Jaundice

Jaundice is the hallmark of liver disease, but usually is only apparent fairly late clinical tests are relatively insensitive to disease the most commmon diseases of the liver are fatty change cirrhosis metastasis

 

Liver capsule

(Image courtesy of Ashley Davidoff M.D.)

Size

normal palpation below the right costal margin lateral to rectus inspiration liver edge can normally be palpated and can move can move 1-3 cms percussion dullness starts below right nipple and infracostal right costal margin craniocaudad span 12-15cms emphysema may cause downward displacement with apparent enlargement abnormal enlargement of the liver has multiple causes either due to an increase in size of the hepatocytes (eg fatty change) fluid content in the interstitium (eg right heart failure) neoplastic disease eg primary HCC or metastatic disease Size

Shape

The shape of the liver in clinical setting normal edge felt below right costal margin usually smooth abnormal nodularity most commonly caused by cirrhosis due to a combination of regenerating nodules and the fibrotic retractile process metastasis when on the surface may also give an irregular border

Position

The clinical position of the liver normal RUQ major portion of the liver usually felt in right upper quadrant broad chested patients endomorphic build liver is subcostal and may be difficult to feel in people with ectomorphic build liver easier to feel when abnormal LUQ situs inversus major portion in the LUQ seen in situs inversus (partial or total) Kartageners syndrome asplenia syndrome polysplenia syndrome herniations of the liver can occur into lateral abdominal wall anterior abdominal wall Riedel’s lobe is a normal variant where the right lobe extends to the right lower quadrant

 Character 

Normal: Soft and relatively sharp edge Abnormal: Hard liver most commonly caused by cirrhosis, metastasis, or hepatocellular carcinoma.

Blood supply

The clinical implication of a dual blood supply infarction is rare unless both circulations are affected most commonly seen in severe hypotension or iatrogenic ar traumatic loss of both the portal vein and the hepatic artery hepatocellular carcinoma may be very vascular with a-v shunting resulting in an audible murmur portal venous disease in cirrhosis, results in formation of varices, and porto-systemic anastamoses. (caput Medusa) audible venous hum

 

Capsule

clinical correlate of the liver capsule symptoms, pain capsule is sensitive to pain and acute distension may give rise to pain caused by acute fatty change acute congestion auscultation in disease of the capsule a friction rub may be felt or heard pelvic inflammatory disease (Fitz – Hugh – Curtis disease) liver capsule may be involved with RUQ pain

Relations

liver moves with respiration and this is used to evaluate the liver edge disease of the liver may extend directly to its neighbours congestion of the liver may involve gallbladder fossa resulting in edema in the fossa amebic abscess of the right lobe may extend to diaphragm and right lung resulting in abscesses in both these places