The liver is subject to multiple pathologies many of which produce hepatomegaly, sometimes associated with splenomegaly. A large number of organisms infect the liver sometimes with abscess formation. They include viruses (hepatitis A–G, hemorrhagic), bacteria (particularly from the gut, possible producing a portal pyemia), protozoa (amebiasis, malaria, toxoplasmosis) and worms (a large number of tropical diseases, including hydatid, fascioliasis, schistosomiasis). Schistosomiasis, like tuberculosis, syphilis and sarcoid, is also associated with granuloma formation.
The liver is a prime site for secondary malignant disease and primary tumors are found particularly in tropical areas, often associated with schistosomaisis. The liver may not be enlarged with cirrhosis (from its various causes) or metabolic disorders such as Wilson’s disease and hemochromatosis, but many of these diseases progress to liver failure and portal hypertension. Tables 7 & 8 consider causes of liver enlargement and associated jaundice. Biochemical tests are indicators of whether jaundice is due to primary hepatic disease, hemolytic disorders or posthepatic obstruction. MRI and CT provide valuable information and occasionally it may be necessary to biopsy the organ (figure 32); ensure that full information is available on clotting status, preparation includes the administration of vitamin K.
Table 7 Hepatomegaly
Table 8 Causes of jaundice
The liver move downwards on inspiration and its anterior edge becomes palpable if it extends beyond the costal margin: this occasionally occurs in the normal individual. A large liver extends down towards the right iliac fossa, and the edge is often firm and easily palpable. Use the flat of your outstretched right hand, with the thumb tucked under the palm, placed at right angles to the costal margin. Press the radial border of your index finger into the abdomen during expiration and retain in this position during inspiration, when the descending edge of an enlarged liver is felt against the index finger (figure 33a–d). Preliminary percussion will have indicated the lower edge of liver dullness. If in doubt start to palpate in the right iliac fossa and move upwards one or two fingers breadth at a time, until a liver edge is defined or the costal margin is reached.
Repeat the maneuver to the left of the midline to detect an enlarged left lobe of the liver. An alternative technique is to use the fingertips of both hands, placed alongside each other, parallel with the costal margin pressing inwards and upwards during inspiration, along the same pathway, or using the pulps of your fingers superiorly to detect the descending liver edge (figure 34a,b). It is also possible to feel a firm liver edge from above (figure 34c).
The liver edge is measured in finger or hand-breadths below the costal margin. Note also the shape, consistency, nodularity and tenderness. A soft, one-finger breadth liver edge can be normal as may be a palpable Riedel’s lobe. An enlarged left lobe may be palpable across the midline. Rectus abdominus intersections can be confused for an edge and well developed abdominal musculature can make a soft liver edge difficult to palpate.
Liver pulsation, as in tricuspid regurgitation, is best felt bimanually. Place your right hand over the right upper quadrant and your left opposite it, in the right loin (figure 35).
Cholecystitis is the commonest gall bladder disease encountered in most countries, and is often associated with gall stones. Carcinoma of the biliary tree may give rise to an enlarged gall bladder and progressive jaundice.
An enlarged gall bladder extends downwards, usually as a smooth enlargement from the liver edge in the midclavicular line. Rolling the patient to 45 degrees on the left side increases its visibility as well as facilitating palpation (figure 36a). A mucocele of the gall bladder is often palpable, but enlargement usually indicates malignant obstruction.
An enlarged gall bladder may also be palpable bimanually and may be confused with a palpable right kidney, the latter being further posterior.
Tenderness over the gall bladder is present in acute cholecystitis and, with the hand depressed over the site of the gall bladder, ask the subject to breathe in deeply (figure 36b). Tenderness, producing sudden stopping of inspiration, elicited in this fashion is called a positive Murphy’s sign.