How is the liver assessed in an abdominal exam?

Updated: Dec 02, 2020
  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Kurt E Roberts, MD  more...
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The span of the liver, for example, should be measured in the right midclavicular line. Presence of splenomegaly begins with gentle palpation from the umbilicus in an upward diagonal direction into the left upper quadrant. Support of the flank on the left may support and aid in projection of the spleen toward the examiners fingers. Enlarged or cystic kidneys may also be palpated with this maneuver. [1] It should be noted if the spleen, the liver, or both cross the midline.

Percussion of intercostals spaces is required to determine the cephalad border of the liver and of the spleen and thus to unequivocally establish the presence of organomegaly. Percussion is performed by tapping on the examiner’s hand with the second digit of the other hand. It may be an invaluable maneuver to determine size. The caregiver should be able to distinguish between hyperinflation of the lungs (as seen in asthma or cystic fibrosis or any obstructive pulmonary disease) from true hepatosplenomegaly. If the latter is present, the examiner should attempt to determine if the enlarged organs are firm and/or heterogeneous from an infiltrative process or have a normal consistency from congestion (see Table 2 in Preparation).

If determining the size of the liver is difficult, the scratch test may provide additional information. The diaphragm of the stethoscope is held over the liver, and the examiner listens for change in the quality of sound as the opposite hand gently scratches the abdomen moving in a semicircle around the stethoscope. [1]

Table 2. Correlation of Physical Findings With Diagnostic Possibilities (Open Table in a new window)

Physical Finding

Disease Process to Consider

Epigastric tenderness

Acid peptic disease (GER, gastritis, PUD)

Discomfort with minimal movement


Distension with fullness left lower quadrant


Diffuse tenderness with increased tympany

IBS vs small bowel obstruction

Tenderness at McBurney's point


Tenderness medial to McBurney's point

Meckels diverticulum

Increased tenderness with inspiration in RUQ (Murphy sign)

Gallbladder pathology

Pain with lifting extended right leg against resistance (Psoas sign)

Retrocecal appendicitis or other retroperitoneal irritation (abscess of Crohn disease, pancreatitis, pyelonephritis)

Bulging flanks

Ascites or obesity

Shifting dullness


Pain with deep knee squats

Retrocecal appendicitis

"Hepatosplenomegaly" with cephalad borders at lower ribs

Hyperinflation as seen in obstructive pulmonary disease

Hepatomegaly or hepatosplenomegaly with jaundice and/or caput medusae

Cirrhosis with portal hypertension

Hepatomegaly or hepatosplenomegaly without jaundice and normal consistency of enlarged organs

Congestion secondary to heart failure

Hepatomegaly or hepatosplenomegaly without jaundice and firm consistency of enlarged organs

Storage or Infiltrative disease process including leukemia and other neoplasia

Firm hepatomegaly without splenomegaly or jaundice, especially with increased blood pressure

Congenital hepatic fibrosis

Jaundice with liver tenderness, and/or enlargement


Jaundice with normal liver findings

Gilbert syndrome, hemolytic process, metabolic disease, early hepatitis

Pain relieved by sitting up

Pancreatitis, retroperitoneal pathology

Periumbilical bruising and edema (Cullen's sign)

Hemorrhagic pancreatitis

Bruising of flanks (Grey Turner sign)

Hemorrhagic pancreatic, renal hemorrhage

Isolated splenomegaly

Splenic trauma, extra-hepatic portal hypertension, splenic sequestration, hemolytic diseases, certain storage diseases

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