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[Skill Modules >> Liver & Ascites >> Techniques ]

Techniques: Liver & Ascites

Technique: Liver

Approach the examination of the liver from the right side of the patient. Have the patient lying supine. Preserve the patientís privacy by draping the top of their body with the gown and below the waist with a sheet. For the best exam, make sure the patient is warm and comfortable. Additionally make sure your hands are warm so as to not startle the patient.


Look for gross asymmetries across the abdomen. Look at the skin for signs of liver disease, such as caput medusa, or spider angiomata.


Follow the inspection of the liver, as with the rest of the abdominal exam, with auscultation. Listen over the area of the liver for bruits or venous hums.


Percuss for the upper and lower margins of the liver. Place your non-dominant hand palm down flat on the abdomen with the fingers parallel to the lower costal margin pointed toward the midline. Percuss with the middle finger of your dominant hand on the middle finger of your non-dominant one.

Begin percussion over the lungs and move from the area of resonant lung sounds to the areas of dullness. Mark the area of change. Repeat the same process from below, moving again from resonance over the bowel to dullness and again mark the area of change. Start in the lower right quadrant so as to not miss a greatly enlarged liver. Measure the vertical distance from the top to the bottom. You can also use palpation to determine the lower border.


Begin palpation over the right lower quadrant, near the anterior iliac spine. Palpate for the liver with one or two hands palm down moving upward 2-3 cm at a time towards the lower costal margin. Have the patient take a deep breath. The liver will move downward due to the downward movement of the diaphragm. Feel for the liver to hit the caudal aspect of your palpating hand. Palpate the bottom margin of the liver for the texture of the liver, i.e. soft/ firm/hard/nodular.

Scratch Test

Several different techniques have been described for this exam. One is to place the diaphragm over the area of the liver and then scratch parallel to the costal margin until the sound intensity drops off marking the edge of the liver. Other techniques involve different patterns of the scratching, for example as in spokes of a wheel and other places for placing the stethoscope such as over the abdomen.

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Technique: Ascites

There are several physical examination maneuvers described for detection of ascites described below that are at least moderately sensitive and specific. No single maneuver is both highly sensitive and specific; therefore at least two maneuvers are necessary to increase the accuracy of physical exam for ascites.

Bulging Flanks
  1. With the patient supine, the examiner visually observes whether the flanks are pushed outward (presumably by large amounts of ascitic fluid)
  2. Positive test: simply the presence of bulging flanks
Note: A patient with an obese abdomen may also have flanks that bulge, although the fat of obesity extends further posterior than fluid in the peritoneum.
Flank Dullness
flank dullness
  1. The patient is examined in the supine position.
  2. Direct percussion is done over the abdomen, from the umbilicus to the flanks.
  3. The location of the transition from tympany to dullness is noted.
  4. Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas
Note: The tympany over the umbilicus occurs in ascites because bowel floats to the top of the abdominal fluid at the level of the fluid meniscus.
Shifting Dullness
shifting dullness
  1. This maneuver is performed with the patient supine.
  2. Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.
  3. The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.
  4. Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.
Note: The shift in zone of tympany with position change will usually be at least 3 cm when ascites is present.
Fluid Wave
  1. Have the patient lying supine.
  2. The patient or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient's mid abdomen, applying with slight pressure.
  3. The examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank.
  4. Positive test: The examiner is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

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