VOL. 122, No.

2
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THE SIGNIFICANCE OF A PALPABLE LIVER*

A CORRELATION OF CLINICAL AND RADIOISOTOPE STUDIES

By ARTHUR T. ROSENFIELD, M.D.,t IGOR LAUFER, M.D.4 and PETER B. SCHNEIDER, M.D.
BOSTON, MASSACHUSETTS

H EPATIC palpation is routinely per- scan can give a measure of liver size that
formed and widely used to diagnose correlates well with autopsy findings.
liver enlargement. A palpable liver edge Methods to evaluate liver size on radio-
first draws attention to possible liver en- isotope scan using multiple levels of back-
largement, but most texts add the proviso ground erase,’4 planimetry,6 and area’ and
that percussion is necessary to define the volume calculations’#{176} have all been advo-
upper border of the 81213 However, cated. We have recently shown that a
their emphasis is placed on exclusion of single vertical measurement made at a
major downward displacement of the dia- point halfway between the xiphoid and
phragm and liver rather than on the use of right liver margin has excellent correlation
percussion and palpation together to ob- with hepatic disease.”
tam an exact liver span. In a limited series, Since many clinicians still accept the
Peternel et al.7 found that the upper border philosophy of F. M. Hanger, Jr. that “one
of the liver as determined by percussion good feel of the liver is worth any two liver
was frequently lower than that determined function tests,”2 the present study, using
by hepatic scintiscan (up to cm.). In our method, not only compares palpation
addition, pathology in the lower right with the radioisotope scan as an index of
pleural cavity such as consolidation may hepatomegaly, but also correlates both
make liver dullness seem higher than it those modalities with laboratory and tissue
actually is.’ The limitations of hepatic diagnosis to determine their relative reli-
percussion are well recognized and it ap- ability as criteria for hepatic pathology. In
pears that in practice palpation alone is addition, the projection of the liver below
widely. accepted as adequate for the detec- the right costal margin on scan is com-
tion of hepatomegaly. This is evidenced by pared with palpability.
our review of hospital charts which showed
MATERIAL AND METHOD
that percussion was frequently neglected
even when the liver edge was palpated. One hundred in-patient liver scans were
Furthermore, many patients, solely on the chosen randomly from scannings per-
basis of palpable edge, have been referred formed between 1967 and 1972 (age range
for liver scanning to evaluate “hepato- 24-85 years). These consisted of approxi-
megaly. mately equal numbers of studies done with
A comparison of physical examination colloidal Au’98 and Tc9lm sulfur colloid. The
with autopsy findings9 in a series of patients scans were made on a 5 inch dual head
showed that palpability was not a good rectilinear scanner with use of image dif-
index of hepatomegaly, but that study was fusion (data blending), and similar tech-
limited by variable time interval between nical factors were used in all cases. The
the physical examination and death and by xiphoid and the costal margin were indi-
the possibility of immediate premortem cated on the scan. At a point half-way be-
changes such as acute hepatic congestion. tween the xiphoid and the right liver mar-
Another study6 demonstrated that the liver gin, the vertical dimension of the liver was
* From the Nuclear Medicine Unit, Departments of Radiology and Medicine, Beth Israel Hospital and Harvard Medical School,
Boston, Massachusetts.
t Present Address: Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
Present Address: Department of Radiology, McMaster University Medical Center, Hamilton, Ontario, Canada.

313
 314 A. T. Rosenfield, I. Laufer and P. B. Schneider OCTOBER, 1974

pability. The scan size (mean ± s.d.) of the

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palpable livers was 15.5 ±3.3 cm. and of the

nonpalpable livers 14.0 ± 2.5 cm. As can be
seen from these data and the Figure, pal-
pability was not a good index of enlarge-
ment of the liver. For further analysis the
cases were divided into those with normal
and abnormal livers. A third group was
#{176}10
defined as those livers found enlarged by
scan.
Normal. Thirty-three of the TOO patients
were normal by all the following criteria:
. Normal SGOT, bilirubin, and LAP
(or alkaline phosphatase where the LAP
was not done) during the entire hospital
admission.
2. No tissue abnormality, if a biopsy or
10 12 14 16 18 20 22 24 26
SCANNED SIZE (cm)
postmortem examination was performed.
Fic. I. Palpability and scan size of liver in all cases 3. No focal abnormalities or heterogene-
of the series. Each column represents the scan ous uptake on the scan.
size ±0.5 cm. of the indicated size. This group is charted 2. The in Figure
scan size was 12.7 ±1.4 a maxi- cm. with
measured. Compared to other lengths, we mum size of 15.4 cm. There were 12 nega-
have shown this measurement to be the tive biopsies or autopsies and no positive
most reliable indicator of hepatic enlarge- ones. Of this group i of the 33 livers were
ment and pathology.” The projection of the palpable with a scan size of 12.9 ± 1.7 cm.
liver below the costal margin was also The i8 nonpalpable livers have a similar
measured. Each patient’s hospital chart size distribution with a mean of 12.5 ±o.6
was independently reviewed. All patients cm.
had determinations of SGOT and alkaline
phosphatase and most also had leucine
NORMAL CASES
amino peptidase (LAP) determinations.
The highest value of these enzymes re-
corded during the admission in which the
scanning was performed was noted for data
analysis. Autopsy or biopsy results, if done
within 6 months of the scan, were noted. U)
U)
The palpability of the liver as indicated on Cl)

the intern’s discharge summary was used

05
for comparison with the scan size. To ex-
U)
clude ambiguous cases, for the purpose of
this paper only, those palpable I cm. or z
more below the right costal margin were
regarded as palpable (i.e. those recorded
as palpable just at the costal margin were
regarded as nonpalpable).

RESULTS 12 14
SCANNED SIZE (cm)
All cases were charted according to scan
FIG. 2. Palpability and scan size of liver in cases
size as in Figure i with an indication of pal- with no evidence of hepatic disease.
 VOL. 122, No. 2 The Significance of a Palpable Liver 315

151
Abnormal. All the remaining 67 cases
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were considered abnormal. Of these, 35

had only abnormal SGOT, bilirubin, and/or
LAP, 3 had a positive tissue diagnosis of
c 101
hepatic disease but normal enzyme studies,
and 29 had both abnormal laboratory
values and a positive tissue diagnosis. The
tissue diagnoses consisted of 23 cases of
metastatic carcinoma, 3 of “fatty’ change,”
2 of cirrhosis, 2 of chronic hepatitis, I of

bile stasis due to common duct obstruction

and I sclerosing angiohamartoma. As can
12 14 16 18 20 22
be seen from Figure 3, the palpable livers SCANNED SIZE (cm)
were distributed throughout this group
FIG. 3. Palpability and scan size of liver in cases
with a scan size of i6. ±3.2 cm., com- with some indication of hepatic disease.
pared to the nonpalpable livers with a
scan size of i 5.o ± 2.7 cm. The largest
livers were all palpable. No significant dif- clinical extension below the costal margin
ference was noted in scan size or frequency of palpable livers which proved not to be
of palpability between the 36 cases which enlarged by scan (Table I: Group iii) was
were abnormal by enzymes alone and the 5.0 ±3.0 cm.
31 biopsy proven cases.
DISCUSSION
Enlarged 6y scan. Based on the analysis
of the normal group,” a size of greater than In only 59 per cent of our cases was there
15.5 cm. on the scan was defined as liver agreement between the presence or ab-
enlargement. All livers enlarged by this sence of hepatic enlargement as defined by
criterion were in the abnormal group dis- the scan and the clinicians’ findings by
cussed above. As can be seen from Figure palpation (Table I: Groups i and iv). The
i, of the 37 cases in this group only 24 were question then arises which of these diag-
palpable. The projection of the liver below nostic maneuvers is the more accurate or
the costal margin on the scan was 5.3 ±3.0 useful. Based on the analysis of our normal
cm. for the palpable livers of this group and group we have been able to define an upper
.6 ±3.0 cm. for the nonpalpable livers. limit of liver size as measured on the scan”;
The clinically noted extension below the i.e., every case in our series with a liver
costal margin of the palpable livers which “height” of I 5.5 cm. or greater, measured
were enlarged by scan (Table I: Group i) vertically at a point half-way between the
was 6.7 ±3.4 cm. For comparison, the midsternal line and the right lateral liver

TABLE I
CORRELATION OF PALPABILITY, ENLARGEMENT BY SCAN, AND DOWNWARD DISPLACEMENT OF LIVER

Distance Below Costal Margin

No. of Enlarged Scan Size
Group Palpable
Cases Scan (cm. ± S.D.) by scan by palpation
(cm. ± S.D.) (cm. ± S.D.)

I 24 + + 18.0±3.0 5.3±3.0 6.7±3.4

II 13 + - 17.6±1.4 5.6±3.0 0
III 28 - + 13.3±1.4 3.4±2.7 5.0±3.0
IV 5 - - 12.7±1.3 2.0±2.3 0
 316 A. T. Rosenfield, I. Laufer and P. B. Schneider OCTOBER, 1974

border, had some evidence of hepatic dis- livers were palpable. It is not clear why
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ease. Such a correlation with disease could such livers should have been missed by
not be derived from the palpability of the palpation. Ascites might interfere with
liver edge. It should be pointed out that palpation but this could have explained
the value for the upper limit of normal of only one of these cases. Obesity or other
scan size that we have adopted may be dif- variations of body build could well play a
ferent for different techniques of liver role, but such factors were not specifically
scanning. Since the liver edge as seen on an evaluated.
isotope scan is never an absolutely sharp A lack of experience on the part of the
line, its actual placement will vary some- physician might result in an inaccurate
what with the contrast properties of the physical examination and contribute to the
final scan image. However, for any given lack of correlation between palpability
scanning technique the normal liver and scan size of the liver. In our study the
“height” can be determined and regardless statement of palpability was taken from
of whether or not this measurement can be the discharge summary and any differences
directly converted to liver weight, which is between the intern and resident or visiting
the ultimate measure of hepatomegaly, it physician would presumably have been re-
serves as an index of liver size which is solved in favor of the most reliable exam-
better related to pathology than palpation. ination. As a further check this point,
of we
A normal liver size by scan obviously does analyzed our results on the basis of tn-
not rule out disease. monthly time periods and found that the
One of the possible explanations for the correlation between scan size and palpabil-
frequent palpability of livers which are not ity did not improve between the first and
enlarged by scan might be that some livers last quarter of the internship year, as it
are displaced downward by low lying might have if the house officers’ clinical
diaphragms. This is undoubtedly true in skills were a major variable.
some cases and indeed in our series there
CONCLUSION
was a significant difference (p <.o) be-
tween the mean displacement below the In conclusion, the chance of a palpable
costal margin of the normal size palpable liver being abnormal in our series is only
and nonpalpable groups (Table I: Groups 37/67 (57 per cent) and similarly the
III and iv). However, that cannot be a gen- chance of a palpable liver being enlarged by
eral explanation, since 14 of the palpable scan is 24/52 (46 per cent).
livers extended a shorter distance below the Palpability alone is not a useful indicator
costal margin than TO of the nonpalpable of hepatic size or disease.
livers. On the other hand, hepatomegaly can be
Another possible explanation is that defined by a simple measurement on the
those livers which are palpated but not radioisotope liver scan which if exceeded is
actually enlarged are diseased and there- an accurate indication of hepatic disease.
fore have a firmer consistency. In our series In our series 33/33 livers exceeding this
this was not the case since only 12 of the limit were abnormal.
28 livers which were palpable but not en- The liver scan is necessary for reliable
larged by scan (Table I: Group III) had assessment of size and may prevent or
any evidence of abnormality. There were limit unnecessary investigations for “hepa-
4 positive autopsies in this group and 6 tomegaly.”
negative ones; 3 biopsies were negative and
i positive. By contrast in Group ii (Table Peter B. Schneider, M.D.
Nuclear Medicine Unit
i) all had an abnormal LAP and 6 had a
Beth Israel Hospital
positive tissue diagnosis (no tissue was re- 330 Brookline Avenue
ported as negative), yet none of these 13 Boston, Massachusetts 02215
 VOL. 122, No. The Significance of a Palpable Liver 3I7

8. PRIoR, J. A., and SILBERSTEIN, J. S. Physical

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