Fig. 5D.39: Hackett’s grading system for palpable splenomegaly.

Fig. 5D.40: Demonstration of classical method of spleen palpation.

If edge is not felt move the hand diagonally towards LUQ by 1 cm during expiration.

Repeat the procedure.

Tip of the fingers are used to feel the splenic tip.

Bimanual (supine position) (Fig. 5D.41):

Place palm of left hand over the left lowermost rib cage posterolaterally, restricting the expansion of

left lower ribs on inspiration. While applying firm pressure with the left hand, ask the patient to take deep inspiration.

Insinuate the right hand beneath the left costal margin and feel for the splenic edge.

Bimanual (right lateral position):

Done with patient lying in right lateral position with the left hip and knee flexed.

Rest of maneuver is similar to above.

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Fig. 5D.41: Demonstration of bimanual method (supine position) of spleen palpation.

Hooking method (supine position) (Fig. 5D.42):

The physician hooks his fingers beneath the left costal margin as the patient inspires.

Fig. 5D.42: Demonstration of hooking method (supine position) of spleen palpation.

For better appreciability, patient is asked to lie down on his left fist just inferior to his left scapula

(Middleton’s maneuver) (Figs. 5D.43A and B)

From above, spleen may be continently palpable with two hands arching below the left costal margin

while patient is asked to take deep breath in/out slowly.

Hooking maneuver (right lateral position):

Examiner stands on left side facing towards the foot end

With one hand hook the left lower costal margin and with other hand, give a counter-pressure from the

posterolateral aspect.

Now ask the patient to take take a deep inspiration and feel for the tip of the spleen, by hooking the

fingers.

Dipping method:

It is done in marked ascites

Similar to dipping method of liver (as described below under the palpation of liver).

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Following methods of percussion have been discussed:

Castell’s method

Traube’s space percussion

Nixon’s method of percussion

Percussion by Castell’s method (spleen percussion sign)

With patient in supine position, percuss in the lowest left intercostal (IC) space in the anterior

axillary line (Figs. 5D.44 and 5D.47) (usually the 8th or 9th IC space—Castell’s point)

This space should remain resonant during full inspiration.

Figs. 5D.43A and B: Demonstration of hooking method with Middleton’s maneuver percussion.

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Fig. 5D.44: Percussing the lowest left intercostal space in anterior axillary line—Castell’s method of

splenic percussion.

Dullness on full inspiration indicates possible splenic enlargement (a positive Castell’s sign).

Most sensitive of all clinical signs with sensitivity 82% and specificity 83%.

Full inspiration Full expiration

Normal Resonant Resonant

Mild splenomegaly* Dull Resonant

Moderate/severe splenomegaly Dull Dull

*Percussion sign is considered positive, when a change in percussion note is observed between full expiration and full inspiration.

Percussion of Traube’s (semilunar) space

It is a semilunar space in the left anterior chest bounded by:

Above by 6th rib

Below by left costal margin

Laterally by midaxillary line. With patient supine, percuss inferior to lung resonance from medial to lateral (Figs. 5D.45 and

5D.47) (as described by Barkun). Normally, a tympanic note heard due to gastric air bubble.

Obliteration of Traube’s space Massive splenomegaly

Left-sided pleural effusion

Pericardial effusion

Enlarged left lobe of the liver

Full stomach or fundic mass

Upward shift of Traube’s space Left diaphragmatic paralysis

Left lower lobe collapse or fibrosis

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Fig. 5D.45: Percussion of Traube’s space.

Fig. 5D.46: Percussing the posterior axillary line in right lateral position (Nixon’s method).

Fig. 5D.47: Landmarks of Traube’s space and Castell’s sign.

Percussion by Nixon’s method

Patient is first placed in the right lateral decubitus position.

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Percussion starts at the midpoint of the left costal margin and is continued upward perpendicular

to the left costal margin (Fig. 5D.46).

Fig. 5D.48: Landmarks for Nixon’s method.

Normally, the level of dullness does not extend further than 8 cm above the costal margin and

splenomegaly is diagnosed if the dullness extends beyond 8 cm.

Causes of splenomegaly

Mild splenomegaly

Acute

infections

Septic shock, infective endocarditis, enteric fever, infectious hepatitis, infectious mononucleosis, brucellosis,

cytomegalovirus, toxoplasmosis

Chronic

infections

Tuberculosis, syphilis, brucellosis, chronic bacteremia, HIV

Parasitic

infestations

Malaria, kala-azar, and schistosomiasis

Inflammation Rheumatoid arthritis, sarcoidosis, systemic lupus erythematosus (SLE)

Others Congestive cardiac failure, thalassemia minor

Moderate splenomegaly

Neoplastic Lymphomas, acute leukemias, chronic lymphocytic leukemia, chronic myeloid leukemia

Nonneoplastic

Cirrhosis of liver (with portal hypertension), chronic hemolytic anemia, malaria, kala-azar, sarcoidosis, infectious mononucleosis, splenic abscess, amyloidosis, hemochromatosis, polycythemia vera

Severe (massive) splenomegaly

Common

causes

Chronic myeloid leukemia, myelofibrosis, kala-azar, primary splenic lymphomas (Hairy cell, mantle cell, marginal

B cell), portal hypertension (extrahepatic portal vein thrombosis), hyper-reactive malarial splenomegaly (tropical

splenomegaly)

Uncommon

causes

Gaucher’s disease, Niemann-Pick disease, thalassemia major, splenic cysts and tumors of spleen, mycobacterium avium complex (MAC) infection in HIV patients

Causes of Hepatosplenomegaly

Common causes of hepatosplenomegaly and associated features have been illustrated in Figure 5D.49.

Examination of Gallbladder

Location: Lateral edge of rectus abdominis near the tip of right 9th costal margin

Moves with respiration

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Upper border continues with liver

Fig. 5D.49: Causes of hepatosplenomegaly.

Causes of enlarged gallbladder:

Carcinoma head of pancreas

Common bile duct (CBD) obstruction

Mucocele of gallbladder

Carcinoma of gallbladder

Murphy’s sign: In acute cholecystitis, at the height of inspiration, patient stops breathing with a gasp

as a mass is felt.

Courvoisier’s law: In a jaundiced patient, if the gallbladder is palpable, it is unlikely to be due to a

CBD gallstone obstruction.

Examination of Kidney

Examination of Left Kidney

The right hand is placed anteriorly in the left lumbar region while the left hand is placed posteriorly in

the left loin (Fig. 5D.50).

Ask the patient to take a deep breath in, press the left hand forward and the right hand backward,

upward and inward.

Left kidney is usually not palpable (except when low lying or enlarged).

If palpable, it is described as bimanually palpable and ballotable.

Bimanually palpable: As it can be felt as a swelling between both right and left hands.

Ballotable: It can be pushed from one hand to the other. It is due to perinephric fat which allows the

free movement of the kidney in the retroperitoneum.

Palpation of Right Kidney

Place the right hand horizontally in the right lumbar region anteriorly with the left hand placed

posteriorly in the right loin (Fig. 5D.51).

Push forwards with the left hand, press the right hand inward and upward and ask the patient to take

a deep breath in.

The lower pole of the right kidney, unlike the left, is commonly palpable in thin patients and is felt as a

smooth, rounded swelling which descends on inspiration.

It is also bimanually palpable and ballotable.

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