Examine this patient's abdomen.



· Shortness of breath, leg oedema (heart failure).

· History of alcohol ingestion, cirrhosis.

· History of malignancies (secondaries in the liver).

· History of leukaemia or lymphoma.


· Enlarged liver: comment on its size, tenderness, surface (smooth or irregular); percuss the upper border (normally in the fifth

intercostal space in the right midclavicular line) and auscultate for bruit (N Engl J Med 1962; 266: 554-5; JAMA 1968; 206:

2518-20; Postgrad Med 1977; 62: 131-4).

· Remember: how far the liver extends below the costal margin is of less importance than 'liver span', particularly in patients with

emphysema or flattened diaphragms.

Note, By percussion, the mean liver size is 7 cm for women and 10.5 cm for men. A liver span 2-3 cm larger or smaller than these

values is considered abnormal. The liver size depends on several factors including age, sex, body size, shape and the examination

technique utilized (e.g. palpation versus percussion versus radio-graphic) (Ann Intern Med 1969; 70:1183-9).

Proceed as follows:

· Look for the following signs: -Spleen for ascites. - Signs of cirrhosis. - Lymph nodes. - Raised JVP. - Hepatic flap.

· At this stage you may be asked to look for nervous system signs of alcoholism (peripheral neuropathy, proximal myopathy,

cerebellar syndrome, bilateral sixth cranial nerve palsy as in Wernicke's encephalopathy, recent memory loss and confabulation

in Korsakoff's psychosis).


This patient has a nodular, hard hepatomegaly (lesion) which indicates secondaries in the liver. I would like to look for a primary,

particularly in the gastrointestinal tract (aetiology).


What does a tender liver indicate?

A stretch of its capsule due to a recent enlargement, as in cardiac failure or acute hepatitis.

What are the common causes of a palpable liver in the UK?

· Cardiac failure (firm, smooth, tender, mild to massive enlargement).

· Cirrhosis (non-tender, firm; in later stages the liver decreases in size).

· Secondaries in the liver (enlarged with rock-hard or nodular consistency).


Mention some less common causes of hepatomegaly.

· Leukaemia and other reticuloendothelial disorders.

· Infections - glandular fever, infectious hepatitis.

· Primary biliary cirrhosis.

· Haemochromatosis.

· Sarcoid, amyloid.

· Tumours - hepatoma, hydatid cysts.

Note. The liver may be felt without being enlarged in the following circumstances: increased diaphragmatic descent, presence of

emphysema with an associated depressed diaphragm, thin body habitus with a narrow thoracic cage, presence of a palpable

Riedel's lobe and right-sided pleural effusion.

In which condition does a pulsatile liver occur?

Tricuspid regurgitation.

What does a hepatic arterial bruit over the liver indicate?

The hepatic arterial bruit has been described in alcoholic hepatitis, primary or metastatic carcinoma. Although reported to occur in

cirrhosis, it is rare without associated alcoholic hepatitis (Lancet 1966; ii: 516-19).

What does the presence of an abdominal venous hum indicate?

It is virtually diagnostic of portal venous hypertension (usually due to cirrhosis) (Br Heart J 1950; 12: 343-50). When present together

with the hepatic arterial bruit in the same patient, it suggests cirrhosis with either alcoholic hepatitis or cancer.

What do you know about Cruveilhier-Baumgarten syndrome?

It is the presence of the abdominal venous hum in portal hypertension secondary to cirrhosis (Am J Med 1954; 17: 143-50).

What does a hepatic friction rub indicate?

In a young woman it could be due to gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome) and in others it could indicate hepatic

neoplasm with inflammatory changes or infection in or adjacent to the liver. The presence of a hepatic rub with a bruit usually

indicates cancer of the liver (JAMA 1979; 241: 1495), whereas the presence of the hepatic rub, bruit and abdominal venous hum

indicates that a patientwilh cirrhosis has developecl n hepatoma


Dame Sheiia Sherlock, Emeritus Professor of Medicine, Royal Free Hospital, London, is a doyen of liver diseases.

Hans Popper (1903-1988), Professor of Pathology at Chicago and the founding dean of Mount Sinai School of Medicine in New York; he is regarded

as the founding father of hepatology.

Howard Clarence Thomas, contemporary Professor of Medicine, St Mary's Hospital Medical School, Paddington, London; his main interest is viral