10. Batas atas liver berada dua jari di bawah arcus costae dextra.

The patient physical examination shows the liver... Up to now, a considerably accurate way to measure the size of liver is by palpation. According to Stanford School of Medicine, the normal upper liver border is following 5-7-9 rule. It means the upper border of liver is in: 5th intercostal space in the midclavicular line 7th intercostal space in the midaxillary line, and 9th intercostal space in the scapular line(inferior border of scapula).

Another result different with that rule may indicate a pathological condition. The lowering of liver upper border can be cause by the abnormal condition of the liver or the liver is only affected by another organ. A book I found in NCBI said that a patient with emphysema would have a lower liver upper and lower border because the patient lung is hyperexpanded and his diaphragma is also flattened. In another case, large right pleural effusion would do the same, but in this case its hard to distinc the dullness of effussion or yhe liver. The complete differential diagnosis of liver percussion pathology shown in the table below: Table xxx. Examination Findings Associated with Specific Liver Diseases Liver disease Acute hepatitis Chronic hepatitis Palpation Smooth; surface tender Firm liver edge Nodules rare; tender Fulminant hepatitis Cirrhosis Tender surface Nontender, firm Shrinking size Variable; late stages, liver decreases in size Size Enlarged Enlarged, especially left lobe

Hepatocellular carcinoma (hepatoma)

Nodules, if present, large and Moderate to massive enlargement hard Nontender

Metastatic carcinoma

Large nodules Nontender

Enlarged

Liver disease Fatty liver Right heart failure

Palpation Smooth surface Firm, smooth, tender

Size Enlarged Mild to massive enlargement

In primary liver cancer, the consistency of liver is infiltrated by cancer cells which grow rapidly. The same enlargement occurs in lymphoma. Beside, in fatty liver the liver is enlarged by infiltration of fatty hepatocytes and the enlargement of them.

Text citation: Wolf DC. Evaluation of the Size, Shape, and Consistency of the Liver. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 94. Available from: http://www.ncbi.nlm.nih.gov/books/NBK421/ http://stanfordmedicine25.stanford.edu/the25/pulmonary.html

table citation: Wolf DC. Evaluation of the Size, Shape, and Consistency of the Liver. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 94. Available from: http://www.ncbi.nlm.nih.gov/books/NBK421/