Abdominal Percussion and Liver Enlargement

nishes a more amphoric percussion sound than the stomach. When, however, they are filled with fluid or solid accumulations, the situation of these accumulations can be marked out on the surface by the dullness on percussion. The peculiar feeling of such enlargements will generally enable you to decide as to their true character; they feel like no other tumors. On being examined through the abdominal walls, they are felt to be hard and resistant; but if one finger be pressed steadily upon them for one or two minutes, they -will at last indent like a hard snowball; and as there is not the slightest elasticity about them, the indentation remains after tlie pressure is removed (Simpson). As these accumulations most frequently collect in the descending colon, the percussion sound over this portion is usually less resonant than over the ascending or transverse colon. According to Dr. Bennet, in a practical point of view it is often useful to determine whether a purgative by the mouth or an enema is likely to open the bowels most rapidly. If there is dullness in the left iliac fossa in the track of the descending colon, that portion of the intestine must be full of feces, and an enema is indicated. If, on the other hand, the sound in the left iliac fossa is tympanitic, and in the right dull, an enema is of little service, as it will not extend to the cecum, and purgatives by the mouth are indicated. Sometimes the whole colon, or the transverse portion, or, what is more common, the sigmoid flexure of the large intestine, becomes distended with fecal accumulations, giving rise to circumscribed abdominal enlargement and to flatness on percussion over that portion of the abdomen which corresponds to the situation of the intestines. Care must be taken not to confound this condition with an enlarged liver, spleen, tumors, etc.<Callout type="important" title="Important">Always ensure you correctly identify the source of any abdominal enlargement before treating.</Callout> The percussion sound over the small intestines, unless they are distended with gas, is higher pitched and less amphoric than that of the surrounding large intestines. There are no physical signs to indicate the abnormal changes which occur in this position of the alimentary canal, except an increase in the tympanitic resonance which exists when they are distended with gas.<Callout type="risk" title="Risk">Misdiagnosis can lead to improper treatment and worsening of symptoms.</Callout> Liver. Our diagnosis in any case of hepatic disease rests mainly on the size, form, and position of the liver as determined by percussion and palpation. The first step, then, in studying the physical signs indicative of disease of this organ, is to become familiar with its normal boundaries.<Callout type="tip" title="Tip">Remember that the right lobe of the liver occupies the right hypochondrium, lying completely in the hollow formed by the diaphragm.</Callout> The upper boundary of the organ is determined by percussing with moderate force from the right nipple downwards until the flatness of the percussion sound indicates that a solid organ has been reached; draw a line at this point. Then percuss downwards from the axilla, and from a point a little to the right of the median line in front, in the same manner, until the same change occurs in the percussion sound; a line drawn through the points which mark the change in the percussion sound along these lines determines the upper boundary of the lines; and it will be found generally to correspond to the base of the ensiform cartilage on the median line in front to the fifth intercostal space on the line of the right nipple, to the seventh rib in the axillary region, and to the ninth rib in the dorsal region. The lower boundary of the organ is determined by percussing downwards from the line of flatness already determined, and noting the points where the tympanitic sounds of the stomach and large intestine occur, which will generally be found to correspond anteriorly with the free border of the ribs, and to a point three inches below the ensiform cartilage on the median line; laterally, in the axillary region to the tenth intercostal space, and posteriorly, in the dorsal region to the twelfth rib. The flatness of the left lobe usually reaches two inches to the left of the median line.<Callout type="gear" title="Gear">A stethoscope is essential for accurate percussion.</Callout> The smooth edge of the lower margin of the liver in health, especially in thin subjects, can be distinctly felt behind the free border of the ribs. The healthy liver in its normal position evidently influences very little the percussion sound over the soft half of the abdomen, which, as has already been stated, when the organs there situated are normal and empty, yields tympanitic resonance from immediately below the margin of the ribs to the pubes; if, therefore, the percussion sound is dull, and the dullness is uninterrupted to the margin of the ribs on the right side, we have good reason for believing that the liver is the organ diseased.<Callout type="warning" title="Warning">Failure to recognize a liver issue can delay treatment and worsen patient condition.</Callout> The normal boundaries of the liver already defined may be greatly altered without any abnormal change occurring in the organ itself. These normal changes, unless remembered, may lead to errors in diagnosis. Thus, congenital malformations, may give rise to an increase in the area of hepatic dulness. An accurate history of the patient, however, will keep us from error in such cases.<Callout type="beginner" title="Beginner">In children, the liver is proportionally larger than in adults.</Callout> The practice of tight lacing may cause displacement and malformation of the liver, and thus give rise to apparent hepatic enlargement; the marks which this practice leaves on the chest-walls will be sufficient to attract our attention, and so prevent mistake.<Callout type="risk" title="Risk">Tight lacing can lead to misdiagnosis if not recognized.</Callout> Diseases of the thoracic organs and abnormal conditions of the other abdominal viscera sometimes cause displacement of the liver, simulating very closely hepatic enlargement; these we will consider under the head of differential diagnosis of diseases of the liver.<Callout type="tip" title="Tip">Always consider differential diagnoses when suspecting liver issues.</Callout> Variations in the Size of the Liver in Hepatic Diseases. Variations in the size of the liver occur in almost every disease to which it is subject. It is increased in size, in fatty liver, in waxy liver, in hydatid tumor, in abscess of liver, in congestion, in acute hepatitis, in obstruction of the bile ducts, and in cancer. It is diminished in size in cirrhosis and in acute atrophy.<Callout type="important" title="Important">Remember that different diseases cause varying degrees of liver enlargement.</Callout> Enlargements of the liver were divided by Dr. Bright into smooth and irregular. Dr. Murcherson has divided them into painless and painful enlargements. Both of these divisions, it seems to me, have their objections; and in giving the physical signs of the various diseases accompanied by enlargement of the organ, it is hardly practicable to adopt either of them exclusively.<Callout type="risk" title="Risk">Misclassification can lead to improper treatment.</Callout> Fatty Liver. — In fatty degeneration of the liver the organ is uniformly enlarged; there are no circumscribed bulgings; its normal shape is unaltered; there is no expansion of the lower ribs; it never gives rise to ascites, and it is not attended by any visible enlargement of the superficial veins.<Callout type="tip" title="Tip">Fatty liver can be detected by a soft, cushion-like enlargement below the margin of the ribs.</Callout> On palpation below the margin of the ribs on the right side, and in the epigastrium, a soft cushion-like enlargement is readily detected, extending not unfrequently as low as the umbilicus; its outer surface is smooth, and its lower margin is rounded, and not well defined; it is never tender on pressure. On percussion there is flatness over the surface of the abdomen corresponding to the enlargement.<Callout type="important" title="Important">Flatness on percussion indicates fatty liver.</Callout> Waxy Liver. — In waxy or amyloid degeneration, the organ undergoes greater enlargement than in fatty degeneration; it often becomes so large as to fill the whole abdominal cavity; its growth is slow, usually extending over a period of two or three years.<Callout type="warning" title="Warning">Waxy liver can be mistaken for other conditions due to its gradual and uniform enlargement.</Callout> The enlargement is uniform, and the area of hepatic dulness is consequently increased on percussion in every direction, — more, however, in front than behind. There is often on inspection a visible tumor below the margin of the ribs, but there is no bulging of the ribs themselves.<Callout type="important" title="Important">Waxy liver can be identified by its smooth surface and well-defined lower margin.</Callout> On palpation, that portion of the organ below the ribs is dense, firm, and resistant; the outer surface is smooth; the lower margin is sharp and well defined. Pain and tenderness are rarely present, so that the portion of the organ below the ribs, as in fatty degeneration, can be manipulated without giving the patient any inconvenience.<Callout type="risk" title="Risk">Failure to recognize waxy liver can lead to improper treatment.</Callout> When excessive, it is almost always accompanied by ascites. Hydatid Tumors of the Liver. — Hydatid cysts, when small or deep-seated, cannot be detected by physical examination; but when large or superficially seated hydatid cysts are recognized by abnormal increase in the area of hepatic dulness, — the outline of the dulness being irregular, — and by the globular form of the enlargement on the surface of the organ. Sometimes these cysts are so large as to cause the organ to fill a large portion of the abdominal cavity and encroach on the right pleural cavity; the natural form of the organ is greatly altered, the enlargements taking place more in one direction than in another.<Callout type="important" title="Important">Hydatid cysts can be identified by their irregular outline and globular shape.</Callout> Sometimes percussion over a large hydatid cyst will give rise to a characteristic vibration known as hydatid frumentus; this vibration is produced by the impulse of the smaller cysts that are contained in a large one. A hydatid liver encroaching on the thoracic cavity gives rise to flatness on percussion, and absence of respiratory sound from the base of the chest upwards as far as the tumor extends, the upper boundary of the flatness being arched.<Callout type="warning" title="Warning">Hydatid cysts can cause respiratory issues if not recognized.</Callout> It is distinguished from pleuritic effusion in that a change in the position of the body does not change the line of percussion dullness. On palpation, sometimes the enlarged portion below the ribs has an elastic or even fluctuating feel, and if a large cyst be near the surface it may give rise to a sense of fluctuation; the surface over these enlargements is smooth, the organ is not tender on pressure, and its growth is slow.<Callout type="important" title="Important">Hydatid cysts can sometimes have an elastic or fluctuating feel.</Callout> Abscess of the Liver. — When hepatic abscesses exist, from whatever cause, it depends entirely upon their situation whether an external tumor is produced or not; if the abscess occupies the posterior portion of the right lobe, the liver is pushed down so that its margin is perceptible below the free border of the ribs, and the flatness on the right side, posteriorly, extends higher than natural.<Callout type="warning" title="Warning">Abscesses can cause respiratory issues if they encroach on the thoracic cavity.</Callout> When an abscess is superficial, and is pointing externally, a distinct tumor is felt below the ribs; and there is always more or less bulging of the ribs if the right lobe is affected. The situation of the tumor varies according as the right or left lobe is affected; a tumor arising from such a cause is easily traced as connected with the liver, of which it evidently forms a part, the flatness on percussion being continuous.<Callout type="important" title="Important">Abscesses can be identified by their distinct tumors and bulging ribs.</Callout> Sometimes the organ is enormously enlarged, its free border extending below the umbilicus, the surface of the enlargement being smooth, and usually tender on pressure. The sensation to the examiner on making light pressure will be soft and fluctuating, or that of elastic tenseness.<Callout type="risk" title="Risk">Failure to recognize abscesses can lead to improper treatment.</Callout> In some rare instances, abscesses produce an uneven or lobulated condition of the surface; under such circumstances it may be mistaken for cancer, unless the rational symptoms and history of the case be included in the elements of diagnosis. The enlargement goes on rapidly.<Callout type="important" title="Important">Abscesses can cause a lobulated liver surface.</Callout> With a correct history of the case, the diagnosis is easily made. Congestion of the Liver. — The most simple form of hepatic enlargement is that which results from congestion. When the liver is thus loaded with blood, a slight fulness is perceptible on the right side.<Callout type="warning" title="Warning">Congestion can be mistaken for other conditions due to its subtle symptoms.</Callout> On palpation, the space immediately below the ribs is occupied by a smooth, hard, resisting enlargement corresponding to the natural shape of the liver, which is not usually tender on pressure. There is no well-defined tumor.<Callout type="important" title="Important">Congestion can be identified by its smooth and hard enlargement.</Callout> On percussion a flat sound is elicited, an inch or two below the margin of the ribs, on the right side. Obstruction of the Bile Ducts. — An enlargement of the liver similar to the one just noticed occurs, when from any cause there is obstruction in the biliary ducts, and an accumulation of bile takes place in the liver.<Callout type="important" title="Important">Bile duct obstruction can be identified by a general liver enlargement.</Callout> Sometimes when this occurs, in addition to the general enlargement detected by the slight uniform increase in the normal area of hepatic dulness, a globular projection is detected at a point corresponding to the transverse fissure of the liver, with the elastic feel of deep-seated fluid; this tumor is the distended gall bladder.<Callout type="warning" title="Warning">Bile duct obstruction can be mistaken for other conditions due to its subtle symptoms.</Callout> Acute Hepatitis. — The physical signs of acute hepatitis do not differ materially from those of simple congestion, except in the excessive tenderness that exists on pressure over that portion of the organ which descends below the ribs.<Callout type="important" title="Important">Acute hepatitis can be identified by its excessive tenderness.</Callout> Cancer of the Liver. — In most cases of cancer, the diagnosis is easily made. On Percussion the area of the hepatic dulness is always increased, sometimes extremely so; the organ is found to occupy the greater portion of the epigastrium, extending beyond the median line, into the left hypochondium, pushing the diaphragm upwards, and often descending below the ribs, to the crest of the ilium.<Callout type="warning" title="Warning">Cancer can be mistaken for other conditions due to its subtle symptoms.</Callout> On Palpation, irregular nodules of various size are distinctly felt through the abdominal walls, projecting from the surface of that portion of the enlarged organ which is below the free border of the ribs; these prominences are usually harder than the surrounding hepatic tissue, and there is more or less tenderness on pressure over them.<Callout type="important" title="Important">Cancer can be identified by irregular nodules and hardness.</Callout> Cancer of the liver may or may not be accompanied by ascites. Occasionally the surface of the liver in cancer is perfectly smooth, and in such cases you will be unable to detect the disease by the physical signs.<Callout type="warning" title="Warning">Smooth surfaces can indicate advanced cancer.</Callout> Decrease in the size of the Liver, The liver is diminished in size in cirrhosis, and in acute atrophy. Cirrhosis of the Liver. — In fully developed cases of cirrhosis of the liver, the organ is always diminished in size, and there is more or less abdominal dropsy.<Callout type="important" title="Important">Cirrhosis can be identified by its decreased size.</Callout> The only evidence of this disease furnished by inspection is a visible enlargement of the superficial veins. Percussion. — The area of the normal hepatic flatness is diminished; its limits are determined as follows: If the abdominal cavity is distended with dropsical accumulations, the patient should be placed partly on the left side, so that the fluid will gravitate from the hepatic region; the percussion flatness then, instead of extending to the free border of the ribs, will often give place to tympanitic resonance, an inch or more above their free margin, and instead, also, of extending across the median line into the left hypochondrium, will rarely reach that line; while the vertical measurement of hepatic dulness on a line with the right nipple does not often exceed two and a half inches.<Callout type="important" title="Important">Cirrhosis can be identified by its reduced percussion flatness.</Callout> Palpation. — By firm pressure with the ends of the fingers upwards, little nodules will often be felt on the under surface of the organ; sometimes when the distension of the abdomen from dropsical accumulation has been very great, we can get no information by palpation until after the performance of paracentesis.<Callout type="warning" title="Warning">Cirrhosis can be difficult to diagnose without fluid removal.</Callout> Atrophy of the Liver. — The only physical sign of atrophy of the liver is obtained from rapid diminution in the size of the organ, as ascertained by percussion, its surface remaining smooth; the diminution never being accompanied with ascites.<Callout type="important" title="Important">Atrophy can be identified by a rapid reduction in liver size.</Callout> Differential Diagnosis of Diseases of the Liver. The sources which may lead to error in the conclusion that the liver is the seat of disease when it is not, are, fecal accumulations in the ascending and transverse colon; enlargement of the right kidney; diseases of the stomach; displacement of the liver by disease in the right side of the chest; enlargement of the spleen; tumors of the omentum, and ovarian tumors.<Callout type="important" title="Important">Always consider differential diagnoses when suspecting liver issues.</Callout> Fecal Accumulations. — To distinguish these accumulations from enlargement of the liver, by physical examination, is always difficult and sometimes impossible; they give rise to a distinct tumor below the border of the ribs which by percussion and palpation seem