Spleen and Liver Examination OSCE — Palpation, Percussion, and Causes

Why Spleen and Liver Examination Is Tested

Detection of organomegaly is a core clinical skill tested throughout medical training. Examiners assess this station because it requires correct technique, anatomical knowledge, understanding of organ-specific signs, and the ability to generate a differential diagnosis for findings. Candidates frequently lose marks through incorrect starting position, direction of palpation, or inability to discuss causes of organomegaly.

Preparation

Wash hands, introduce yourself, confirm identity, obtain consent, and ensure adequate exposure (abdomen from xiphisternum to symphysis pubis, ideally to groin). The patient should lie flat with arms by their sides. Ask about tenderness before palpating.

Liver Examination

Palpation Technique

Begin palpation in the right iliac fossa — a massively enlarged liver can be missed if you start in the right upper quadrant. Place the radial border of your right index finger parallel to the right costal margin, pressing gently inward and upward. Ask the patient to breathe in deeply — the liver descends on inspiration and will meet your fingers. Move superiorly in 2 cm steps towards the costal margin. Mark the lower border.

The upper border of liver dullness is assessed by percussion — start in the right lung (resonant), percuss downward until dull (normally at the 6th intercostal space in the mid-clavicular line). The liver span is measured between the upper and lower borders.

Normal liver span: 8–12 cm in the mid-clavicular line. Greater than 12 cm is hepatomegaly.

Characteristics of an Enlarged Liver

Note:

• Size (cm below costal margin)
• Surface — smooth (hepatitis, CCF, fatty liver) vs nodular (cirrhosis, metastases)
• Edge — sharp (normal/hepatitis) vs irregular or rounded (malignancy)
• Consistency — soft, firm, or hard/rock-hard (malignancy)
• Tenderness — tender (hepatitis, CCF, acute alcohol) vs non-tender
• Pulsatility — pulsatile liver = tricuspid regurgitation

Causes of Hepatomegaly

Spleen Examination

Palpation Technique

The spleen enlarges inferiorly and medially from the left upper quadrant towards the right iliac fossa. Begin in the right iliac fossa and move towards the left costal margin, with your hand at 45° to the costal margin. Ask the patient to breathe in — the spleen notch may be palpable. Move in 2 cm steps towards the left costal margin.

Key features distinguishing spleen from other LUQ masses:

• Cannot get above it (extends to left costal margin)
• Notch palpable on medial border (not always, but pathognomonic if present)
• Moves inferomedially on inspiration
• Dull to percussion (unlike kidney which can be resonant if bowel overlies)
• Not ballottable (unlike kidney)

Percussing Traube's Space

Traube's space is the tympanic area over the stomach bubble in the left lower anterior chest (bounded by the 6th rib superiorly, the left costal margin inferiorly, and the mid-axillary line laterally). Normally tympanic. Dullness in Traube's space suggests splenomegaly (or a full stomach — ask if the patient has eaten).

Castell's Sign

Percuss in the lowest left intercostal space in the mid-axillary line during inspiration and expiration. Dullness on both occasions is normal. Dullness on inspiration but not expiration (or dullness throughout) is Castell's sign positive, suggesting splenomegaly. Useful when the spleen is just tipped.

Ballottement

Ballottement is used to assess a retroperitoneal mass (kidney). For the spleen (intraperitoneal), ballottement is NOT appropriate. This is a key examiner question: "Can you ballotte the spleen?" — the correct answer is NO.

Grading Splenomegaly

Causes of Splenomegaly

Portal Hypertension Signs

When you detect hepatosplenomegaly, look for signs of portal hypertension:

• Splenomegaly — due to increased portal venous pressure
• Caput medusae — dilated periumbilical veins (flow away from umbilicus in portal hypertension)
• Ascites — fluid thrill, shifting dullness
• Peripheral oedema
• Hepatic encephalopathy — asterixis (flap), constructional apraxia, confusion

Hepatosplenomegaly Differential

Both organs enlarged simultaneously suggests:

• Lymphoma / leukaemia / myeloproliferative disease
• Infective: EBV, CMV, malaria
• Portal hypertension with chronic liver disease
• Systemic inflammatory disease: sarcoidosis, amyloidosis
• Storage disorders: Gaucher's, Niemann-Pick

Mark-Scheme Checklist

Common Mistakes

Frequently Asked Questions

"How do I correctly percuss Traube's space and what does it mean?"

Traube's space is a roughly triangular tympanic area in the left lower chest representing the gastric air bubble. It is bounded superiorly by the left lobe of the liver and the 6th rib, inferiorly by the left costal margin, and laterally by the mid-axillary line. To percuss it, start medially and work laterally across the space. Normally the area is tympanic because the stomach contains air. Dullness throughout Traube's space suggests the spleen has enlarged and is displacing the stomach — this can be an early sign of splenomegaly before the organ is palpable. However, Traube's space will also be dull if the patient has recently eaten a large meal (full stomach) or if there is a left pleural effusion — always clarify when the patient last ate. Traube's space has a sensitivity of around 60-70% for splenomegaly, so a negative result does not exclude it. Combine with Castell's sign and palpation for the most reliable assessment.

"What are the key features that distinguish a spleen from a kidney on examination?"

This is a classic OSCE viva question. Key distinguishing features: the spleen is intraperitoneal and the kidney retroperitoneal — you can get above the kidney but NOT above the spleen (it is contiguous with the left costal margin). The spleen has a notch on its medial border, which if palpable is pathognomonic. The spleen moves inferomedially on inspiration; the kidney moves inferiorly. The spleen is dull to percussion because it is covered by peritoneum; the kidney may be resonant if overlying bowel is present. You can ballotte the kidney (bimanual, anterior push elicits posterior displacement) but NOT the spleen. The spleen is not palpable below the lower pole in the way the kidney is. In practice, a very large left-sided mass with dullness, a notch, and movement on inspiration is almost always a spleen — CML or myelofibrosis should be high on your differential.

"What are the causes of a pulsatile liver and what does it indicate?"

A pulsatile liver occurs when increased right atrial pressure is transmitted to the hepatic veins, causing the liver to expand and retract with each cardiac cycle. The most important cause is tricuspid regurgitation (TR) — the incompetent tricuspid valve allows right ventricular systolic pressure to be transmitted back through the right atrium into the hepatic veins. Other causes of transmitted pulsation include severe right heart failure, constrictive pericarditis, and Budd-Chiari syndrome (rare). In the OSCE, if you detect a pulsatile liver, state that you would like to auscultate the heart for a pansystolic murmur loudest at the lower left sternal edge, accentuated on inspiration (TR), look for raised JVP with prominent v waves, and assess for peripheral oedema and ascites. Tricuspid regurgitation in the context of a pulsatile liver, raised JVP, and signs of right heart failure is a classic clinical syndrome examiners test.

"What investigations would you request after finding hepatomegaly in an OSCE?"

Your investigation plan should be structured and justified. Bloods: FBC (anaemia, thrombocytopaenia in hypersplenism, white cell count — leukaemia), liver function tests (hepatitis pattern vs cholestatic pattern), coagulation (synthetic function), renal function and electrolytes, hepatitis B and C serology, autoimmune panel (ANA, anti-smooth muscle, anti-mitochondrial antibody), ferritin and transferrin saturation (haemochromatosis), immunoglobulins, and CMV/EBV titres if infective cause suspected. Imaging: abdominal ultrasound is first-line — assesses liver size, echogenicity, nodularity, biliary dilatation, portal vein flow, spleen size, and ascites. CT abdomen with contrast (triple phase) is used for focal lesions or suspected malignancy. MRI liver (hepatocyte-specific contrast) for further characterisation of focal lesions. Tissue: liver biopsy for histological diagnosis when non-invasive workup is inconclusive. Bone marrow biopsy if haematological malignancy is suspected. In the OSCE, prioritise investigations by clinical likelihood and say what you expect each to show.

"How does portal hypertension cause splenomegaly?"

Portal hypertension is defined as an increased gradient between portal venous pressure and hepatic venous pressure (hepatic venous pressure gradient, HVPG >5 mmHg; clinically significant >10 mmHg). In cirrhosis, architectural distortion and increased intrahepatic vascular resistance cause portal pressure to rise. This increased back-pressure in the portal system is transmitted to the splenic vein, causing congestion and engorgement of the splenic sinusoids. Chronically elevated splenic venous pressure leads to reticuloendothelial hyperplasia, extramedullary haematopoiesis, and fibrous tissue deposition, resulting in splenomegaly. The enlarged spleen then sequesters and destroys platelets, red blood cells, and white blood cells — hypersplenism — causing thrombocytopaenia (the most sensitive marker), anaemia, and leucopaenia. In severe portal hypertension, the spleen can be massively enlarged. Other portosystemic collaterals develop simultaneously: oesophageal varices, rectal varices, caput medusae, and spontaneous splenorenal shunts.

"What causes massive splenomegaly and how do I remember them?"

Massive splenomegaly (below the umbilicus) has a limited differential that examiners frequently ask about. The mnemonic CALM covers the key causes: CML (chronic myeloid leukaemia — often the largest spleens seen clinically), All others haematological (myelofibrosis, hairy cell leukaemia, lymphoma), Leishmaniasis (visceral — kala-azar, endemic in tropics/Mediterranean), Malaria (especially hyperreactive malarial splenomegaly/tropical splenomegaly syndrome). Gaucher's disease (lysosomal storage disorder) is the key metabolic cause. In the UK, the most common cause of massive splenomegaly is CML — these patients often present incidentally with a large firm mass in the left abdomen. Myelofibrosis presents with massive splenomegaly due to extramedullary haematopoiesis after bone marrow fibrosis. Always mention that you would take a travel history (malaria, leishmaniasis) and request a full blood count and blood film as first-line investigations.

Related guides: Abdominal Examination OSCE · Ascites Examination OSCE · Chronic Liver Disease History OSCE · Jaundice History OSCE · Blood Results Interpretation OSCE