Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Diagnostics Capt Donald O. Castell & Barbara B. Frank To cite this article: Capt Donald O. Castell & Barbara B. Frank (1977) Diagnostics, Postgraduate Medicine, 62:6, 131-134, DOI: 10.1080/00325481.1977.11714708 To link to this article: http://dx.doi.org/10.1080/00325481.1977.11714708
Published online: 07 Jul 2016.
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Date: 08 June 2017, At: 09:56
special aspects of • pr1mary care • AH too often in clinical practice, abdominal examinatien is limited to determining whether the liver, spleen, or other abdominal mass is palpable or whether tenderness is present. This is unfortunate, since a more careful examination may provide extremely useful information about the presence of disease, particularly within the liver. This article discusses percussion and auscultation of the abdomen and the importance of these techniques in the diagnosis of abnormalities of the liver and spleen. We hope it will serve as a reminder that thorough abdominal examination should include a laying on not only of the hands but also of the stethoscope.
Percussion Use of percussion in diagnosis was first introduced in the 18th century by Leopold Auenbrugger in Vienna. The technique and the original descriptions by Auenbrugger, which were based on experiments performed on the chest cavity of cadavers, have been popularized, and percussion is commonly used in the diagnosis of chest lesions. Appreciation seems to be lac king, however, for the potential value of percussion in abdominal examinatien. Spleen size- We became aware of the usefulness of percussion in evaluating spleen size during clinical evaluation of patients with infectious mononucleosis and associated progressive changes in size of this organ. We noted that with use of gentle percussion over the splenic region, we were able to follow regression in size of the organ to normal. In normal persons, percussion over the lowest intercostal space in the left anterior axillary line usually produces a resonant note that persists throughout the full phase of inspiration. In patients who recently had had palpable splenomegaly, however, we found that a change in the note from resonant to dull was often detectable during deep inspiration, presumably because at that time the moderately enlarged spleen descends to a position beneath the percussing finger. The spleen normally rests on the posterolateral wall of the abdominal cavity adjacent to the ninth through llth ribs'; thus it
Vol. 62 • No. 6 • December 1977 • POSTGRADUATE MEDICINE
diagnostics ABDOMINAL EXAMINATION Role of Percussion and Auscultation Capt Donald O. Casteil, MC, USN National Naval Medical Center Bethesda
Barbara B. Frank, MD Crozer-Chester Medical Center Chester, Pennsylvania
Percussion and auscultation should be a routine part of abdominal examination, as these techniques are effective in early detection of liver and spleen abnormalities.
131
diagnostics---------------------------· Figure 1. Technique for eliciting "spleen percussion sign." Sensing finger is placed over lowest intercostal space in approximate anterior axillary line. Figure 2. Approximate size and location of normal liver.
Figure 3. Possible location of "depressed" liver in patient with chronic obstructive pulmonary disease. Note that although size of organ may be normal, lower border of liver might easily be palpated below costal margin.
Figure 4. "Squaring off" effect in liver in patient with diffuse hepatic disease, such as cirrhosis. Note striking prominence of left lobe, which often results in span of dullness in midsternal line similar in size to that in midclavicular line.
seems unlikely that dullness would be noted in the anterior axillary line in a patient with a spleen normal in size and location. To verify the potential usefulness of this "spleen percussion sign," one of us (D.O.C.) did a study 2 comparing the size of the spleen as gauged by percussion (figure 1) with its actual size as measured by radioisotope scanning in patients and controls. Results confirmed that in patients with moderate splenomegaly, a defini te change in percussion note from resonant to dull occurs in the
132
Figure 5. Schematic representation of sources of possible abnormal auscultatory findings over liver region: (1) hepatoma, often associated with systolic bruit; (2) hepatic metastases, often associated with relatively pathognomonic friction rub; (3) dilated abdominal collateral veins, which may be associated with venous hum of Cruveilhier-Baumgarten syndrome.
lowest interspace in the left anterior axillary line during deep inspiration. In persons without splenic enlargement demonstrable by radioisotope scanning, the percussion note remains resonant throughout ali phases of respiration. 2 This study showed that splenic percussion is a useful method of detecting moderate degrees of splenomegaly and may provide evidence of enlargement before the spleen has attained sufficient size to become palpable. In the years since the study was done, the spleen percussion sign has indeed proved to be of
POSTGRADUATE MEDICINE • December 1977 • Vol. 62 • No. 6
considerable value in the clinical assessment of patients with possible splenomegaly. Liver size-Percussion over the liver area (figure 2) is probably the most useful application of the technique in diagnosis of abdominal abnormalities. AU too often, unfortunately, liver size is described by a statement such as "the liver was palpable three fingerbreadths below the rib margin." Since the variation in size of examiners' fingers is almost as great as the variation in examiners, fingerbreadths make a poor substitute for centimeters, as recently observed by Chalmers. 3 Furthermore, the extent of liver palpable below the costal margin tells nothing about the true size of the organ (figure 3). Both the upper and the lower borders must be located to determine total size, and this can be accomplished only by means of percussion. Definitive standards have been established for normal liv~r size as determined by percussion. 4 lt is of interest that the span of dullness shows a significant correlation with body size, ie, with heigh t or, more specifically, with estimated total lean body mass. This observation is not surprising, since autopsy data show that the weight of the liver and of other organs correlates weil with body size.' The mean span of liver dullness in the midclavicular line is 7.0 cm for women and 10.5 cm for men. It is essential to percuss carefully over the li ver. The total span of dullness in the midclavicular line can then be compared with previously established normal values (table 1). A 10-cm span of liver dullness is likely to represent hepatomegaly in a 5-ft taU, 100-lb woman but is weil within normal limits in a 6-ft taU, 200-lb man. Determination of liver dullness is important to detect not only hepatomegaly but also decreasing liver size in suspected fulminant hepatitis. An additional aspect of liver percussion that is helpful in the clinical appraisal of possible liver disease relates to the fact that
Vol. 62 • No. 6 • December 1977 • POSTGRADUATE MEDICINE
table 1. average span of liver dullness· on percussion in normal subjects* Height (ln.)
60 63 66 69 72 75
Liver dullness (cm) Midclavicular line
Midsternal line
Men
Women
Men
Women
8.25 9.00 9.75 10.25 11.00 11.75
6.00 6.75 7.50 8.00 8.75 9.50
6.00 6.50 7.00 7.50 8.00 8.50
4.00 4.50 5.00 5.50 5.75 6.25
•From Castel/ et al. •
with a normal liver, the span of dullness in the midsternal line (midline) is smaller than that in the midclavicular line (table 1). In patients with diffuse hepatic abnormalities, there is often a "squaring off" effect (figure 4}, with the span of dullness being equal in both lines. This alteration is particularly apparent in cirrhosis, in which enlargement of the left hepatic lobe is sometimes striking .
Auscultation of the Liver Although most clinicians listen with a stethoscope over the abdomen, they usually do so with the intent of evaluating bowel sounds or detecting bruits, or both. Auscultation over the liver, although often neglected, may be of definite clinical value and frequently provides useful diagnostic information. Three important diagnostic sounds should be sought. Systolic bruit-A systolic bruit over the liver is occasionally encountered in a normal person and is probably due to kinking or tortuosity of the arterial supply to the organ. ln sorne patients, epigastric bruits have been shown to be due to stenosis of the celiac artery, usually from extrinsic compression. 6 In patients with established cirrhosis, however, a systolic bruit often heralds the presence of a primary hepatoma (figure 5). Hepatocellular carcinoma is an extremely vascular tumor, and consequently the relative importance of a systolic bruit heard over the liver as a
133
diagnostics------------------------
Donald O. Casteil
Barbara B. Frank
Dr Casteil is chief, internai medicine service, National Naval Medical Center, and professer of medicine, Uniformed Services University of the Health Sciences, Bethesda. Dr Frank is chief of gastroenterology, Crozer-Chester Medical Center, Chester, Pennsylvania, and clinical associate professer, division of gastroenterology, department of medicine, Hahnemann Medical College and Hospital, Philadelphia.
diagnostic clue to hepatoma bas been stressed. 7 This finding is not of absolute value, however, since such a bruit may also be present in patients with acute alcoholic hepatitis. Friction rub-A hepatic friction rub almost invariably indicates the presence of metastatic involvement of the liver 8 (figure 5). The rub probably results from adhesion of serosally implanted metastases to the overlying peritoneum. A friction rub over the liver bas rarely been reported to occur with primary hepatoma or more rarely with acute
gonococcal perihepatitis (Fitz-HughCurtis syndrome) 9 ; it is sound clinical judgment, however, to consider such a rub indicative of metastatic disease until there is proof to the contrary. Venous hum-A venous hum beard over the liver or between the liver and the umbilicus is reportedly an indication of portal hypertension in patients with cirrhosis and a patent umbilical vein (Cruveilhier-Baumgarten syndrome) (figure 5). Although the sign is probably diagnostic, it appears to be encountered only rarely in clinical practice.
Summary Clinicians should not minimize or overlook the importance of percussion of the liver and the spleen and of auscultation over the liver as routine parts of abdominal examination. Splenic percussion can be used to detect splenomegaly even before the spleen becomes palpable. The span of liver dullness on percussion can be compared with established normal standards to dete~t hepatomegaly or alterations caused by cirrhosis. A systolic bruit, a friction rub, or a venous hum detected by auscultation over the liver is an important sign of liver disease. • Address reprint requests to Capt Donald O. Casteil, MC, USN, Internai Medicine Service, National Naval Medical Center, Bethesda, MD 20014.
References 1. Gray H: The spleen in anatomy of the human body. In Goss CM (Editor): Gray's Anatomy of the Human Body. Philadelphia, Lea & Febiger, 1973, pp 768-772 2. Casteil DO: The spleen percussion sign: A useful diagnostic technique. Ann Intern Med 67:12651267, 1967 3. Chalmers TC: Centimeters, even inches, but no fingers. N Engl J Med 282:397-398, 1970 4. Casteil DO, O'Brien KD, Muench H, et al: Estimation of liver size by percussion in normal individuals. Ann Intern Med 70:1183-1189, 1969 5. Rezek PR, Millard M: Autopsy Pathology. Springfield, Ill, Charles C Thomas, Publisher, 1963, p 464
134
6. McLoughlin MJ, Colapinto RJ, Hobbs BB: Abdominal bruits: Clinical and angiographie correlation. JAMA 232:1238-1242, 1975 7. Clain D, Wartnaby K, Sherlock S: Abdominal arterial murmurs in liver disease. Lancet 2:516-519, 1966 8. Fenster LF, Klatskin G: Manifestations of metastatic tumors of liver: A study of eighty-one patients subjected to needle biopsy. Am J Med 31:238-248, 1961 9. Fitzhugh T: Acute gonococcie peritonitis of right upper quadrant in women. JAMA 102:2094-2096, 1934
POSTGRADUATE MEDICINE • December 1977 • Vol. 62 • No. 6
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Diagnostics Capt Donald O. Castell & Barbara B. Frank To cite this article: Capt Donald O. Castell & Barbara B. Frank (1977) Diagnostics, Postgraduate Medicine, 62:6, 131-134, DOI: 10.1080/00325481.1977.11714708 To link to this article: http://dx.doi.org/10.1080/00325481.1977.11714708
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 2
View related articles
Citing articles: 5 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [The UC San Diego Library]
Date: 08 June 2017, At: 09:56
special aspects of • pr1mary care • AH too often in clinical practice, abdominal examinatien is limited to determining whether the liver, spleen, or other abdominal mass is palpable or whether tenderness is present. This is unfortunate, since a more careful examination may provide extremely useful information about the presence of disease, particularly within the liver. This article discusses percussion and auscultation of the abdomen and the importance of these techniques in the diagnosis of abnormalities of the liver and spleen. We hope it will serve as a reminder that thorough abdominal examination should include a laying on not only of the hands but also of the stethoscope.
Percussion Use of percussion in diagnosis was first introduced in the 18th century by Leopold Auenbrugger in Vienna. The technique and the original descriptions by Auenbrugger, which were based on experiments performed on the chest cavity of cadavers, have been popularized, and percussion is commonly used in the diagnosis of chest lesions. Appreciation seems to be lac king, however, for the potential value of percussion in abdominal examinatien. Spleen size- We became aware of the usefulness of percussion in evaluating spleen size during clinical evaluation of patients with infectious mononucleosis and associated progressive changes in size of this organ. We noted that with use of gentle percussion over the splenic region, we were able to follow regression in size of the organ to normal. In normal persons, percussion over the lowest intercostal space in the left anterior axillary line usually produces a resonant note that persists throughout the full phase of inspiration. In patients who recently had had palpable splenomegaly, however, we found that a change in the note from resonant to dull was often detectable during deep inspiration, presumably because at that time the moderately enlarged spleen descends to a position beneath the percussing finger. The spleen normally rests on the posterolateral wall of the abdominal cavity adjacent to the ninth through llth ribs'; thus it
Vol. 62 • No. 6 • December 1977 • POSTGRADUATE MEDICINE
diagnostics ABDOMINAL EXAMINATION Role of Percussion and Auscultation Capt Donald O. Casteil, MC, USN National Naval Medical Center Bethesda
Barbara B. Frank, MD Crozer-Chester Medical Center Chester, Pennsylvania
Percussion and auscultation should be a routine part of abdominal examination, as these techniques are effective in early detection of liver and spleen abnormalities.
131
diagnostics---------------------------· Figure 1. Technique for eliciting "spleen percussion sign." Sensing finger is placed over lowest intercostal space in approximate anterior axillary line. Figure 2. Approximate size and location of normal liver.
Figure 3. Possible location of "depressed" liver in patient with chronic obstructive pulmonary disease. Note that although size of organ may be normal, lower border of liver might easily be palpated below costal margin.
Figure 4. "Squaring off" effect in liver in patient with diffuse hepatic disease, such as cirrhosis. Note striking prominence of left lobe, which often results in span of dullness in midsternal line similar in size to that in midclavicular line.
seems unlikely that dullness would be noted in the anterior axillary line in a patient with a spleen normal in size and location. To verify the potential usefulness of this "spleen percussion sign," one of us (D.O.C.) did a study 2 comparing the size of the spleen as gauged by percussion (figure 1) with its actual size as measured by radioisotope scanning in patients and controls. Results confirmed that in patients with moderate splenomegaly, a defini te change in percussion note from resonant to dull occurs in the
132
Figure 5. Schematic representation of sources of possible abnormal auscultatory findings over liver region: (1) hepatoma, often associated with systolic bruit; (2) hepatic metastases, often associated with relatively pathognomonic friction rub; (3) dilated abdominal collateral veins, which may be associated with venous hum of Cruveilhier-Baumgarten syndrome.
lowest interspace in the left anterior axillary line during deep inspiration. In persons without splenic enlargement demonstrable by radioisotope scanning, the percussion note remains resonant throughout ali phases of respiration. 2 This study showed that splenic percussion is a useful method of detecting moderate degrees of splenomegaly and may provide evidence of enlargement before the spleen has attained sufficient size to become palpable. In the years since the study was done, the spleen percussion sign has indeed proved to be of
POSTGRADUATE MEDICINE • December 1977 • Vol. 62 • No. 6
considerable value in the clinical assessment of patients with possible splenomegaly. Liver size-Percussion over the liver area (figure 2) is probably the most useful application of the technique in diagnosis of abdominal abnormalities. AU too often, unfortunately, liver size is described by a statement such as "the liver was palpable three fingerbreadths below the rib margin." Since the variation in size of examiners' fingers is almost as great as the variation in examiners, fingerbreadths make a poor substitute for centimeters, as recently observed by Chalmers. 3 Furthermore, the extent of liver palpable below the costal margin tells nothing about the true size of the organ (figure 3). Both the upper and the lower borders must be located to determine total size, and this can be accomplished only by means of percussion. Definitive standards have been established for normal liv~r size as determined by percussion. 4 lt is of interest that the span of dullness shows a significant correlation with body size, ie, with heigh t or, more specifically, with estimated total lean body mass. This observation is not surprising, since autopsy data show that the weight of the liver and of other organs correlates weil with body size.' The mean span of liver dullness in the midclavicular line is 7.0 cm for women and 10.5 cm for men. It is essential to percuss carefully over the li ver. The total span of dullness in the midclavicular line can then be compared with previously established normal values (table 1). A 10-cm span of liver dullness is likely to represent hepatomegaly in a 5-ft taU, 100-lb woman but is weil within normal limits in a 6-ft taU, 200-lb man. Determination of liver dullness is important to detect not only hepatomegaly but also decreasing liver size in suspected fulminant hepatitis. An additional aspect of liver percussion that is helpful in the clinical appraisal of possible liver disease relates to the fact that
Vol. 62 • No. 6 • December 1977 • POSTGRADUATE MEDICINE
table 1. average span of liver dullness· on percussion in normal subjects* Height (ln.)
60 63 66 69 72 75
Liver dullness (cm) Midclavicular line
Midsternal line
Men
Women
Men
Women
8.25 9.00 9.75 10.25 11.00 11.75
6.00 6.75 7.50 8.00 8.75 9.50
6.00 6.50 7.00 7.50 8.00 8.50
4.00 4.50 5.00 5.50 5.75 6.25
•From Castel/ et al. •
with a normal liver, the span of dullness in the midsternal line (midline) is smaller than that in the midclavicular line (table 1). In patients with diffuse hepatic abnormalities, there is often a "squaring off" effect (figure 4}, with the span of dullness being equal in both lines. This alteration is particularly apparent in cirrhosis, in which enlargement of the left hepatic lobe is sometimes striking .
Auscultation of the Liver Although most clinicians listen with a stethoscope over the abdomen, they usually do so with the intent of evaluating bowel sounds or detecting bruits, or both. Auscultation over the liver, although often neglected, may be of definite clinical value and frequently provides useful diagnostic information. Three important diagnostic sounds should be sought. Systolic bruit-A systolic bruit over the liver is occasionally encountered in a normal person and is probably due to kinking or tortuosity of the arterial supply to the organ. ln sorne patients, epigastric bruits have been shown to be due to stenosis of the celiac artery, usually from extrinsic compression. 6 In patients with established cirrhosis, however, a systolic bruit often heralds the presence of a primary hepatoma (figure 5). Hepatocellular carcinoma is an extremely vascular tumor, and consequently the relative importance of a systolic bruit heard over the liver as a
133
diagnostics------------------------
Donald O. Casteil
Barbara B. Frank
Dr Casteil is chief, internai medicine service, National Naval Medical Center, and professer of medicine, Uniformed Services University of the Health Sciences, Bethesda. Dr Frank is chief of gastroenterology, Crozer-Chester Medical Center, Chester, Pennsylvania, and clinical associate professer, division of gastroenterology, department of medicine, Hahnemann Medical College and Hospital, Philadelphia.
diagnostic clue to hepatoma bas been stressed. 7 This finding is not of absolute value, however, since such a bruit may also be present in patients with acute alcoholic hepatitis. Friction rub-A hepatic friction rub almost invariably indicates the presence of metastatic involvement of the liver 8 (figure 5). The rub probably results from adhesion of serosally implanted metastases to the overlying peritoneum. A friction rub over the liver bas rarely been reported to occur with primary hepatoma or more rarely with acute
gonococcal perihepatitis (Fitz-HughCurtis syndrome) 9 ; it is sound clinical judgment, however, to consider such a rub indicative of metastatic disease until there is proof to the contrary. Venous hum-A venous hum beard over the liver or between the liver and the umbilicus is reportedly an indication of portal hypertension in patients with cirrhosis and a patent umbilical vein (Cruveilhier-Baumgarten syndrome) (figure 5). Although the sign is probably diagnostic, it appears to be encountered only rarely in clinical practice.
Summary Clinicians should not minimize or overlook the importance of percussion of the liver and the spleen and of auscultation over the liver as routine parts of abdominal examination. Splenic percussion can be used to detect splenomegaly even before the spleen becomes palpable. The span of liver dullness on percussion can be compared with established normal standards to dete~t hepatomegaly or alterations caused by cirrhosis. A systolic bruit, a friction rub, or a venous hum detected by auscultation over the liver is an important sign of liver disease. • Address reprint requests to Capt Donald O. Casteil, MC, USN, Internai Medicine Service, National Naval Medical Center, Bethesda, MD 20014.
References 1. Gray H: The spleen in anatomy of the human body. In Goss CM (Editor): Gray's Anatomy of the Human Body. Philadelphia, Lea & Febiger, 1973, pp 768-772 2. Casteil DO: The spleen percussion sign: A useful diagnostic technique. Ann Intern Med 67:12651267, 1967 3. Chalmers TC: Centimeters, even inches, but no fingers. N Engl J Med 282:397-398, 1970 4. Casteil DO, O'Brien KD, Muench H, et al: Estimation of liver size by percussion in normal individuals. Ann Intern Med 70:1183-1189, 1969 5. Rezek PR, Millard M: Autopsy Pathology. Springfield, Ill, Charles C Thomas, Publisher, 1963, p 464
134
6. McLoughlin MJ, Colapinto RJ, Hobbs BB: Abdominal bruits: Clinical and angiographie correlation. JAMA 232:1238-1242, 1975 7. Clain D, Wartnaby K, Sherlock S: Abdominal arterial murmurs in liver disease. Lancet 2:516-519, 1966 8. Fenster LF, Klatskin G: Manifestations of metastatic tumors of liver: A study of eighty-one patients subjected to needle biopsy. Am J Med 31:238-248, 1961 9. Fitzhugh T: Acute gonococcie peritonitis of right upper quadrant in women. JAMA 102:2094-2096, 1934
POSTGRADUATE MEDICINE • December 1977 • Vol. 62 • No. 6
