The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

Examination of the Liver

Introduction: The liver is in general easier to feel than is the spleen. The left lobe can be palpated in the epigastrium in most patients. Proper clinical examination provides information on liver size, consistency, and tenderness. Examination over time can provide information about the liver’s reaction to certain conditions, particularly hepatitis and congestive  heart failure.


[Stanford 25 Video forthcoming, see bates video below.]


  • Before beginning, know the normal boundaries of percussion, specifically the “579 rule” of liver dullness as described in the pulmonary exam page.
  • Starting in the midclavicular line at about the 3rd intercostal space,  lightly percuss and move down.
  • Percuss inferiorly until dullness denotes the liver’s upper border (usually at 5th space in MCL–see the ‘579’ rule in Pulmonary exam).
  • Reposition percussion to below the umbilicus on the midclavicular line, begin in an area of tympany.
  • Percuss superiorly until dullness indicates the liver’s inferior border.
  • Measure span in centimeters.


  • Liver span: commonly clinically underestimated.
    • Midclavicular line: normally 6-12cm.
    • Midsternal line: normally 4-8cm.
  • False positives for enlarged liver span: right pleural effusion, consolidated lung.
  • COPD may depress diaphragm and hence depress liver borders, but not span.


  • With patient supine, place right hand on patient’s abdomen, just lateral to the rectus abdominis, well below lower border of liver dullness.
  • Ask patient to take a deep breath, try to feel the liver edge as it descends.
  • Be sure to allow liver to pass under the fingers of your right hand, note texture.
    • Pressing too hard may prevent this.
      • Some advocate using the left hand below the ribs to push up on the liver, but I think it adds nothing.



  • The normal liver may be slightly tender.
  • Greater tenderness suggests inflammation (e.g. hepatitis) or congestion (e.g. congestive heart dz).


  • Firm, bluntness/rounding of edge, & irregularity of edge suggest abnormality.
  • Obstructed, distended gallbladder may be palpable on inferior liver edge.
  • At times you can palpate nodules and if rock hard and umbilicated (central dimple) suggests malignancy.

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Written by stanford25admin

June 7, 2010 at 3:31 pm

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