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June 15, 1994, Vol 271, No. 23 >
ARTICLE | June 15, 1994

Physical Examination of the Liver FREE

C. David Naylor, MD, DPhil, FRCPC
[+] Author Affiliations

Reprints not available.


JAMA. 1994;271(23):1859-1865. doi:10.1001/jama.1994.03510470063036
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References

CLINICAL SCENARIO  The patient in your examining room is new to the practice. He is 52 years old, emigrated from Southeast Asia about 10 years ago, and has no specific complaints except fatigue. On examination you find little of note except that his liver edge is firm, easily felt, and extends about 6 cm below the costal margin across much of the right upper quadrant. The span, by light percussion, is 17 or 18cm. Should you be concerned? What does the research literature tell us about the meaning of these findings?Ideally, the clinical meaning of physical examination findings should be established in research studies that account for the overall context, including other signs and details from the medical history. This approach is difficult in liver disease, because the physical manifestations of hepatic dysfunction are protean and many multisystem diseases affect the liver. Our focus, therefore, is on physical examination

REFERENCES

1 +
Sapira JD.  Why perform a routine history and physical examination? South Med J . 1989;;82:364-365.
2 +
Zuidema PJ, Van der Meer C.  Systolic liver murmurs in primary carcinoma of the liver. Trop Geogr Med . 1966;;18:265-271.
3 +
Fenster LF, Klatskin G.  Manifestations of metastatic tumors of the liver. Am J Med . 1961;;31:238-248.
4 +
Sherman HI, Hardison JE.  The importance of a coexistent hepatic rub and bruit. JAMA . 1979;;241: 1495.
5 +
Sapira JD. The Art and Science of Bedside Diagnosis . Baltimore, Md: Urban & Schwarzenberg; 1989;:377-384.
6 +
Ramakrishnan T.  Venous hum of the Cruveilhier-Baumgarten syndrome. Arch Intern Med . 1978;;138: 826.
7 +
Hardison JR.  Venous hum of the Cruveilhier-Baumgarten syndrome. Arch Intern Med . 1977;;137: 1623-1624.
8 +
Zoneraich S, Zoneraich O.  Diagnostic significance of abdominal arterial murmurs in liver and pancreatic disease: a photoarteriographic study. Angiology . 1971;;22:197-205.
9 +
Clain D, Wartnaby K, Sherlock S.  Abdominal arterial murmurs in liver disease. Lancet . 1966;;2: 516-519.
10 +
Motoki T, Hayashi T, Katoh Y, Sakamoto T, Takeda T, Murao S.  Hepatic bruits in liver tumours. Lancet . 1978;;2:259.
11 +
Motoki T, Hayashi T, Katoh Y, Sakamoto T, Takeda T, Murao S.  Hepatic bruits in malignant liver tumors. Am J Gastroenterol . 1979;;71:582-586.
12 +
Meyhoff HH, Roder O, Andersen B.  Palpatory estimation of liver size. Acta Chir Scand . 1979;;145: 479-481.
13 +
Kingston M, Ali MA, Lewall D.  Hepatic tumors in Saudi Arabia: a practical approach to diagnosis. Cancer . 1985;;55:1579-1585.
14 +
Peternel WW, Schaefer JW, Schiff L.  Clinical evaluation of size and hepatic scintiscan. Am J Dig Dis . 1966;;11:346-350.
15 +
Espinoza P, Ducot B, Pelletier G, et al.  Inter-observer agreement in the physical diagnosis of alcoholic liver disease. Dig Dis Sci . 1987;;32:244-247.
16 +
Palmer ED.  Palpability of the liver edge in healthy adults. US Armed Forces Med J . 1958;;9: 1685-1690.
17 +
Naffalis J, Leevy CM.  Clinical examination of liver size. Am J Dig Dis . 1963;;8:236-243.
18 +
Ralphs DNL, Venn G, Kan O, Palmer JG, Cameron DE, Hobsley M.  Is the undeniably palpable liver ever 'normal'? Ann R Coll Surg Engl . 1983;; 65:159-160.
19 +
Sullivan S, Krasner N, Williams R.  The clinical estimation of liver size: a comparison of techniques and an analysis of the source of error. BMJ . 1976;; 2:1042-1043.
20 +
Halpern S, Coel M, Ashburn W, et al.  Correlation of liver and spleen size: determinations by nuclear medicine studies and physical examination. Arch Intern Med . 1974;;134:123-124.
21 +
Ariel IM, Briceno M.  The disparity of the size of the liver as determined by physical examination and by hepatic gamma-scanning in 504 patients. Med Pediatr Oncol . 1976;;2:69-73.
22 +
Rosenfield AT, Laufer I, Schneider PB.  The significance of a palpable liver. Am J Roentgenol Radiat Therapy Nucl Med . 1974;;122:313-317.
23 +
Walk L.  Liver size and its post-mortem change. Radiologe . 1983;;23:189-191.
24 +
Simel DL, Samsa GP, Marchar DB.  Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol . 1991;;44: 763-770.
25 +
DaCosta JC Jr. Principles and Practice of Physical Diagnosis . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1915;:542.
26 +
Bokhari SI, DeSa'Neto A, Desser KB, Benchimol A.  Inspiratory augmentation of hepatic pulsation in tricuspid insufficiency. Chest . 1979;;76:89-90.
27 +
George DS, Marsh C, Leier CV.  A-wave:liver. Clin Cardiol . 1988;;11:349-350.
28 +
Pelteret RM, de Moor MM.  Unusual cause of pulsatile liver: a case report. S Afr Med J . 1988;; 74:74-75.
29 +
Muller O, Shillingford J.  Tricuspid incompetence. Br Heart J . 1954;;16:195-207.
30 +
Bhatia ML, Tewari HL.  Hepatic pulsations in constrictive pericarditis. Indian Heart J . 1974;;26: 165-170.
31 +
Manga P, Vythilingum S, Mitha AS.  Pulsatile hepatomegaly in constrictive pericarditis. Br Heart J . 1984;;52:465-467.
32 +
Osler W. The Principles and Practice of Medicine . New York, NY: Appleton and Co; 1893;:428-456.
33 +
Theodossi A, Knill-Jones RP, Skene A, et al.  Inter-observer variation of symptoms and signs in jaundice. Liver . 1981;;1:21-32.
34 +
Naylor CD, McCormack DG, Sullivan SN.  The midclavicular line: a wandering landmark. Can Med Assoc J . 1987;;136:48-50.
35 +
Naylor CD, McCormack DG, Driedger AA, Cradduck TD.  Assessing liver size: clinical span versus scintigraphic span and tomographic volume. Clin Invest Med . 1988;;11:C90, R573.
36 +
Fuller GN, Hargreaves MR, King DM.  Scratch test in clinical examination of the liver. Lancet . 1988;;2:181.
37 +
Skrainka B, Stahlhut J, Knight F, Holmes RA, Butt JH.  Measuring liver span: bedside examination versus ultrasound and scintiscan. J Clin Gastroenterol . 1986;;8:267-270.
38 +
Blendis LM, McNeilly WJ, Sheppard L, Williams R, Laws JW.  Observer variation in the clinical and radiological assessment of hepatosplenomegaly. BMJ . 1970;;1:727-730.
39 +
Castell DO, O'Brien KD, Muench H, Chalmers TC.  Estimation of liver size by percussion in normal individuals. Ann Intern Med . 1969;;70:1183-1189.
40 +
Sapira JD, Williamson DL.  How big is the normal liver? Arch Intern Med . 1979;;139:971-973.
41 +
Malchow-Moller A, Rasmussen SN, Jensen AM, Keilding N, Skovgaard LT, Juhl E.  Clinical estimation of liver size. Dan Med Bull . 1984;;31:63-67.
42 +
Theodossi A, Spigelhalter DJ, Portmann B, Eddleston ALWF, Williams R.  The value of clinical, biochemical, ultrasound and liver biopsy data in assessing patients with liver disease. Liver . 1983;; 3:315-326.
43 +
Theodossi A.  The value of symptoms and signs in the assessment of jaundiced patients. Clin Gastroenterol . 1985;;14:545-557.
44 +
Harding SR, Cowan DHC.  The midclavicular line: a wandering landmark. Can Med Assoc J . 1987;;136:921.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

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1 +
Sapira JD.  Why perform a routine history and physical examination? South Med J . 1989;;82:364-365.
2 +
Zuidema PJ, Van der Meer C.  Systolic liver murmurs in primary carcinoma of the liver. Trop Geogr Med . 1966;;18:265-271.
3 +
Fenster LF, Klatskin G.  Manifestations of metastatic tumors of the liver. Am J Med . 1961;;31:238-248.
4 +
Sherman HI, Hardison JE.  The importance of a coexistent hepatic rub and bruit. JAMA . 1979;;241: 1495.
5 +
Sapira JD. The Art and Science of Bedside Diagnosis . Baltimore, Md: Urban & Schwarzenberg; 1989;:377-384.
6 +
Ramakrishnan T.  Venous hum of the Cruveilhier-Baumgarten syndrome. Arch Intern Med . 1978;;138: 826.
7 +
Hardison JR.  Venous hum of the Cruveilhier-Baumgarten syndrome. Arch Intern Med . 1977;;137: 1623-1624.
8 +
Zoneraich S, Zoneraich O.  Diagnostic significance of abdominal arterial murmurs in liver and pancreatic disease: a photoarteriographic study. Angiology . 1971;;22:197-205.
9 +
Clain D, Wartnaby K, Sherlock S.  Abdominal arterial murmurs in liver disease. Lancet . 1966;;2: 516-519.
10 +
Motoki T, Hayashi T, Katoh Y, Sakamoto T, Takeda T, Murao S.  Hepatic bruits in liver tumours. Lancet . 1978;;2:259.
11 +
Motoki T, Hayashi T, Katoh Y, Sakamoto T, Takeda T, Murao S.  Hepatic bruits in malignant liver tumors. Am J Gastroenterol . 1979;;71:582-586.
12 +
Meyhoff HH, Roder O, Andersen B.  Palpatory estimation of liver size. Acta Chir Scand . 1979;;145: 479-481.
13 +
Kingston M, Ali MA, Lewall D.  Hepatic tumors in Saudi Arabia: a practical approach to diagnosis. Cancer . 1985;;55:1579-1585.
14 +
Peternel WW, Schaefer JW, Schiff L.  Clinical evaluation of size and hepatic scintiscan. Am J Dig Dis . 1966;;11:346-350.
15 +
Espinoza P, Ducot B, Pelletier G, et al.  Inter-observer agreement in the physical diagnosis of alcoholic liver disease. Dig Dis Sci . 1987;;32:244-247.
16 +
Palmer ED.  Palpability of the liver edge in healthy adults. US Armed Forces Med J . 1958;;9: 1685-1690.
17 +
Naffalis J, Leevy CM.  Clinical examination of liver size. Am J Dig Dis . 1963;;8:236-243.
18 +
Ralphs DNL, Venn G, Kan O, Palmer JG, Cameron DE, Hobsley M.  Is the undeniably palpable liver ever 'normal'? Ann R Coll Surg Engl . 1983;; 65:159-160.
19 +
Sullivan S, Krasner N, Williams R.  The clinical estimation of liver size: a comparison of techniques and an analysis of the source of error. BMJ . 1976;; 2:1042-1043.
20 +
Halpern S, Coel M, Ashburn W, et al.  Correlation of liver and spleen size: determinations by nuclear medicine studies and physical examination. Arch Intern Med . 1974;;134:123-124.
21 +
Ariel IM, Briceno M.  The disparity of the size of the liver as determined by physical examination and by hepatic gamma-scanning in 504 patients. Med Pediatr Oncol . 1976;;2:69-73.
22 +
Rosenfield AT, Laufer I, Schneider PB.  The significance of a palpable liver. Am J Roentgenol Radiat Therapy Nucl Med . 1974;;122:313-317.
23 +
Walk L.  Liver size and its post-mortem change. Radiologe . 1983;;23:189-191.
24 +
Simel DL, Samsa GP, Marchar DB.  Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol . 1991;;44: 763-770.
25 +
DaCosta JC Jr. Principles and Practice of Physical Diagnosis . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1915;:542.
26 +
Bokhari SI, DeSa'Neto A, Desser KB, Benchimol A.  Inspiratory augmentation of hepatic pulsation in tricuspid insufficiency. Chest . 1979;;76:89-90.
27 +
George DS, Marsh C, Leier CV.  A-wave:liver. Clin Cardiol . 1988;;11:349-350.
28 +
Pelteret RM, de Moor MM.  Unusual cause of pulsatile liver: a case report. S Afr Med J . 1988;; 74:74-75.
29 +
Muller O, Shillingford J.  Tricuspid incompetence. Br Heart J . 1954;;16:195-207.
30 +
Bhatia ML, Tewari HL.  Hepatic pulsations in constrictive pericarditis. Indian Heart J . 1974;;26: 165-170.
31 +
Manga P, Vythilingum S, Mitha AS.  Pulsatile hepatomegaly in constrictive pericarditis. Br Heart J . 1984;;52:465-467.
32 +
Osler W. The Principles and Practice of Medicine . New York, NY: Appleton and Co; 1893;:428-456.
33 +
Theodossi A, Knill-Jones RP, Skene A, et al.  Inter-observer variation of symptoms and signs in jaundice. Liver . 1981;;1:21-32.
34 +
Naylor CD, McCormack DG, Sullivan SN.  The midclavicular line: a wandering landmark. Can Med Assoc J . 1987;;136:48-50.
35 +
Naylor CD, McCormack DG, Driedger AA, Cradduck TD.  Assessing liver size: clinical span versus scintigraphic span and tomographic volume. Clin Invest Med . 1988;;11:C90, R573.
36 +
Fuller GN, Hargreaves MR, King DM.  Scratch test in clinical examination of the liver. Lancet . 1988;;2:181.
37 +
Skrainka B, Stahlhut J, Knight F, Holmes RA, Butt JH.  Measuring liver span: bedside examination versus ultrasound and scintiscan. J Clin Gastroenterol . 1986;;8:267-270.
38 +
Blendis LM, McNeilly WJ, Sheppard L, Williams R, Laws JW.  Observer variation in the clinical and radiological assessment of hepatosplenomegaly. BMJ . 1970;;1:727-730.
39 +
Castell DO, O'Brien KD, Muench H, Chalmers TC.  Estimation of liver size by percussion in normal individuals. Ann Intern Med . 1969;;70:1183-1189.
40 +
Sapira JD, Williamson DL.  How big is the normal liver? Arch Intern Med . 1979;;139:971-973.
41 +
Malchow-Moller A, Rasmussen SN, Jensen AM, Keilding N, Skovgaard LT, Juhl E.  Clinical estimation of liver size. Dan Med Bull . 1984;;31:63-67.
42 +
Theodossi A, Spigelhalter DJ, Portmann B, Eddleston ALWF, Williams R.  The value of clinical, biochemical, ultrasound and liver biopsy data in assessing patients with liver disease. Liver . 1983;; 3:315-326.
43 +
Theodossi A.  The value of symptoms and signs in the assessment of jaundiced patients. Clin Gastroenterol . 1985;;14:545-557.
44 +
Harding SR, Cowan DHC.  The midclavicular line: a wandering landmark. Can Med Assoc J . 1987;;136:921.

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