Examination of the Gallbladder and Liver (OSCE)

Positioning

• expose from nipples to pubis
• have patient lying supine on bed with knees flexed

INSPECTION

(from foot of the bed)

• level of comfort, jaundice
• abdominal distension, bulging flanks, visible abdominal mass
• prominent veins (caput medusae)

PALPATION

• patient relaxed and breathing slowly
• LIGHT palpation over entire abdomen, save tender areas to last
• DEEP palpation with finger tips, feel with inspiration, relocate during expiration

LIVER

• start in RLQ with the examining hand parallel to the rectus muscles, advance hand superiorly with expirations and anticipate the liver edge striking the forefinger on inspiration
• attempt to feel the surface of the liver
• describe: consistency, tenderness, nodularity, pulsations

GALLBLADDER

• orient hand perpendicular to the costal margin feeling from medial to lateral below the right costal margin (feels bulbous, focally rounded mass that moves downward on inspiration)

• Murphy’s sign (cholecystitis)
• place left hand with forefinger parallel to and at the RLCM and with thumb pressing on the intersection of the costal margin and the lateral border of the abdominal rectus muscle
  • + → pain elicited around the area pressed during a deep inspiration

PERCUSSION

• measure at the same point in the respiratory cycle

• LOWER BORDER: start below the umbilicus and percuss upward at right MCL and mid sternal line to liver dullness
• UPPER BORDER (6th ICS in MCL): from lung resonance and percuss downward to liver dullness
• measure liver span (liver span is 10 at MCL, 6 at MSL)

AUSCULTATION

• hepatic friction rub (tumour, inflammation, infarct)
• venous hum (portal hypertension)
• bruit (HCC, acute ETOH hepatitis, AV malformation)
• Another new technique to measure the borders of the liver is the "Kamil Ševela" technique, which I was taught in the hospital. You place the stethoscope on the xiphoid process for auscultation, at the same time you scratch from below the right nipple/breast and you hear clearly the liver borders. The first sound is when the liver appears, and when the sound dissapears it is the end of the liver. The sounds are clearly audible, and it's a very useful tool to know the borders of the liver.

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