Teaching Plan 5

notre dame

hepatomegaly

Normal liver  its lower edge comes just to the lower edge

of ribs ( costal margin )on the right side  The edge: thin, firm, cannot be palpated below the edge of costal margin  1500g

Convex surfaces

Coronal ligaments attach to diaphragm

Concave surfaces

diagnosis  History  Physical examination

Physical examination

history  When did you notice a fullness or lump in

the abdomen?  How much has it changed or enlarged?  What other symptoms are also present?  Is there abdominal pain?  Is there any vomiting?  Is there any yellowing of skin?

history  Is there any unusual-colored or paled-

colored stools?  Have you had any fevers?  What medications are you taking?  How much alcohol do you consume?

Method: The right hand may be held either parallel or perpendicular to the long axis of the patient. In the midclavicular starting at the anterior superior iliac crest, examiner presses down firmly and asks patient to inhale deeply. This allows the liver to move down to meet your fingertips.

few centimeters toward the rib cage and repeat the maneuver. Do this continuously until you feel the liver or reach the coastal margin. √ Normally the liver is not palpable, but sometimes the examiner may feel the edge of the normal liver at or slightly below the right costal margin. √ When the liver is palpated, a firm edge will strike the fingers

√ In the midsternal line, from the level of the umbilicus, repeat the above maneuvers to palpate the liver. √ Most doctors like to use bimanual maneuvers to palpate the liver. To do this, place the left hand at right lower posterior chest wall parallel to, or supporting patient’s right 11-12th ribs or at lower sternal area to limit the chest respiration to make right hand palpation more

肝 ..\..\教学相关图片\肝脾肾触诊.rm脾肾触诊

below the costal margin, however, the organ should be considered abnormally large. √ An exception is a congenitally large right lobe of the liver, which occasionally extends quite far into the right flank. √ Another exception is seen in severe, chronic emphysema( 肺气 肿 ), in which the diaphragms are depressed by the overexpanded lung, displacing the liver below the costal margin. In both instances the total mass of

（ 2 ） If you feel the liver, detect the edge (sharp or round), tender or not, hard or soft and repeat the process laterally and medially to define the contour. For masses within the liver, describe the same characteristics as above and listen for a bruit over the mass.

Features of hepatomegaly  Palpable below the right costal margin ( in

gross hepatomegaly, it may extend to the left costal margin)  Downward movement on insiration  Dullness to percussion

Characteristic of the liver  Size  Consistancy: hard, film  Definition of liver edge:smooth, knobbly  Tenderness: engorged liver in right heart

failure  Pulsatility: as in tricuspid stenosis

Differetial diagnosis  Pulsatile liver  Fatty liver and nonalcoholic steatohepatitis

(NASH) 非酒精性脂肪肝

Pulsatile liver  Liver move with arterial pulsation  Expansile pulsation: Placing the hands on

opposite sides of liver and observing that the surfaces move apart in systole  Tricuspid insufficiency is the usual cause

Fatty liver and nonalcoholic steatohepatitis (NASH)  Increased accumulation of fatin hepatocytes  Associated with: obesity,

hypertriglyceridemia, diabetes, older age  Symptomatic in early stage  Later :cirrhosis, signs and symptoms of portal hypertension, hepatic insufficiency  Transaminases may or may not be elevated