Palpation of the Abdomen
XUE Huiping
? Palpation and percussion usually follow
inspection in the examination of the other
body systems,
? Following inspection,the examiner
should perform auscultation of the
abdomen,
This change in the order of
examination is necessary because the
auscultatory findings may be markedly
altered by any manipulation of the
abdominal wall,Consequently
percussion and palpation,which may
increase or decrease peristaltic sounds,
are deferred until auscultation has
been completed,
The final step in the abdominal
examination is palpation,This
procedure is usually the most
important and often the most
difficult to perform accurately,
1,the principle of palpation
a) To relax the patient
? For the patient,
--- continue to lie supine with arms relaxed on the
chest or at the sides
--- may be further relaxed by instructing him to
breathe slowly and deeply
? For the examiner,
1) make certain that his hands are warm
2) assure the patient that he will make an effort
not to cause discomfort and follow up this
assurance
3) tackle with the ticklish patient
? If the patient exhibits ticklishness,
the examiner should disregard it and
try to continue,
? If this proves unsuccessful,it is
useful to have the patient place his
own hand on his abdomen,since this
never tickles,
? The examiner may tentatively exert
pressure on the abdomen through the
patient’s own hand,and gradually
increase the pressure,while assuring
the patient that the examination will
cause no discomfort,
? When the patient has relaxed,the
examiner again places his own hand on
the abdomen and allows the patient to
maintain contact with his hand,This
usually completes the relaxation of the
ticklish patient,and the examination
proceeds as usual,
4) begins with gentle exploration of the
abdominal wall and with no effort made to
palpate deeply
5) As with inspection,the initial step in palpation
may be facilitated by distracting conversation or
questions regarding the history,
6) If the patient remains tense or if the abdominal
wall is very muscular,better results may be
obtained by having the patient flex the thighs and
knees,
It should be emphasized again that
during the preliminary stages
muscle relaxation is the goal,At
this time no attempt should be
made either to elicit discomfort or
to palpate for a mass or enlarged
viscus,
b) To palpate four
quadrants superficially
from LLQ
counterclockwise
? To palpate all areas of the
abdomen counterclockwise and
superficially from left lower
quadrant screening for
tenseness(紧张度 ),
tenderness(压痛 ),masses,etc,
? Examination begins
with gentle maneuvers
and then palpation
occurs more deeply,
? Examiner uses the palms
of his hands with fingers
together and arm relaxed
and forearm on a horizontal
plane,
? The examiner presses
with his fingers,
c) To palpate four
quadrants deeply
? Using the palmer surface of
the fingers,examiner palpates
in four quadrants to identify
masses,tenderness,pulsations,
etc,
? The abdominal wall should be
depressed more than 2 cm,
? When deep palpation is difficult,
examiner may want to use left
hand placed over right hand to
help exert pressure,
? If a mass is suspected,determine its size,
contour,mobility,tenderness,smoothness,
irregularity,the hardness or softness and
listen with stethoscope for a bruit over the
mass,
? If there is tenderness,determine the
point of maximum tenderness and its
distribution,
? To check for rebound tenderness,
1) palpate deeply at the point of
tenderness,pause briefly,then remove
the fingers quickly,
2) Watch the patient’s face to see
whether it hurts,
3) Then check other areas in the same
manner for comparison,
2,the contents of palpation
a) abdominal tenseness腹壁紧张
度
In normal persons,abdominal wall is
somewhat tense,but usually soft when
palpated and easily depressed,and is
called abdominal softness(腹壁柔软 ),
While some pathological
conditions can lead to an
increase or decrease of
abdominal tenseness,
1) The increase of abdominal
tenseness
? Abdominal tenseness increases,not
accompanyed by muscle spasm,is due to
the increase of abdominal contents,as
gastrointestinal flatulence(肠胃胀气 ),
artificial pneumoperitoneum(人工气腹 ),
ascites,etc,
Board-like rigidity板状腹
If abdominal wall is palpated as obviously
tense,even as rigid as a board,board-like
rigidity is so called,This sign is caused by
the spasm of abdominal muscle due to
peritoneal irritation,as the perforation of
the gastrointeatinal diseases or rupture of
the viscera,
Dough kneading sensation
揉面感；柔韧感
If abdominal wall is palpated as pliable
and tough,and if it has resistance
and is not easily depressed,then the
examiner feels the sensation of dough
kneading,This sign is usually seen in
tuberculosis peritonitis or cancerous
peritonitis,
2) The decrease of
abdominal tenseness
The decrease of abdominal
tenseness is caused by the decrease
or disappearance of abdominal
muscle’s tension(张力 ),the sign
usually found in
chronic deeline(消耗性疾病 ) or
drainage of large amount of ascites,
b) tenderness and rebound tenderness
压痛和反跳痛
After relaxation is obtained,the examining
hand is first moved gently over the entire
abdomen,and an estimate of the muscle tone
in the various quadrants is made,Following
general palpation an attempt should be made
to detect and localize any painful area (i,e,
tenderness) within the abdomen,Two types
of pain may be elicited by palpation,
1,Visceral(内脏的 )
? This is pain that arises from an organic
lesion or functional disturbance within an
abdominal viscus,For example,it is the
type seen in an obstructive lesion of the
intestine in which there is a buildup of
pressure and distention of the gut,
? This type of pain has sveral
characteristics,it is dull,poorly localized,
and difficult for the patient to
characterize,
2,Somatic(躯体的；体壁的 )
? This is similar to the distress noted in painful
lesions of the skin,
? It is sharp,bright,and well localized,
? It is not caused primarily by involvement of
the viscera; rather it indicates involvement of
one of the somatic structures,such as the
parietal peritoneum or the abdominal wall
itself,
2,Somatic(躯体的；体壁的 )
? It should be pointed out that an
inflammatory process originating in a
viscus will produce visceral pain that
may extend to involve the peritoneum,
Inflammation of the peritoneum would then
result in somatic pain,
Eg,appendicitis(阑尾炎 ),
-- The pain is at first poorly localized,dull,ill
defined,and primarily midiline (when it is
entriely visceral in origin),
-- Later,as the inflammation spreads to the
peritoneum,the pain becomes sharp,bright,and
well localized in the right lower quadrant over
the involved region,
After a painful area is located,the examiner
should determine whether the pain is constant
under the pressure of the examing hand or if it
is transient,tending to disappear even though
pressure is continued over the area,
--- Pain caused by inflammation usually
remains unchanged or increases as pressure is
applied,
--- Visceral pain as the result of distention or
contraction of a viscus tends to become less
severe while pressure is maintained,
Occasionally the examiner may have difficulty
in distinguishing visceral pain from that arising
in somatic structures,such as the spine and
abdominal wall,An example of abdominal wall
discomfort is seen in patients with fibrositis(纤
维组织炎 ),These types of pain may be
differentiated by having the patient tense his
abdominal muscles,which may be
accomplished by forcefully elevating his head
while keeping his shoulders flat on the table,
Under these conditions increased tension of the
abdominal wall will accentuate the pain if it
originates in somatic structures,On the other
hand,discomfort from intra-abdominal sources
will be less severe with the abdomen tense than
when relaxed,
rebound tenderness
? When pain has been elicited,the examiner
should test for the phenomenon of rebound
tenderness,
? This is found only when the peritoneum
overlying a diseased viscus becomes inflamed,?
? Although it may be produced in different ways,
the most common is to press firmly over a region
distant from the tender area and then suddenly
release the pressure,The patient will feel a sharp
stab of pain in the area of disease if true rebound
tenderness is present,
This is a test for peritoneal irritation,Palpate
deeply and then quickly release pressure,If it
hurts more when you release,the patient has
rebound tenderness,
? For example,pressure applied in the
right lower quadrant and then suddenly
released will cause a marked increase in
pain over an area of diverticulitis(憩室炎 )
in the left quadrant,
? 1) Rebound tenderness may also be
elicited by having pressure over the tender
area and having the patient cough or strain,
2) Marked tenderness to percussion in
the area is usually seen in this situation,
This type of tenderness indicates
widespread inflammation of the
peritoneum (peritonitis),At times,if the
area involved is small,rebound tenderness
may be elicited only over the most tender
area of the abdomen,
Viscera
u To palpate liver at
midclavicular and midsternal
lines
Method,
? The right hand may be held either
parallel or perpendicular to the long axis
of the patient,
? In the midclavicular starting at the
anterior superior iliac crest,examiner
presses down firmly and asks patient to
inhale deeply,This allows the liver to
move down to meet your fingertips,
? If you feel nothing,press up a few
centimeters toward the rib cage and repeat
the maneuver,Do this continuously until
you feel the liver or reach the costal margin,
? Ordinarily the liver is not palpable,
although not infrequently the examiner may
feel the edge of the normal liver at or
slightly below the right costal margin,When
the liver is palpated,a firm edge will strike
the fingers upon inspiration,
? In the midsternal line,from the level of
the umbilicus,repeat the above maneuvers
to palpate the liver,
? Most doctors like to use bimanual
maneuvers to palpate the liver,To do this,
place the left hand at right lower posterior
chest wall parallel to,or supporting
patient’s right 11-12th ribs or at lower
sternal area to limit the chest respiration to
make right hand palpation more effective,
(Fig),
Note,（ 1） When felt more than 1cm below
the costal margin the organ should be
considered abnormally large,An exception is a
congenitally large right lobe of the liver,which
occasionally extends quite far into the right
flank,Another exception is seen in severe,
chronic emphysema(肺气肿 ),in which the
diaphragms are depressed by the overexpanded
lung,displacing the liver below the costal
margin,In both instances the total mass of the
liver is within normal limits,
（ 2） If you feel the liver,detect the edge
(sharp or round),tender or not,hard or soft
and repeat the process laterally and medially to
define the contour,For masses within the liver,
describe the same characteristics as above and
listen for a bruit over the mass,
l Size
1) Ordinarily the liver is not palpable,or the
liver can not be felt more than 1cm below the
lower coastal margin,and can not be felt more
than upper 1/3 distance of the line from
xiphoid to umbilicus or more than 3cm under
the xiphoid,
2) Failure to feel the liver does not mean that
the liver is normal,
3) Measurement of the liver is done in the
midclavicular line and midsternal line,
l Texture/quality质地
The quality of liver is classified into three grades,
softness(质软 ),toughness(质韧 ),and hardness(质硬 ),
1) Normally the quality of liver is soft and tender,just like
the pouted(撅嘴 ) lip,
2) In acute hepatitis or fatty liver(脂肪肝 ),the quality of
liver is slightly tough,
3) In chronic hepatitis or blood stasis of liver,liver is
more tough and usually as tough as apex nasi(鼻尖 ),
4) In liver cirrhosis,the quality of liver is hard,
5) In liver carcinoma,the quality of liver is extremely
hard and as hard as forehead(前额 ),
l Surface and edge
To observe whether the surface of liver is smooth
or not,whether there is any node(结节 ) or not,
and whether the edge is thin or thick and is regular
or irregular,The character of the surface of the
liver should be described,Not infrequently large
metastatic masses may be present and palpable in
the liver,In some persons with cirrhosis,the
anterior surface of the liver will have a granular
feel,This is easily felt in the thin individual,
l Tenderness
Normally liver cannot be palpated as
tenderness unless the liver is irritated by
the liver chitonitis (that is,inflammation
of the diolame包膜 of the liver) or pulled
by the enlargement of itself,
l Pulsation搏动
1) Normally you cannot palpate any pulsation
of the liver,
2) If you palpate the pulsation of the liver,you
should pay attention to its direction,that is,
whether it is unidirectional(单向性 ) or
expansile(扩张性 ),
3) The former one,unidirectional pulsation,
is usually a conductive one(传导性搏动 ),That
is caused by the the conduction of the pulsation
of aorta abdominalis(腹主动脉 ),
If you put your hand on the sufface of the liver,
you will feel your hand is pushed upward,
4) The later one,expansile pulsation,is the
pulsation of the liver per se and usually found
in tricuspid valve insufficiency(三尖瓣关闭不
全 ),Because the contractive pulsation of right
ventricle conducts to liver through right atrium
and then inferior vena cava,If you put your
hand on the sufface of the liver,you will have
the opening-closing sensation,
The positive Hepatojugular reflux
sign(肝－颈静脉回流征 ),If you
press the liver,you will find the
dilated jugular vein becomes more
bulged or distended,as from the
enlargement of liver passive
congestion resulted from right failure,
u To palpate spleen from
umbilicus to left costal margin
1) In examining for splenic enlargement,
the examiner should stand at the patient’s
right side,
2) His left hand is placed over the
patient’s left costovertebral angle,exerting
pressure to move the spleen anteriorly,At
the same time his right hand is worked
gently under the left anterior costal margin,
3) With the examiner’s hands stationary in
this position,the patient is instructed to
take a deep breath,
1) If there is significant enlargement of the
spleen,it will be palpated as a firm mass
that slides out from under the ribs,
bumping against the finger of the
examiner’s right hand,The spleen
normally moves down with inspiration,
2) If splenic enlargement cannot be felt by
the technique just described,the patient
should then be rolled slightly toward the
right so that the spleen may fall anteriorly,
The examining hands are again placed
as described and the procedure is
repeated,Occasionally a spleen that
cannot be felt with the patient in the
supine position may be palpated by
this maneuver,
3) When the spleen can be felt,it must
be considered abnormal,since the
normal spleen is not palpable,
Notes,
（ 1） Starting from the level of the
umbilicus (or below the percussed
dullness),
（ 2） The maneuver is similar
to that used to palpate the liver,
but is more subtle because the
spleen is more mobile and
deeper than the liver,
（ 3） If the spleen is not
palpated,have the patient roll
on his right side and repeat
palpation,
（ 4） Measurement of the
spleen is the same as that of the
liver and is usually expressed as
centimeters under the costal
margin in the midclavicular and
under the xiphoid process in
the midsternal lines,
（ 5） A moderately or greatly
enlarged spleen is best described by
a drawing,especially the three lines
which are presented schematically
in the following diagram (Fig),
(NOTE,Severe splenomegaly may
cause rupture when spleen is
vigorously palpated,so palpate
gently and carefully),
Line 1,The distance between left costal
border and the lower edge of spleen along
left midclavicular line
Line 2,The distance between the crossing
point of left midclavicular line and left
costal border and the
most remote point of the spleen
Line 3,(when the spleen is extremely large
and exceeds the anterior midline.) The
distance between the right border of the
spleen and the anterior midline,If the
spleen indeed exceeds the anterior midline,
The mark,+” is used to indicate
“exceeding”,while, –, is used to indicate
“not exceeding”,
In clinical practice,
splenomegaly is classified into
three levels,
level 1 (slight enlargement轻度肿大 ),
During deep respiration,the lower edge of
spleen is not more than 2cm below the
costal border
level 2 (moderate enlargement中度肿
大 ),
During deep respiration,the lower edge of
spleen is more than 2cm below the costal
border but above the umbilical horizontal
line
level 3 (severe enlargement高度肿大 ),
During deep respiration,the lower edge of
Spleen is below the umbilical horizontal
line or over anterior midline
u To palpate gall bladder
Method,Put right hand below the costal
margin or lower border of liver at
midclavicular line (grossly equal to the
lateral border of the right rectus
muscles) and palpate deeply to check for
tenderness or bulging,
? Under normal circumstances,the gallbladder
cannot be palpated,
? However,in a jaundiced patient,the right
upper quadrant should always be carefully
palpated for a soft,cystic mass,approximately 6
to 8 cm in diameter,which appears to be
attached to the liver and moves with respiration,
This is an exceedingly valuable sign in
differentiating jaundice caused by cancer of the
head of the pancreas or the common bile duct
from that caused by gallstones,
? In the presence of tumor of the
common bile duct or head of the pancreas,
the wall of the gallbladder is normal,and
consequently the organ is capable of
distending to the point that it is palpable,
Such sign is named Courvoisier sign,
? On the other hand,if the obstruction is
caused by gallstones,the gallbladder wall
is inflamed,and this diseased organ is not
capable of distention,Therefore,the
gallbladder will not become palpable,
u To check for Murphy’s sign
If pain is found in the gallbladder area but
gallbladder is not palpated,the examiner
should put his left hand on the lower lateral rib
cage with the 4 fingers stretching superiorly and
the thumb hooked under the costal margin,
Press down to the point of gallbladder
tenderness and ask the patient to breathe deeply
and check to see whether the patient stops
breathing,changes facial expression,or
complains of pain,The sign is indicative of the
inflammation of gallbladder,
u To palpate kidneys bimanually
For palpation of the kidney,examiner puts
his left hand below left rib cage,at the
costospinal angle,and lifts up,Examiner
uses his right hand to palpate deeply from
umbilical level in the left midclavicular line,
and moves progressively upward,The
lower pole of the kidney may be felt as a
smooth,round,and deep structure that
moves relatively little with respiration,
This maneuver is repeated on the right
side to palpate the right kidney,Normally
the kidney is not palpated,Sometimes the
lower pole of the right kidney may be felt
in normal patients,During deep
inspiration,if more than half of the kidney
is palpated,nephroptosis(肾下垂 ) is
considered,Repeat the maneuver with the
patient in sitting and standing positions if
you wish to expose the kidney further,
Summary and Questions,
1,General principle of
palpation,Relax the
patient is the goal,
2,Board-like rigidity and
Dough kneading sensation
3,Two types of pain may
be elicited by palpation,
visceral pain and somatic
pain,
4,To palpate liver at
midclavicular and midsternal
lines
5,To palpate spleen from
umbilicus to left costal margin
6,A moderately or greatly
enlarged spleen is best
described by a drawing,
especially the three lines,
1) How to tell the patient
to relax before and during
palpation?
2) What does Board-like
rigidity mean?
3) How to palpate liver and
spleen?
4) What does
hepatojugular reflux sign
refer to?
THANKS!
XUE Huiping
? Palpation and percussion usually follow
inspection in the examination of the other
body systems,
? Following inspection,the examiner
should perform auscultation of the
abdomen,
This change in the order of
examination is necessary because the
auscultatory findings may be markedly
altered by any manipulation of the
abdominal wall,Consequently
percussion and palpation,which may
increase or decrease peristaltic sounds,
are deferred until auscultation has
been completed,
The final step in the abdominal
examination is palpation,This
procedure is usually the most
important and often the most
difficult to perform accurately,
1,the principle of palpation
a) To relax the patient
? For the patient,
--- continue to lie supine with arms relaxed on the
chest or at the sides
--- may be further relaxed by instructing him to
breathe slowly and deeply
? For the examiner,
1) make certain that his hands are warm
2) assure the patient that he will make an effort
not to cause discomfort and follow up this
assurance
3) tackle with the ticklish patient
? If the patient exhibits ticklishness,
the examiner should disregard it and
try to continue,
? If this proves unsuccessful,it is
useful to have the patient place his
own hand on his abdomen,since this
never tickles,
? The examiner may tentatively exert
pressure on the abdomen through the
patient’s own hand,and gradually
increase the pressure,while assuring
the patient that the examination will
cause no discomfort,
? When the patient has relaxed,the
examiner again places his own hand on
the abdomen and allows the patient to
maintain contact with his hand,This
usually completes the relaxation of the
ticklish patient,and the examination
proceeds as usual,
4) begins with gentle exploration of the
abdominal wall and with no effort made to
palpate deeply
5) As with inspection,the initial step in palpation
may be facilitated by distracting conversation or
questions regarding the history,
6) If the patient remains tense or if the abdominal
wall is very muscular,better results may be
obtained by having the patient flex the thighs and
knees,
It should be emphasized again that
during the preliminary stages
muscle relaxation is the goal,At
this time no attempt should be
made either to elicit discomfort or
to palpate for a mass or enlarged
viscus,
b) To palpate four
quadrants superficially
from LLQ
counterclockwise
? To palpate all areas of the
abdomen counterclockwise and
superficially from left lower
quadrant screening for
tenseness(紧张度 ),
tenderness(压痛 ),masses,etc,
? Examination begins
with gentle maneuvers
and then palpation
occurs more deeply,
? Examiner uses the palms
of his hands with fingers
together and arm relaxed
and forearm on a horizontal
plane,
? The examiner presses
with his fingers,
c) To palpate four
quadrants deeply
? Using the palmer surface of
the fingers,examiner palpates
in four quadrants to identify
masses,tenderness,pulsations,
etc,
? The abdominal wall should be
depressed more than 2 cm,
? When deep palpation is difficult,
examiner may want to use left
hand placed over right hand to
help exert pressure,
? If a mass is suspected,determine its size,
contour,mobility,tenderness,smoothness,
irregularity,the hardness or softness and
listen with stethoscope for a bruit over the
mass,
? If there is tenderness,determine the
point of maximum tenderness and its
distribution,
? To check for rebound tenderness,
1) palpate deeply at the point of
tenderness,pause briefly,then remove
the fingers quickly,
2) Watch the patient’s face to see
whether it hurts,
3) Then check other areas in the same
manner for comparison,
2,the contents of palpation
a) abdominal tenseness腹壁紧张
度
In normal persons,abdominal wall is
somewhat tense,but usually soft when
palpated and easily depressed,and is
called abdominal softness(腹壁柔软 ),
While some pathological
conditions can lead to an
increase or decrease of
abdominal tenseness,
1) The increase of abdominal
tenseness
? Abdominal tenseness increases,not
accompanyed by muscle spasm,is due to
the increase of abdominal contents,as
gastrointestinal flatulence(肠胃胀气 ),
artificial pneumoperitoneum(人工气腹 ),
ascites,etc,
Board-like rigidity板状腹
If abdominal wall is palpated as obviously
tense,even as rigid as a board,board-like
rigidity is so called,This sign is caused by
the spasm of abdominal muscle due to
peritoneal irritation,as the perforation of
the gastrointeatinal diseases or rupture of
the viscera,
Dough kneading sensation
揉面感；柔韧感
If abdominal wall is palpated as pliable
and tough,and if it has resistance
and is not easily depressed,then the
examiner feels the sensation of dough
kneading,This sign is usually seen in
tuberculosis peritonitis or cancerous
peritonitis,
2) The decrease of
abdominal tenseness
The decrease of abdominal
tenseness is caused by the decrease
or disappearance of abdominal
muscle’s tension(张力 ),the sign
usually found in
chronic deeline(消耗性疾病 ) or
drainage of large amount of ascites,
b) tenderness and rebound tenderness
压痛和反跳痛
After relaxation is obtained,the examining
hand is first moved gently over the entire
abdomen,and an estimate of the muscle tone
in the various quadrants is made,Following
general palpation an attempt should be made
to detect and localize any painful area (i,e,
tenderness) within the abdomen,Two types
of pain may be elicited by palpation,
1,Visceral(内脏的 )
? This is pain that arises from an organic
lesion or functional disturbance within an
abdominal viscus,For example,it is the
type seen in an obstructive lesion of the
intestine in which there is a buildup of
pressure and distention of the gut,
? This type of pain has sveral
characteristics,it is dull,poorly localized,
and difficult for the patient to
characterize,
2,Somatic(躯体的；体壁的 )
? This is similar to the distress noted in painful
lesions of the skin,
? It is sharp,bright,and well localized,
? It is not caused primarily by involvement of
the viscera; rather it indicates involvement of
one of the somatic structures,such as the
parietal peritoneum or the abdominal wall
itself,
2,Somatic(躯体的；体壁的 )
? It should be pointed out that an
inflammatory process originating in a
viscus will produce visceral pain that
may extend to involve the peritoneum,
Inflammation of the peritoneum would then
result in somatic pain,
Eg,appendicitis(阑尾炎 ),
-- The pain is at first poorly localized,dull,ill
defined,and primarily midiline (when it is
entriely visceral in origin),
-- Later,as the inflammation spreads to the
peritoneum,the pain becomes sharp,bright,and
well localized in the right lower quadrant over
the involved region,
After a painful area is located,the examiner
should determine whether the pain is constant
under the pressure of the examing hand or if it
is transient,tending to disappear even though
pressure is continued over the area,
--- Pain caused by inflammation usually
remains unchanged or increases as pressure is
applied,
--- Visceral pain as the result of distention or
contraction of a viscus tends to become less
severe while pressure is maintained,
Occasionally the examiner may have difficulty
in distinguishing visceral pain from that arising
in somatic structures,such as the spine and
abdominal wall,An example of abdominal wall
discomfort is seen in patients with fibrositis(纤
维组织炎 ),These types of pain may be
differentiated by having the patient tense his
abdominal muscles,which may be
accomplished by forcefully elevating his head
while keeping his shoulders flat on the table,
Under these conditions increased tension of the
abdominal wall will accentuate the pain if it
originates in somatic structures,On the other
hand,discomfort from intra-abdominal sources
will be less severe with the abdomen tense than
when relaxed,
rebound tenderness
? When pain has been elicited,the examiner
should test for the phenomenon of rebound
tenderness,
? This is found only when the peritoneum
overlying a diseased viscus becomes inflamed,?
? Although it may be produced in different ways,
the most common is to press firmly over a region
distant from the tender area and then suddenly
release the pressure,The patient will feel a sharp
stab of pain in the area of disease if true rebound
tenderness is present,
This is a test for peritoneal irritation,Palpate
deeply and then quickly release pressure,If it
hurts more when you release,the patient has
rebound tenderness,
? For example,pressure applied in the
right lower quadrant and then suddenly
released will cause a marked increase in
pain over an area of diverticulitis(憩室炎 )
in the left quadrant,
? 1) Rebound tenderness may also be
elicited by having pressure over the tender
area and having the patient cough or strain,
2) Marked tenderness to percussion in
the area is usually seen in this situation,
This type of tenderness indicates
widespread inflammation of the
peritoneum (peritonitis),At times,if the
area involved is small,rebound tenderness
may be elicited only over the most tender
area of the abdomen,
Viscera
u To palpate liver at
midclavicular and midsternal
lines
Method,
? The right hand may be held either
parallel or perpendicular to the long axis
of the patient,
? In the midclavicular starting at the
anterior superior iliac crest,examiner
presses down firmly and asks patient to
inhale deeply,This allows the liver to
move down to meet your fingertips,
? If you feel nothing,press up a few
centimeters toward the rib cage and repeat
the maneuver,Do this continuously until
you feel the liver or reach the costal margin,
? Ordinarily the liver is not palpable,
although not infrequently the examiner may
feel the edge of the normal liver at or
slightly below the right costal margin,When
the liver is palpated,a firm edge will strike
the fingers upon inspiration,
? In the midsternal line,from the level of
the umbilicus,repeat the above maneuvers
to palpate the liver,
? Most doctors like to use bimanual
maneuvers to palpate the liver,To do this,
place the left hand at right lower posterior
chest wall parallel to,or supporting
patient’s right 11-12th ribs or at lower
sternal area to limit the chest respiration to
make right hand palpation more effective,
(Fig),
Note,（ 1） When felt more than 1cm below
the costal margin the organ should be
considered abnormally large,An exception is a
congenitally large right lobe of the liver,which
occasionally extends quite far into the right
flank,Another exception is seen in severe,
chronic emphysema(肺气肿 ),in which the
diaphragms are depressed by the overexpanded
lung,displacing the liver below the costal
margin,In both instances the total mass of the
liver is within normal limits,
（ 2） If you feel the liver,detect the edge
(sharp or round),tender or not,hard or soft
and repeat the process laterally and medially to
define the contour,For masses within the liver,
describe the same characteristics as above and
listen for a bruit over the mass,
l Size
1) Ordinarily the liver is not palpable,or the
liver can not be felt more than 1cm below the
lower coastal margin,and can not be felt more
than upper 1/3 distance of the line from
xiphoid to umbilicus or more than 3cm under
the xiphoid,
2) Failure to feel the liver does not mean that
the liver is normal,
3) Measurement of the liver is done in the
midclavicular line and midsternal line,
l Texture/quality质地
The quality of liver is classified into three grades,
softness(质软 ),toughness(质韧 ),and hardness(质硬 ),
1) Normally the quality of liver is soft and tender,just like
the pouted(撅嘴 ) lip,
2) In acute hepatitis or fatty liver(脂肪肝 ),the quality of
liver is slightly tough,
3) In chronic hepatitis or blood stasis of liver,liver is
more tough and usually as tough as apex nasi(鼻尖 ),
4) In liver cirrhosis,the quality of liver is hard,
5) In liver carcinoma,the quality of liver is extremely
hard and as hard as forehead(前额 ),
l Surface and edge
To observe whether the surface of liver is smooth
or not,whether there is any node(结节 ) or not,
and whether the edge is thin or thick and is regular
or irregular,The character of the surface of the
liver should be described,Not infrequently large
metastatic masses may be present and palpable in
the liver,In some persons with cirrhosis,the
anterior surface of the liver will have a granular
feel,This is easily felt in the thin individual,
l Tenderness
Normally liver cannot be palpated as
tenderness unless the liver is irritated by
the liver chitonitis (that is,inflammation
of the diolame包膜 of the liver) or pulled
by the enlargement of itself,
l Pulsation搏动
1) Normally you cannot palpate any pulsation
of the liver,
2) If you palpate the pulsation of the liver,you
should pay attention to its direction,that is,
whether it is unidirectional(单向性 ) or
expansile(扩张性 ),
3) The former one,unidirectional pulsation,
is usually a conductive one(传导性搏动 ),That
is caused by the the conduction of the pulsation
of aorta abdominalis(腹主动脉 ),
If you put your hand on the sufface of the liver,
you will feel your hand is pushed upward,
4) The later one,expansile pulsation,is the
pulsation of the liver per se and usually found
in tricuspid valve insufficiency(三尖瓣关闭不
全 ),Because the contractive pulsation of right
ventricle conducts to liver through right atrium
and then inferior vena cava,If you put your
hand on the sufface of the liver,you will have
the opening-closing sensation,
The positive Hepatojugular reflux
sign(肝－颈静脉回流征 ),If you
press the liver,you will find the
dilated jugular vein becomes more
bulged or distended,as from the
enlargement of liver passive
congestion resulted from right failure,
u To palpate spleen from
umbilicus to left costal margin
1) In examining for splenic enlargement,
the examiner should stand at the patient’s
right side,
2) His left hand is placed over the
patient’s left costovertebral angle,exerting
pressure to move the spleen anteriorly,At
the same time his right hand is worked
gently under the left anterior costal margin,
3) With the examiner’s hands stationary in
this position,the patient is instructed to
take a deep breath,
1) If there is significant enlargement of the
spleen,it will be palpated as a firm mass
that slides out from under the ribs,
bumping against the finger of the
examiner’s right hand,The spleen
normally moves down with inspiration,
2) If splenic enlargement cannot be felt by
the technique just described,the patient
should then be rolled slightly toward the
right so that the spleen may fall anteriorly,
The examining hands are again placed
as described and the procedure is
repeated,Occasionally a spleen that
cannot be felt with the patient in the
supine position may be palpated by
this maneuver,
3) When the spleen can be felt,it must
be considered abnormal,since the
normal spleen is not palpable,
Notes,
（ 1） Starting from the level of the
umbilicus (or below the percussed
dullness),
（ 2） The maneuver is similar
to that used to palpate the liver,
but is more subtle because the
spleen is more mobile and
deeper than the liver,
（ 3） If the spleen is not
palpated,have the patient roll
on his right side and repeat
palpation,
（ 4） Measurement of the
spleen is the same as that of the
liver and is usually expressed as
centimeters under the costal
margin in the midclavicular and
under the xiphoid process in
the midsternal lines,
（ 5） A moderately or greatly
enlarged spleen is best described by
a drawing,especially the three lines
which are presented schematically
in the following diagram (Fig),
(NOTE,Severe splenomegaly may
cause rupture when spleen is
vigorously palpated,so palpate
gently and carefully),
Line 1,The distance between left costal
border and the lower edge of spleen along
left midclavicular line
Line 2,The distance between the crossing
point of left midclavicular line and left
costal border and the
most remote point of the spleen
Line 3,(when the spleen is extremely large
and exceeds the anterior midline.) The
distance between the right border of the
spleen and the anterior midline,If the
spleen indeed exceeds the anterior midline,
The mark,+” is used to indicate
“exceeding”,while, –, is used to indicate
“not exceeding”,
In clinical practice,
splenomegaly is classified into
three levels,
level 1 (slight enlargement轻度肿大 ),
During deep respiration,the lower edge of
spleen is not more than 2cm below the
costal border
level 2 (moderate enlargement中度肿
大 ),
During deep respiration,the lower edge of
spleen is more than 2cm below the costal
border but above the umbilical horizontal
line
level 3 (severe enlargement高度肿大 ),
During deep respiration,the lower edge of
Spleen is below the umbilical horizontal
line or over anterior midline
u To palpate gall bladder
Method,Put right hand below the costal
margin or lower border of liver at
midclavicular line (grossly equal to the
lateral border of the right rectus
muscles) and palpate deeply to check for
tenderness or bulging,
? Under normal circumstances,the gallbladder
cannot be palpated,
? However,in a jaundiced patient,the right
upper quadrant should always be carefully
palpated for a soft,cystic mass,approximately 6
to 8 cm in diameter,which appears to be
attached to the liver and moves with respiration,
This is an exceedingly valuable sign in
differentiating jaundice caused by cancer of the
head of the pancreas or the common bile duct
from that caused by gallstones,
? In the presence of tumor of the
common bile duct or head of the pancreas,
the wall of the gallbladder is normal,and
consequently the organ is capable of
distending to the point that it is palpable,
Such sign is named Courvoisier sign,
? On the other hand,if the obstruction is
caused by gallstones,the gallbladder wall
is inflamed,and this diseased organ is not
capable of distention,Therefore,the
gallbladder will not become palpable,
u To check for Murphy’s sign
If pain is found in the gallbladder area but
gallbladder is not palpated,the examiner
should put his left hand on the lower lateral rib
cage with the 4 fingers stretching superiorly and
the thumb hooked under the costal margin,
Press down to the point of gallbladder
tenderness and ask the patient to breathe deeply
and check to see whether the patient stops
breathing,changes facial expression,or
complains of pain,The sign is indicative of the
inflammation of gallbladder,
u To palpate kidneys bimanually
For palpation of the kidney,examiner puts
his left hand below left rib cage,at the
costospinal angle,and lifts up,Examiner
uses his right hand to palpate deeply from
umbilical level in the left midclavicular line,
and moves progressively upward,The
lower pole of the kidney may be felt as a
smooth,round,and deep structure that
moves relatively little with respiration,
This maneuver is repeated on the right
side to palpate the right kidney,Normally
the kidney is not palpated,Sometimes the
lower pole of the right kidney may be felt
in normal patients,During deep
inspiration,if more than half of the kidney
is palpated,nephroptosis(肾下垂 ) is
considered,Repeat the maneuver with the
patient in sitting and standing positions if
you wish to expose the kidney further,
Summary and Questions,
1,General principle of
palpation,Relax the
patient is the goal,
2,Board-like rigidity and
Dough kneading sensation
3,Two types of pain may
be elicited by palpation,
visceral pain and somatic
pain,
4,To palpate liver at
midclavicular and midsternal
lines
5,To palpate spleen from
umbilicus to left costal margin
6,A moderately or greatly
enlarged spleen is best
described by a drawing,
especially the three lines,
1) How to tell the patient
to relax before and during
palpation?
2) What does Board-like
rigidity mean?
3) How to palpate liver and
spleen?
4) What does
hepatojugular reflux sign
refer to?
THANKS!
