Percussion determination of Kurlov's dimensions
Assessment of organ size is based on measuring three lines. During the examination, quiet percussion is applied. The border of the sound transition from tympanic to dull is always marked along the edge of the pleximeter finger facing the clear sound zone.
- First dimension (along the right midclavicular line). The upper point is found by percussing from top to bottom from the clear pulmonary sound through the intercostal spaces to dullness. This found upper border becomes the main reference point. The lower border is determined by percussing from the umbilicus upward. The normal distance between them is about 9 cm.
- Second dimension (along the midline). The lower point is sought similarly — from the umbilicus upward. The upper border cannot be found by percussion because the sternum dampens the sound. Therefore, a conventional horizontal line is drawn from the upper point of the first dimension to intersect with the midline. The norm is about 8 cm.
- Third dimension (along the left costal arch). Percussion is performed along the costal arch, starting approximately from the anterior axillary line. The upper point is projected from the second dimension, and the lower point is found by percussion. The norm is about 7 cm.
If the liver is enlarged, the first dimension is recorded as a fraction: the numerator indicates the total size in centimeters, and the denominator indicates the portion extending downward beyond the costal margin.
Deep gliding palpation technique
Palpation according to Obraztsov's method is the main way to assess liver properties. For its successful execution, complete relaxation of the patient's abdominal wall is required.
- Preparation: The patient lies on their back with extended arms and knees bent. The physician is on the right.
- Actions of the left hand: The physician places the left hand on the lower part of the patient's chest and compresses it. This limits the mobility of the ribs during inspiration and forces the diaphragm to push the liver downward more forcefully.
- Actions of the right hand: The right hand is placed flat on the abdomen. The fingers are aligned along the estimated edge of the liver, which was previously found by percussion.
- Mechanics of movement: The physician sinks their fingers deep into the abdomen synchronously with the patient's breathing. During a deep breath, the descending edge of the organ encounters the fingers and slides off them, creating the characteristic sensation of a "step".
Assessment of the liver edge and features in ascites
During palpation, the physician assesses the shape, density, surface relief, and tenderness of the organ.
Normally, the liver is soft, the surface is smooth, the edge is sharp (thin) and painless. When pathologies develop, the tissue properties change:
- Congestive heart failure: the edge becomes rounded and tender due to capsule stretching. A specific sign is hepatojugular reflux — swelling of the jugular veins when pressure is applied to the liver.
- Cirrhosis: the tissue is dense, the edge and surface are uneven, palpation is usually painless.
- Oncology: the liver acquires a stony hardness.
The problem of ascites: With pronounced fluid accumulation in the abdominal cavity, standard techniques are uninformative. In such cases, the physician uses ballottement palpation: the right hand is placed below the umbilicus and makes jerking upward movements. The "floating ice cube" sign appears — the tactile sensation of a dense, displaceable organ striking the fingers.
Main causes of hepatomegaly
True enlargement of the liver is called hepatomegaly. It is important to assess not only the fact of organ growth but also the dynamics: for example, rapid enlargement is typical for carcinoma, while rapid reduction is typical for massive necrosis or cirrhosis (shrinkage).
Diseases leading to hepatomegaly are divided into several groups:
- Hemodynamic: venous congestion in right ventricular failure, constrictive pericarditis, Budd-Chiari syndrome.
- Infectious: viral hepatitis, purulent abscesses, leptospirosis, echinococcosis, as well as granulomatous processes (syphilis, tuberculosis).
- Non-infectious (toxic and metabolic): fatty steatosis, alcoholic damage, amyloidosis, metal metabolism disorders (hemochromatosis, Wilson's disease).
- Obstructive (obstructive jaundice): impaired bile outflow due to calculi in the ducts, strictures, or tumors (e.g., of the pancreatic head).
Briefly: answers to topical questions
At the level of which rib is the upper border of the liver located along the right midclavicular line normally?
Normally, the upper border of the liver along the right midclavicular line is projected onto the 4th intercostal space. This border is relatively constant compared to the lower one.
Projection of the upper border along other lines:
- Left midclavicular line — 5th intercostal space;
- Right parasternal line — cartilage of the 5th rib;
- Right midaxillary line — 8th rib;
- At the spine — 11th rib.
Class and exam questions
How to distinguish true hepatomegaly from organ prolapse (ptosis)?
With ptosis, the lower edge is palpated below the costal margin, but percussion reveals that the upper border of liver dullness is also shifted downward. At the same time, the organ dimensions themselves according to Kurlov remain normal.
What is the essence of the "floating ice cube" sign?
This sign is detected during ballottement palpation in patients with ascites. It represents the sensation of a dense organ striking the researcher's fingers through a layer of accumulated fluid.
What does hepatojugular reflux indicate?
Swelling of the jugular vein when pressure is applied to an enlarged, tender liver indicates right ventricular failure and the presence of pronounced venous congestion in the systemic circulation.
What else to study on this topic
- Pathogenesis of venous congestion in Budd-Chiari syndrome and tricuspid valve defects
- Metabolic storage diseases: hemochromatosis and Wilson's disease
- Differential diagnosis of jaundice (obstructive form)
- Hepatosplenic syndrome: mechanisms of combined enlargement of the liver and spleen
- Specific parasitic liver infestations (echinococcosis, schistosomiasis)
Master the entire topic in the "Propaedeutics" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Percussion and palpation of the liver" and 3,152 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 113 video lessons on the subject
Other topics in the section "Liver, Biliary Tract, and Spleen"
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.