I. Biliary Tract Examination (Liver, Gallbladder, Bile Ducts)
1. Inspection
- Observe for:
- Jaundice (yellowing of skin/sclera) → suggests biliary obstruction.
- Scratch marks → from cholestatic pruritus.
- Dilated veins (in chronic liver disease).
2. Palpation
- Gallbladder: Normally not palpable.
- If palpable:
- Smooth, tense, and painful: Acute cholecystitis.
- Non-tender, enlarged gallbladder + jaundice: Courvoisier’s sign → suspect malignancy of pancreatic head or common bile duct.
- Murphy’s Sign:
- Palpate RUQ and ask patient to inhale.
- Positive if patient halts inspiration due to pain → suggests acute cholecystitis.
3. Percussion
- Over the right subcostal area.
- Tenderness may be present in inflammation.
4. Auscultation
- Usually not helpful unless vascular bruits are suspected (rare).
II. Pancreas Examination
Note: The pancreas lies retroperitoneally, so it’s not directly palpable unless massively enlarged or displaced due to a mass or cyst.
1. Inspection
- Epigastric fullness in pancreatic cysts or pseudocysts.
- Jaundice if pancreatic head tumor compresses bile duct.
2. Palpation
- Deep palpation in the epigastrium may elicit:
- Tenderness in acute pancreatitis.
- A mass (e.g., cancer, cyst).
- A board-like rigidity in severe peritonitis (pancreatic rupture/necrosis).
- Cullen’s Sign: Bluish discoloration around umbilicus → hemorrhagic pancreatitis.
- Grey-Turner’s Sign: Bluish discoloration of flanks → retroperitoneal bleeding.
3. Percussion
- Not diagnostic for the pancreas itself.
- May reveal dullness in the upper abdomen in large masses or fluid collections.
4. Auscultation
- Usually non-contributory.
- In rare cases, a bruit may be heard in vascular tumors or aneurysms involving the pancreatic region.