incontinence Rather Than in Complete Fecal Incontinence. Diseases of the Colon & Rectum. 2015;58:1186-1193.
Vedamurthy M, Vedamurthy A. Spider nevi: A presenting feature of chronic liver disease. Indian Journal of Dermatology, Venereology and Leprology. 2008;74:397-398.
 Vine L, McCracken G, Needs S, Ryley N, George K. PTU-117 Cutaneous Stigmata Of Chronic Liver Disease; What Do They Mean? Gut. 2014;63 Suppl 1:A90-A90.
Waintraub D, Felig DM. An unusual cause of a rectal mass: a malpositioned pessary. The American journal of gastroenterology. 2015;110:1140.
 Walshe JM. The Kayser-Fleischer ring. British journal of hospital medicine (London, England : 2005). 2014;75:C38.
Wolff HH. Familial Intestinal Polyposis with pigmentation of lips, oral mucosa, face and digits. The Lancet. 1952;259:446-448.
 Yasui H. Rovsing's Sign. The British Medical Journal. 1958;1:1163-1163. Zoli V, Silvani S, Vincenzi C, Tosti A. Allergic Contact Cheilitis. Contact Dermatitis. 2006;54:296-297.