Introduction (Use the acronym WIPER to prepare for the examination)
- W - Wash your hands
- I - Introduce yourself and confirm patient details
- P - Permission - gain consent to proceed with the examination, including explaining relevant details
- E - Expose the patient appropriately, gather Equipment
- R - Position the patient lying back at 45 degrees comfortably
- Inspection
- Jaundiced
- Weight loss and cachexia
- Liver flap/asterixis
- Spider naevi
- Large waves in JVP - Tricuspid regurgitation
- Hands
- Finger clubbing: Cirrhosis, IBD
- Dupuytren's contracture, Palmar erythema - Liver disease
- Leuconychia "white nails" seen with a low albumin
- Palmar erythema in chronic liver disease
- Asterixis - Flapping tremor seen with hepatic encephalopathy
- Palpation of liver
- Start in right lower quadrant with the edge of the left hand parallel to a liver edge.
- Ask the patient to breathe deeply and see if you can feel live edge descending.
- If not repeat 3 cm higher and ask patient to take a deep breath
- Try to feel liver edge under the tips of your fingers
- If palpated determine
- Is it hard or craggy or soft and smooth
- Count finger breaths below ribs
- Auscultation
- Listen for a bruit may suggest a hepatoma - Cruveilhier-Baumgarten bruit
Interpretation
- Hard irregular and non-tender - cancer
- Smooth firm non-tender - cirrhosis or lymphoma
- Smooth tender enlarged - CCF, Alcohol, hepatitis
- Pulsatile - Tricuspid regurgitation
- Hepatomegaly: Some causes - Metastases, Cirrhosis, CCF, Lymphoma