OSCE Station Guide: Examination of the Liver and Spleen in Neonates, Infants, and Children

OSCE Station Overview

• Objective: Demonstrate the correct clinical technique for examining the liver and spleen in a newborn, an infant, and an older child.
• Candidate Instructions: Introduce yourself, obtain parental consent (or assent from older children), wash your hands with warm water/hand rub, properly position the patient, and systematically perform inspection, palpation, and percussion.
• Examiner Focus: Look for precision in age-specific landmarks, hands-on clinical skills, correct posture, and the ability to measure and describe organomegaly objectively.

General Principles and Pre-requisites for the Station

• Examiner Positioning: Always stand on the right side of the patient.
• Warm Hands: Ensure your hands and stethoscope chest piece are warm to touch. Touching a child with cold hands triggers reflex abdominal guarding.
• Adequate Exposure: Undress the child to fully expose the abdomen from the nipple line to the mid-thighs/groin. Make sure to cover non-examined areas with a sheet to provide privacy.
• Look at the Face: Crucial Examiner Tip: During palpation, do not look at your hand or the child's abdomen. Watch the child's face continuously to detect any wincing, apprehension, or signs of tenderness.
• Tender Areas Last: If the history or light palpation reveals any tender area, always examine that specific region last.

1. Examination of the Liver and Spleen in a Small Neonate (Newborn)

Pre-requisites & Positioning

• Setting: Conduct the examination on a fully exposed baby, ideally placed under a radiant warmer to prevent cold stress.
• State of the Baby: Catch the baby in a state of quiet wakefulness. Poking a crying or resisting baby is clinically fruitless, as a rigid abdomen masks all findings.
• Sequence: Use the "Look, Listen, Feel" sequence. Check the respiratory rate and abdominal shape first, then auscultate, and finally palpate the abdomen before the baby starts crying.

Step-by-Step Liver Palpation

• Technique: Place your warm finger pads gently on the abdominal wall lateral to the rectus abdominis; avoid sudden poking with fingertips.
• Direction: Start in the Right Lower Quadrant (RLQ) and work slowly upwards towards the right subcostal margin.
• Left Lobe Assessment: Repeat this procedure centrally/epigastric region to assess the left lobe of the liver, which can enlarge independently in neonates.
• Clinical Findings:
  • Normal Variant: A soft liver edge is normally palpable up to 1 to 2 cm (or 1 to 3 cm) below the right costal margin with a soft, smooth edge.
  • Pathological Hepatomegaly: A liver edge felt > 3.5 cm below the costal margin in a newborn suggests true hepatomegaly.

Step-by-Step Spleen Palpation

• Anatomy: In small neonates, the spleen enlarges straight down towards the left iliac fossa (LIF), unlike in older children.
• Direction: Place your fingers in the Left Lower Quadrant (LLQ) and work slowly upwards towards the left subcostal area.
• Clinical Findings:
  • Normal Variant: A palpable spleen tip (soft, smooth, non-tender, < 1–2 cm) is a normal variant in 30% of healthy newborns.

2. Examination of the Liver and Spleen in an Infant (1 Month to 1 Year)

Pre-requisites & Positioning

• Lap Examination: If the infant is irritable or has stranger anxiety, examine them sitting on the mother’s lap. If examined supine on the table, keep both hip and knee joints flexed to relax the abdominal wall.
• Pacification: If the infant is fussy, they can be put to the mother’s breast to pacify them and relax the abdominal rectus muscles.

Step-by-Step Liver Palpation

• Technique: Place your right hand parallel to the right costal margin, starting in the right iliac fossa.
• Respiratory Coordination: Press gently inward during expiration and allow passive outward movement. Hold your hand completely still during inspiration, letting the descending liver edge strike the radial border of your index finger.
• Cephalad Movement: Gently advance your hand 1–2 cm closer to the costal margin only during the expiration phase.
• Clinical Findings:
  • Normal Variant: A soft liver edge palpable 1 to 2 cm below the subcostal margin is normal.
  • Normal Liver Span: In infants, the normal liver span is 5 to 6.5 cm.

Step-by-Step Spleen Palpation

• Technique: Start palpating from the right/left lower quadrant, moving towards the left costal margin.
• Clinical Findings:
  • Normal Variant: Spleen tip is normally palpable in 15% of infants under 6 months of age.
  • Significant Splenomegaly: Spleen is significantly enlarged if it is palpable at least 1 cm below the costal margin in an infant older than 6 months.

3. Examination of the Liver and Spleen in an Older Child (>1 Year)

Positioning and Preparation

• Position: The child must lie completely flat and supine on a firm couch.
• Postural Tricks: Flex the child’s hips and knees to relax the abdominal musculature. Keep their arms relaxed by their side (not behind the head, which tenses the rectus muscles). Turn the child's head slightly to the left.
• Diverting Attention: Talk to the child politely throughout the exam to distract them and keep the abdomen soft.

Palpation of the Liver: Two Core Methods

• Method A: One-handed (Conventional Radial Border) Method:
  1. Place your right hand flat in the right iliac fossa (RIF) with the index finger oriented parallel to the right costal margin (fingers pointing towards the rectus abdominis).
  2. Ask the child to take slow, deep breaths.
  3. Exert gentle inward pressure. Feel for the descending liver edge striking the radial/lateral side of your index finger at the height of deep inspiration.
  4. Move your hand 1–2 cm upwards only during the expiration phase. Keep the hand completely still while the child is inhaling.
  5. Repeat until you reach the subcostal margin.
• Method B: Two-handed (Hutchison's) Method:
  1. Place both hands flat and side-by-side on the right subcostal margin with the fingers pointing directly towards the ribs.
  2. Move your examining fingers gradually upwards with successive deep breaths.
  3. The descending liver edge will strike the tips of almost all ten fingers, which is highly sensitive and preferred in obese children.

Percussion and Liver Span Measurement

• Core Principle: True hepatomegaly is determined by the total liver span, not just the extent below the costal margin. Conditions like emphysema or pleural effusion can push the diaphragm down, mimicking hepatomegaly despite a normal liver span.
• Step 1: Determine the Upper Border of Dullness:
  1. Percuss down the right midclavicular line (MCL) starting from the 2nd intercostal space (resonant note).
  2. Move progressively downwards until the note changes from resonant to dull. This normal transition point is at the 5th or 6th intercostal space. Mark this upper border.
• Step 2: Determine the Lower Border: Palpate the lower liver edge as described earlier and mark this point.
• Step 3: Measure: Use a tape measure to find the distance between the two marked points.
• Normal Liver Span by Age:
  • 1 to 5 years: 6 to 7 cm
  • 5 to 10 years: 7 to 9 cm
  • 10 to 15 years: 8 to 10 cm

Palpation of the Spleen: Three Core Manoeuvres

• Anatomy: In older children, the spleen enlarges diagonally from the left hypochondrium towards the Right Iliac Fossa (RIF).
• Method A: Classical Supine Palpation:
  1. Crucial: Always start palpating from the Right Iliac Fossa (RIF). If you start near the costal margin, you will completely miss a massive spleen.
  2. Place your right hand in the RIF with fingers pointing diagonally towards the left costal margin.
  3. Place your left hand posterolaterally over the left lower rib cage to support and gently push the spleen forward.
  4. Move your hand diagonally upwards during expiration, and hold still during deep inspiration, allowing the spleen tip to slide against your finger pads.
• Method B: Bimanual Palpation in Right Lateral Position (Shots Manoeuvre):
  1. If the spleen is not palpable supine, turn the child into the right lateral decubitus position.
  2. Support the lower left rib cage posterolaterally with your left hand and use your right hand to palpate during deep inspiration.
• Method C: Middleton's Hooking Manoeuvre (for minor/tip enlargement):
  1. Stand on the left side of the child, facing their feet.
  2. Use the hooked fingers of your left hand to palpate under the left costal margin.
  3. Place your right hand on the posterolateral aspect of the child's lower left thorax and exert gentle forward pressure to push the spleen into the hooked fingers.

Percussion of the Spleen

• Castell's Method:
  • Percuss in the lowest intercostal space (8th or 9th) in the left anterior axillary line.
  • Normal: Note is resonant and remains resonant during both full expiration and full inspiration.
  • Positive Castell's Sign: The percussion note changes from resonant to dull during full inspiration, indicating early splenic enlargement.
• Traube's Space Percussion:
  • Percuss Traube's semilunar space (bounded by the 6th rib superiorly, midaxillary line laterally, and left costal margin inferiorly).
  • Normal: Resonant/tympanitic note due to the stomach fundus.
  • Splenomegaly: The note becomes dull to percussion.
• Nixon's Method:
  • Place the child in the right lateral position.
  • Percuss from the lower level of pulmonary resonance down the posterior axillary line diagonally towards the lower mid-anterior costal margin.
  • Splenomegaly: An upper border of dullness extending > 8 cm above the costal margin suggests splenomegaly.

4. Special Situations: Dipping Method in Ascites

• If the child has tense ascites, fluid will prevent direct palpation of the liver or spleen.
• The Dipping Technique:
  1. Place your hand flat on the abdomen over the liver/spleen area.
  2. Make rapid, sudden dipping movements by flexing your metacarpophalangeal joints.
  3. This quickly displaces the fluid, allowing your fingers to hit the surface of the underlying organ, eliciting a distinct tapping sensation.

5. Grading and Describing Your Findings to the Examiner

Hepatomegaly Grading (Below Costal Margin)

• Mild: < 4 cm enlargement (does not reach the umbilicus).
• Moderate: 4 to 7 cm enlargement (reaches the level of the umbilicus).
• Massive: > 7 cm enlargement (extends well beyond the umbilicus).

Splenomegaly Grading (Hackett's Classification)

• Grade 0: Spleen is not palpable.
• Grade 1: Spleen tip is just palpable below the costal margin on deep inspiration.
• Grade 2: Spleen is palpable, but does not extend beyond a horizontal line halfway between the costal margin and the umbilicus.
• Grade 3: Spleen is palpable up to the level of the umbilicus.
• Grade 4: Spleen is palpable between the umbilicus and the pubic symphysis.
• Grade 5: Spleen extends up to or below the pubic symphysis.

Verbal Presentation To Examiner: Liver Findings

Verbal Presentation To Examiner: Spleen Findings

← 🩺 Examination Skills · See also 🩸 Hemolytic Anemia, 👶 Neonatal Jaundice