Percussion and palpation of the spleen

Topographic percussion according to Kurlov

There are quite a few percussion techniques, which is due to the deep location of the organ and complex anatomical landmarks. Traditionally, Kurlov's method is used in clinical practice.

To perform the examination, the patient should lie on their right side. The trunk rotation should be incomplete—the patient is positioned at an angle to the couch surface.

During percussion, two main dimensions (borders of dullness) are sequentially determined:

• Long axis (longitudinal dimension). Percussion with the pleximeter finger starts from the spine and moves forward strictly along the X (tenth) intercostal space. Normally, this value is 8–9 cm. If the patient has splenomegaly (enlargement) or ptosis (prolapse) of the organ, and the lower pole extends beyond the costal margin, this protruding part must be included in the final measurement.
• Transverse axis (width). To determine this, the midpoint of the just-measured long axis is found. Percussion is performed perpendicularly to this point: the direction of strikes goes from top to bottom (taking into account the patient's lateral position), from the anterior to the posterior axillary line. The normal value of the transverse axis should not exceed 5 cm.

The results are recorded in the medical history as a fraction (e.g., 8/4 cm). It is important to remember that the accuracy of this method is considered low. The spleen lies in close proximity to hollow organs such as the stomach and colon. The gas contained within them produces a prominent tympanic sound that can merge with the organ's sound and significantly distort the borders of dullness.

Deep palpation

Palpation of the organ is based on the rules of deep gliding palpation. The main mechanism allowing the edge to be felt is the respiratory mobility of the spleen. During a deep breath, the diaphragm contracts, pushing the organ downward, causing it to descend and seemingly "roll over" the tips of the physician's fingers.

Correct patient position:

1. The patient lies on their right side (palpation in the supine position is sometimes permitted).
2. The right leg is fully straightened.
3. The left leg (positioned on top) is flexed at the hip and knee joints.

This posture is intentional: it ensures maximum relaxation of the anterior abdominal wall muscles (abdominal press), which is critically important for deep penetration of the palpating hand.

Normally, the spleen is not palpable. If the physician finds that the lower edge of the organ descends into the left hypochondrium and becomes accessible to palpation, this indicates pathology (enlargement or prolapse). In this case, it is necessary to evaluate the properties of the palpable mass in detail:

• Character of the surface (smooth, nodular);
• Consistency (soft, firm/dense);
• Presence or absence of tenderness.

Key diagnostic sign: a characteristic notch can be felt on the anterior border of the enlarged spleen. It is this feature that helps distinguish this organ from other abdominal masses.

Differential diagnosis

The discovery of a mass in the left upper quadrant of the abdomen always requires a differential diagnosis. An enlarged spleen can be mistaken for pathology of neighboring organs.

Most often, the organ must be differentiated from the following structures:

• Left kidney (ptosis or enlargement);
• Left lobe of the liver (hepatomegaly);
• Enlarged pancreas;
• Splenic flexure of the colon (in case of fecal impaction or a neoplastic process).

Clinically, differentiating these conditions can be quite difficult, especially if the specific marginal notch of the spleen cannot be clearly defined during palpation. Therefore, in case of any difficulties, the physician's tactic is to mandatory use instrumental verification methods. First of all, the patient is prescribed an ultrasound examination (ultrasound) of the abdominal cavity, which allows establishing the nature of the palpable mass quickly and accurately.

Class and exam questions

What else to study on this topic

• Features of palpation in the supine patient position
• Assessment of spleen properties: consistency, tenderness, surface character
• Instrumental methods of verifying splenomegaly (Ultrasound)
• Causes of splenomegaly and protrusion of the organ from under the costal margin
• The role of respiratory mobility of abdominal organs in physical diagnostics

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.