Abdominal examination Part 1 quiz

The liver rarely extends > 6 cm across the midline into the left upper quadrant, It has a convex upper surface and usually extends to level of 5th – 6th rib anteriorly in quiet respiration. The lower surface tends to be concave, with the gall bladder in it and descends 2-3 cm in inspiration with the anterior surface rotating slightly to the right. The Falciform ligament is a fold of peritoneum that joins the mid anterior surface of the liver to the diaphragm and anterior abdominal wall and divides the liver into right and left lobes. (Link)

The upper limit of normal in an average sized adult in the right mid clavicular line is 13 cm (Link)

Friction rubs of the liver are always abnormal, but are rare and nonspecific. They can be due to primary and metastatic malignancies (in < 10%), following liver biopsy or with infective and inflammatory conditions. (Link)

Venous hums occur in portal venous hypertension and are a low-pitched murmur with systolic and diastolic components. They arise from communication between the umbilical/paraumbilical and abdominal wall veins and have inconsistent responses to Valsalva, splenic pressure. They can be distinguished from arterial bruits as aterial bruits are rarely continuous. (Link)

A continous murmur can occur with splanchnic circulation AVM or hepatic haemangioma. Many types of liver tumours can cause bruits, however < 3% of hepatic tumours cause bruits. Only 1% of unselected general medical patients have some kind of abdominal bruit and venous hums are usually lower pitched than arterial bruits. (Link)

The measurement of liver span is more important than palpability of its lower border. There is only moderate inter observer agreement for the presence of a palpable liver edge.About 80% of people have some palpable infracostal extension of the liver so a palpable liver has < 50% chance of being enlarged.. Extension > 2 cm below the costal margin (i.e. more than just palpable) is usually due to hepatomegaly (LR+ 2.5, LR- 0.45). (Link)

Amyloidosis usually only causes mild hepatomegaly. (Link)

Sarcoidosis usually only causes mild hepatomegaly. (Link)

Jaundice is difficult to detect clinically unless bilirubin > 40 µmol/L, although it may still be visible at < 40 µmol/L if it is resolving. The sensitivity of the clinical detection of jaundice is 70% for bilirubin levels  > 50 µmol/L, 85% for > 170 µmol/L and 95% for > 250 µmol/L. (Link)

Shifting dullness to percussion is about 75% sensitive and specific for collections of > 500 mL. Bulging flanks is about 80% sensitive and 50% specific. A fluid thrill is about 60% sensitive and 90% specific for ascites. A succussion splash is a sign of gastric outlet obstruction, not of ascites. (Link)

More than 5 is considered abnormal. (Link)

Campbell de Morgan spots are also known as cherry angioma and are due to proliferation of blood vessels. They are the main differential diagnosis of spider naevi, but are are non blanching, are usually 1-2mm in diameter and rarely > 6mm diameter whereas spider naevi can be up to 1cm in diameter. They appear commonly in middle to late age on the chest and usually have no underlying cause. (Link)

Gynaecomastia is considered present if the amount of subareolar breast tissue in a male is > 2mm in diameter. (Link)

Palmar erythema is predominently on the hypothenar eminence, it blotchy (not uniform), blanches and bilateral. (Link)

Palmar erythema is a non specific finding with multiple causes.
It is most commonly idiopathic but 25% of patients with cirrhosis will have it. It occurs in 30% of pregnant women, 60% of patients with Rheumatoid arthritis and is less common in sarcoidosis, SLE, and polyarthritis. It occurs in 20% of patients with thyrotoxicosis, 5% of patients with diabetes mellitus and can be caused by polycythaemia, leukaemia, eczema, psoriasis, cerebral tumours, amiodarone, gemfibrozil, cholestyramine, topiramate and salbutamol. (Link)