• Not at medial or lateral corners of sclera: fat deposition ("dirty sclera") as you age; ask Pt to look up or down
• Not that common in liver disease
• Note: pterygium: fleshy growth at side of sclera

DIAGRAM: Jaundice (sclera)

DIAGRAM: Spider angioma

• Dilated arteriole with small dilated capillaries radiating out
• Disappears with pressure
• Release of pressure - spider fills from centre outwards

• In SVC drainage area (above nipple line)
• Rarely below nipples: reason NK - due to weathering effect (nudist colony: spider angioma all over body?)
• Also in oral & nasal mucous membrane
• Occurs in:

1. Normal
2. Cirrhosis
3. Hepatitis: chronic hep, takes time to develop
4. Rheumatoid arthritis
5. Pregnancies: hormonal changes assoc. with VD

• Abnormal: > 3; only occur recently

DIAGRAM: Telangiectasia

Scattered telangiectasia

DIAGRAM: Palmer erythema

5 SIGNS IN THE HAND

• Aka liver palm
• Increased redness over hypothenar and thenar eminences and tips of fingers
• 1st sign in the hand
• Occurs in:

1. Chronic liver disorder
2. Rheumatoid arthritis
3. Pregnancy
4. Thyrotoxicosis
5. Chronic febrile illness
6. Chronic leukaemia

DIAGRAM: finger clubbing

DIAGRAM: testing for fluctuation at base of nail

Clubbing of fingers and toes: 2nd sign in fingers

4 stages

1. Loss of angle between nail and nailbed
2. Flotation sensation: hold finger near junction between 2 fingers, with out hand use finger to test for sensation; one finger at junction, one finger press on end of fingernail to test for see-saw sensation

[Note: 1 then 2, or 2 then 1]

3. Increased longitudinal curvature (even in long fingernails, the nails should still be straight in normal people)
4. Drumstick formation: NOT in chronic liver disease, COPD, TB; present in cardiac disease (IE, cyanotic congenital heart disease - eg. Tetralogy of Fallot), lung suppurative conditions (empyema, bronchiectasis, abscess, fibrosing alveolitis, ca lung - bronchogenic carcinoma), GID (IBD - UC, CD, malabsorption diseases), cirrhosis liver

Associated conditions

DIAGRAM: Dupuytren's contracture

• 3rd sign in hands
• First affects 4th & 5th tendons
• Occurs in:

1. Normal
2. Cirrhosis, esp. alcohol-related (rarer in Hep B)
3. Diabetes mellitus
4. Systemic fibrosclerosing syndromes

DIAGRAM: leukonychia

White nails (Leukonykia)

• 4th sign in hands
• Rare: whiteness grows out from crescent until crescent obliterated
• Also assoc. with kidney disorders
• If while nail due to anaemia - whole nail would be pale

• 5th hand sign
• Occurs in severe hepatocellular decompensation
• Also occurs in other metabolic disorders - eg. CO2 retention

• Probably of intestinal origin
• Sickly sweet smell of faeces (more sickly sweet than faecal in nature)
• Occurs in:

Changes of body hair distribution

• Endocrine changes: liver normally degrades oestrogens
• Liver dysfunction ® less breakdown of oestrogen -> loss of secondary sexual hair

Testicular atrophy with decreased libido & potency

• Females: decreased libido, difficult to assess

• May be unilateral
• Occurs in:

1. Healthy adolescence
2. Chronic liver disease: more common in alcoholic liver disease
3. Chronic starvation
4. Testicular tumours: secrete oestrogens
5. Drugs (e.g. spironolactone - diuretic used to teach chronic liver disease, digoxin, cimetidine)

• To tell whether it is gynaecomastia or just fat: feel at areolar tissue - should feel like breast tissue and not fat

DIAGRAM: gynecomastia

Ankle pigmentation +/- leg ulcers (decrease in formed elements in blood secondary to enlargement of spleen with BM compensation)

• Ankle pigmentation: also occurs in thalassaemia
• Can regress after splenectomy
• Splenomegaly in chronic liver disease: due to portal HT pushing blood back into spleen
• Ankle (shin) pigmentation should be bilateral
• Also due to local trauma, herbal medicine application (unilateral) - ask Pt if has used any medicine

Signs of fluid retention

Easy bruising, purpura

• Purpura: subcutaneous bleeding
• Due to

1. Clotting factors manufactured in liver
2. Hypersplenism: low platelets

• Gr 1: confused; slurred speech
• Gr 2: drowsy; inappropriate behaviours
• Gr 3: stuporous; obeying only simple commands
• Gr 4: coma
• Gr 5: deep coma; no spontaneous movements

• Greenish jaundice
• Xanthelesma: cholesterol deposits on medial side of eyes(chronic liver disease: all over face)
• Xanthomas: cholesterol deposits at extensor areas
• Scratch marks: pruritis, deposition of bile salts beneath skin

DIAGRAM: Primary biliary cirrhosis (chronic obstructive jaundice): xanthelesma: all around eye

DIAGRAM: cholesterol deposits over neck

DIAGRAM: Summary of stigmata of liver disease

Hand: also Dupuytren's contracture

• Shape

- Fat

- Flatus: constipation

- Faeces: constipation

- Foetus: Pt tells you

- Fluid (bulging flanks): ascites

- Abnormal swellings: eg. Ca liver / colon

• Umbilicus

Note: umbilicus should be vertical in pregnancy

• Movement

1. Thoraco-abdominal respiration (men use abdomen more, women use thorax more)
2. Epigastric pulsation, eg., thin patients, transmitted pulsation (aortic aneurysm)
3. Visible peristalsis in intestinal obstruction

• Surface

1. Striae (acute abdominal distension with sub-cutaneous bleeding), eg., pregnancy, ascites
2. Dilated veins; occur in obstructed IVC or portal hypertension

1. Observe direction of flow: choose vein with no tributaries, use light pressure to empty vein and remove one finger, repeat but remove other finger; the one that fills fastest indicates the direction of flow
2. Increased prominence on standing up: should be increased prominence on standing

• Pigmentation, e.g., pregnancy, Addison's disease

DIAGRAM: dilated veins (infrared)

• Caput medusae
• Umbilicus flattened
• Ascites due to portal HT

DIAGRAM: dilated veins

• IVC obstruction all blood flows upwards
• Portal HT: blood flows away from umbilicus (flows upwards above umbilicus, flows downwards below umbilicus)
• Hernial orifices

• Get patient to relax (bend knees if necessary)
• Exposure from below breasts to pubic symphysis (adequate exposure, not overexposure!)
• Ask for presence of tenderness before touching abdomen
• Start with a gentle general survey of the whole abdomen (all quadrants)

1. Relax patient
2. Detect any gross abnormalities (eg. Ca caecum)
3. Detect any mild tenderness (that Pt may not know)

** THE ESSENCE OF PALPATION **

1. Ask patient to move his abdominal organs by deep breathing
2. Palpating hand kept still to "catch" descending organ(s) - at moment of palpation, hand doesn't move

Note normal surface anatomy

Normal upper rectus muscles not to be mistaken for L lobe

Normal liver maybe palpable on inspiration or be pushed down by thoracic abnormalities

Method of palpation

1. Start from RLQ
2. Hand in waiting position during inspiration; moves up during expiration
3. Bimanual palpation may help in detecting slightly enlarged liver

DIAGRAM: position of liver

• Upper border @ 5th IC
• Right lateral border @costal margin
• Lower edge costal margin
• MCL crosses line joining xiphisternum and umbilicus
• Lower lobe liver crosses rectus muscle: liver quite soft, so usually can't feel normal liver

DIAGRAM: hepatomegaly

• Liver may be pushed down therefore always percuss for upper border of liver

Cardinal Rules of Percussion

1. Percuss from resonant to dull
2. Finger to be percussed parallel to proposed area of dullness
3. Direction of movement of finger perpendicular to dullness

Eg. Ascites: finger to be percussed pointing towards toes

Note

1. Limit of lower border - make measurements at mid-clavicular lines & xiphisternum
2. Upper border: usually at 5th IC space

[(1) & (2) makes the span - quote span at MCL - normal 10cm in Chinese at MCL. N.B. liver can be larger than normal, can also be smaller than normal: eg. Cirrhosis in Chinese may result in small liver - therefore, if you cannot feel lower border, percuss above costal margin from below; upper border: percuss from upwards down]

3. Character of edge: smooth, nodular, sharp
4. Character of surface: smooth, nodular (eg. Ca liver; not the small nodules in cirrhosis, which are only 1cm diameter)
5. Consistency: soft, firm, hard (malignancy)
6. Any tenderness
7. Any bruit: not necessary to mention in every case (unless you are thinking about alcoholic cirrhosis or ca liver)

• Compression of aorta: due to ca liver, intrinsically vascular tumour, alcoholic hepatitis (rare in Chinese)
• Vascular tumour
• Alcoholic hepatitis

• Use finger tips
• Palpate along line joining umbilicus to L ant axillary fold (Gardner's line)
• Large spleens have notches: medial side (splenic hilum)

DIAGRAM: Gardner's Line

• Remember direction of line!
• Start at RLQ
• Move on expiration
• Whole of Gardner's line should be resonant (unless splenomegaly)
• Need to percuss above costal margin

Method to help detection of "difficult" spleens

1. Turn patient towards right
2. "Hook" spleen forward with hand at renal angle (angle formed by lateral border erector spinar muscle and lowest palpable rib) (not at rib - bony structure)
3. Percussion along line of palpation
4. In presence of ascites, try "dipping" of the spleen (ballottement): push down surface of abdomen, see if spleen will bounce back to hit hand
5. Spleen may "float" to a more lateral position in the presence of ascites

DIAGRAM: palpation of kidney: same and opposite sides

Bimanual palpation

 Palpation of the kidneys

• Note: only after you feel the kidney (still in inspiration to trap kidney) should you try bimanual palpation (moving rear hand)
• Bimanual palpation to "trap" rounded lower poles of kidneys on inspiration
• Right kidney lower than left: due to liver

*** Differentiation between spleen and left kidney *** (exam Q!)

1. Bimanual palpation for kidney; spleen is anterior (kidney is retroperitoneal)
2. Subcostal gap absent for spleen
3. Percussion dull for spleen: kidney has overlying bowels (therefore should have at least one segment that is resonant)
4. Notches for spleens > 10 cm

Note

• Both the spleen & the L kidney move with respiration
• Kidney is related to crux of diaphragm
• Spleen doesn't move along Gardner's line during respiration, it enlarges along Gardner's line

• Site
• Size
• Shape
• Localisation (abd. wall, intra-peritoneal, retroperitoneal)
• Movement (with respiration and by itself)
• Tenderness
• Consistency
• Pulsation

For liver, spleen, kidneys and other masses

Ascites

(1) Shifting dullness at flanks

• Percuss from umbilicus laterally until dull
• Hold finger in place
• Turn Pt on side
• Allow time for bowels to "float" after change of patient's posture (may massage abdomen); can be detected only when at least 1 L of fluid is present
• Then percuss laterally to prove previously dull area is not resonant (in fat Pt's: same area will be dull)

(2) Fluid thrill

• Put Pt's hand in mid-line of patient to damp down transmission through abdominal wall
• Flick abdomen on one side, feel for thrill on other side
• An insensitive test for fluid under tension

• Bowel sounds
• Wide range of normal (increased after eating, decreased after defecation)
• Increased bowel sounds for obstructive lesions or other obstructive lesions or other causes of gut hypermotility
• Decreased bowel sounds for adynamic ileus (eg. After surgery)
• "Splashing" for pyloric stenosis
• Shake Pt
• False +ve if tested too soon after meals