Abdominal examination and stigmata of liver disease

01Purpose and principlesWhat the assessment is for and the core concepts behind it.

A good abdominal examination is a sequence of observations linked to clinical questions. Preparation includes hand hygiene, consent, appropriate exposure from xiphisternum to groins while covering breasts and genitalia, a supine patient with supported head and relaxed knees, warm hands and adequate light. Ask where pain is worst and watch the face throughout. In acute illness, physiology and resuscitation take priority over completing a ceremonial routine.

General examination provides the context for abdominal findings. Pallor, cachexia, jaundice, lymphadenopathy, fever, dehydration and bruising change the differential. In liver disease, inspect for clubbing, leukonychia, palmar erythema, Dupuytren contracture and asterixis; assess scleral icterus and oral health; look for spider telangiectasia, gynaecomastia and loss of body hair; then assess ascites, liver, spleen, collateral veins, hernias, peripheral oedema and mental state. Many signs occur in pregnancy, ageing, alcohol exposure or other systemic disease, so clusters and objective tests matter.

The abdominal examination should document scars, distension, movement with respiration, visible masses, veins, stomas and hernias. Gentle palpation identifies tenderness and guarding; deeper palpation assesses masses and organs. Percussion maps liver dullness, a possible spleen and ascites. Auscultation may identify bruits or markedly altered bowel sounds but has limited stand-alone value. Complete the assessment with groin orifices, external genital, rectal or pelvic examination only when clinically indicated, consented and appropriately chaperoned.

Key points

Introduce yourself, confirm identity, explain the examination, obtain consent, offer a chaperone where appropriate, preserve dignity and ask about pain before positioning or exposure.
Start at the end of the bed: distress, colour, body habitus, muscle wasting, mobility, drains, stomas, oxygen and mental state may be more important than a single abdominal sign.
Examine hands, pulse, face, mouth, chest, abdomen, legs and cognition because chronic liver disease and systemic abdominal illness are not confined to the abdomen.
Inspect before touching, auscultate before prolonged palpation when bowel sound interpretation matters, and examine the painful area last.
Guarding, percussion tenderness, rigidity, shock or pain out of proportion is an emergency surgical phenotype; do not repeat forceful manoeuvres while delaying imaging or senior review.
Spider naevi, palmar erythema, gynaecomastia, testicular atrophy, bruising, asterixis and Dupuytren contracture are neither individually sensitive nor specific for cirrhosis.
A palpable liver edge is described by distance, surface, consistency, tenderness and pulsatility; splenic enlargement is confirmed by movement with inspiration and imaging, not percussion alone.
Shifting dullness supports moderate ascites but ultrasound is more sensitive and guides safe paracentesis.

02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.

Peritonism and shockRed flag

Involuntary guarding, rigidity, percussion tenderness, absent movement with breathing, tachycardia, hypotension, cool peripheries or altered mental state suggests perforation, ischaemia, bleeding or severe inflammation.

Decompensated liver diseaseRed flag

Jaundice, ascites, oedema, bruising, sarcopenia, asterixis and confusion form a decompensation cluster. Seek infection, gastrointestinal bleeding, renal injury, alcohol-related hepatitis and medicine precipitants.

Portal hypertension

Splenomegaly, ascites, abdominal wall collaterals, thrombocytopenia, varices or a recanalised umbilical vein support portal hypertension; the direction and anatomy of veins are less reliable than Doppler and imaging.

Hepatomegaly phenotype

A tender liver suggests inflammation or congestion, a pulsatile liver suggests tricuspid regurgitation, and a hard irregular edge raises cirrhosis or metastases. Confirm position and morphology with imaging.

Abdominal mass or obstructionRed flag

A persistent mass, succussion splash, visible peristalsis, distension, vomiting, obstipation or a tense hernia needs urgent investigation, particularly with weight loss or anaemia.

03Method and interpretationA systematic approach to the test and its findings.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Focused observations and bedside glucoseFirst step
Why
Record NEWS2 elements, perfusion, urine output and glucose when acute abdominal or hepatic illness is possible.
Interpretation and limitations
Instability converts an examination finding into an emergency pathway; normal initial observations do not exclude evolving perforation, bleeding or sepsis.
02
Abdominal ultrasound
Why
Confirm ascites, gallbladder or bile-duct disease, organ enlargement, focal liver lesions and portal or hepatic venous flow without ionising radiation.
Interpretation and limitations
Operator, body habitus and bowel gas limit sensitivity. Ultrasound supports but does not replace CT in many acute surgical syndromes.
03
CT abdomen and pelvis
Why
Evaluate perforation, obstruction, ischaemia, haemorrhage, abscess, malignancy and deep organ pathology when the examination suggests acute or structural disease.
Interpretation and limitations
The request should state the clinical question and pregnancy, kidney and contrast risks; a negative scan must still be reconciled with persistent physiological deterioration.
04
Liver and decompensation blood profile
Why
Use FBC, renal and liver profile, INR, glucose, CRP and cultures where infection is possible; add paracetamol, lactate or blood gas in acute injury.
Interpretation and limitations
Normal enzymes do not exclude cirrhosis. INR, bilirubin, creatinine, sodium, platelets and clinical complications provide severity information.
05
Diagnostic paracentesis
Why
Sample new ascites or ascites during acute cirrhosis admission for cell count, bedside culture, albumin and protein after ultrasound assessment.
Interpretation and limitations
Neutrophils at or above 250 cells/mm³ support SBP; pus or polymicrobial growth suggests secondary peritonitis and surgical source assessment.
06
Endoscopy or targeted cancer pathway
Why
Investigate dysphagia, bleeding, iron-deficiency anaemia, altered bowel habit, palpable mass or other site-specific alarm features under current NICE guidance.
Interpretation and limitations
Physical examination neither excludes mucosal cancer nor replaces urgent referral when symptom criteria are met.

04Clinical next stepsHow the result changes management or prompts escalation.

01SequenceComplete abdominal examinationFirst stepA stable patient consents to a clinically indicated abdominal assessment.

1Introduce, identify, explain, consent and position; ask about pain, expose appropriately and preserve dignity with a chaperone where indicated.
2Assess from the end of the bed, hands, pulse, face, mouth and chest, then inspect the abdomen before gentle and deep palpation.
3Percuss liver, spleen and fluid, auscultate for the defined question, and complete groins, legs, cognition or rectal and pelvic assessment only when indicated.
4Summarise positive and important negative findings, propose the leading mechanisms and state the next tests rather than claiming a diagnosis from one sign.

02EscalateAcute abdomen responseEscalationExamination reveals peritonism, shock, pain out of proportion, major bleeding or obstructed hernia.

1Stop non-essential repeated examination, use ABCDE, gain intravenous access, provide analgesia and treat sepsis or haemorrhage under the local emergency protocol.
2Call senior surgical and anaesthetic or critical-care support early and obtain lactate, bloods, crossmatch and pregnancy testing where relevant.
3Request time-critical imaging without delaying theatre when the clinical diagnosis requires immediate source control.
4EscalationReassess physiology and pain after intervention and document the time and recipient of escalation.

03LiverSigns of decompensationJaundice, ascites, encephalopathy, bleeding, oedema or a portal-hypertension cluster is present.

1Assess mental state, glucose, bleeding, infection, renal function and alcohol or medicine precipitants; calculate severity only after immediate threats are addressed.
2Perform prompt ascitic tap when ascites is present during acute admission and arrange ultrasound with portal assessment.
3Use the current BSG/BASL decompensated cirrhosis care bundle and involve gastroenterology or hepatology early.
4Plan variceal, hepatocellular-cancer, nutrition and transplant assessment after stabilisation rather than treating the examination finding in isolation.

05Risks, monitoring and follow-upComplications, safety checks and further assessment.

Repeat abdominal examination when the clinical state changes, using the same descriptors for tenderness, distension, organ size and peritonism.
Trend NEWS2, urine output, glucose and lactate in acute illness and escalate on deterioration even if the first examination was equivocal.
Record weight, abdominal girth only where locally useful, oedema, mental state and renal function in decompensated cirrhosis.
After analgesia or intervention, reassess pain and guarding; appropriate analgesia improves humane and often more reliable examination.
Review imaging, paracentesis and endoscopy results against the original bedside hypothesis and revise it explicitly.
Document consent, chaperone, limits of examination and any declined component without implying that refusal is abnormal.

06Special situationsVariants, exceptions and circumstances that change the usual approach.

Asterixis is not liver-specific

Negative myoclonus occurs in hypercapnia, uraemia and drug toxicity as well as hepatic encephalopathy. Interpret it with cognition and physiology.

Jaundice needs natural light

Scleral icterus can be subtle and artificial lighting misleads. Objective bilirubin confirms the observation and fractionation helps identify mechanism.

A mass needs a description

Site, size, surface, edge, consistency, tenderness, mobility, pulsatility and movement with respiration convey more value than naming an organ prematurely.

Pain does not forbid examination

Explain, begin away from pain, use gentle observation and stop when distress outweighs benefit. Analgesia should not be withheld to preserve signs.

Normal examination has limits

Obesity, guarding, early disease and retroperitoneal anatomy reduce sensitivity. A reassuring abdomen cannot overrule shock, major biochemical abnormality or a strong history.

07Common pitfallsFrequent interpretation and management errors.

01
Performing a rote sequence while ignoring hypotension, confusion or severe pain.
02
Exposing the patient unnecessarily or omitting consent and chaperone discussion.
03
Calling one spider naevus proof of cirrhosis.
04
Repeatedly eliciting rebound tenderness rather than using gentler percussion tenderness and escalating.
05
Describing a mass as hepatomegaly without considering a low diaphragm, renal mass or bowel.
06
Concluding there is no ascites from absent shifting dullness despite a convincing syndrome.