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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 2  |  Page : 382-386

Correlation between clinical examination and ultrasound of liver and spleen span in normal children between 12 and 18 years of age


1 Department of Pediatric, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pediatric, National Liver Institute, Menoufia University, Menoufia, Egypt

Date of Submission22-May-2014
Date of Acceptance07-Sep-2014
Date of Web Publication31-Aug-2015

Correspondence Address:
Abdelrazek M El-Afifi
Aga, Dakahliah 35111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.163889

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  Abstract 

Objectives
The aims of this study were to correlate liver span measured clinically in healthy Egyptian children from 12 to 18 years of age in Dakahliah with ultrasound findings, and to obtain normal values of both liver and spleen spans in Egyptian children.
Background
A sound measurement of the liver size in children of different age groups is necessary to enable the pediatrician to exclude hepatomegaly.
Participants and methods
This study included 331 healthy Egyptian school children from Dakahliah, Aga district, from 12 to 18 years of age of both sexes (224 male and 107 female). The children underwent a complete physical examination and subsequent ultrasonographic scans were performed for the liver and spleen. The liver span in the midclavicular line was estimated clinically by palpation and percussion, both the liver and the spleen were measured by ultrasonography, and the values were tabulated and graphed.
Results
Normal values of liver and spleen measures were classified by age and sex; data were tabulated and graphed. There was a statistically significant correlation between clinical and ultrasound measures of liver span (midclavicular line, midsternal line) in healthy children. The liver span also correlated with body weight, height, and BMI and ultrasound spleen axis.
Conclusion
We could record a standard liver and spleen normogram on Egyptian children from 12 to 18 years of age. Also, clinical estimation of liver span showed a significant correlation with ultrasonographic findings in all our healthy children; thus, we can continue to use clinical methods for the evaluation of liver size in children.

Keywords: clinical method, healthy children, liver size, sonography, spleen size


How to cite this article:
El-Shafie AM, El-Nemr FM, Allam AA, El-Afifi AM. Correlation between clinical examination and ultrasound of liver and spleen span in normal children between 12 and 18 years of age. Menoufia Med J 2015;28:382-6

How to cite this URL:
El-Shafie AM, El-Nemr FM, Allam AA, El-Afifi AM. Correlation between clinical examination and ultrasound of liver and spleen span in normal children between 12 and 18 years of age. Menoufia Med J [serial online] 2015 [cited 2017 Dec 14];28:382-6. Available from: http://www.mmj.eg.net/text.asp?2015/28/2/382/163889


  Introduction Top


Anatomically, the liver lies in the right upper quadrant of the abdomen, just below the diaphragm. The liver growth is a general type of growth. In children, the growth is in high velocity within 1-2 years of age [1] . It is important to evaluate the accurate size of the liver during this period. The clinical assessment of liver size remains an important part of a physical examination and knowledge of its normal values at different ages is essential in children and adolescents. This procedure is usually the first step in detecting an abnormal size of the liver. Although there are more accurate methods of assessing liver size such as ultrasonography (US), such methods are rarely available in clinics and primary healthcare centers in developing countries, and are usually considered as a second step [2] .

Clinical evaluation of liver size is generally performed by palpating the lower border of the liver. However, a better way to determine the liver size is liver span. This assessment is performed by percussion from the upper to the lower edge of the liver [3] .

Ultrasound is an important imaging for evaluation of the liver size in children. It is easy to use, providing a real-time image without anesthesia and ionizing radiation [4] . Assessment of liver size is an important part of the clinical skills of medical students and physicians, and determination of liver span is essential. Accordingly, in day-to-day clinical practice, physicians should be aware of the normal range of liver size in children of all ages [5] .

The spleen is the largest of the ductless glands situated principally in the left hypochondrium. It lies between the fundus of the stomach and the diaphragm; it is highly vascular and of a dark purplish color. Alterations in the size and shape of the liver and spleen occur in a wide variety of conditions. The presence of standards should aid in defining hepatosplenomegaly in various age groups and should help to prevent unnecessary evaluations [6] .

The aims of this study were to measure liver span in healthy Egyptian children from 12 to 18 years of age using both clinical and US methods and to compare between liver measurements obtained by clinical examination and those by ultrasound findings; we also attempted to establish normal values for both liver and spleen spans for healthy Egyptian children of the same age group.


  Participants and methods Top


Participants

In total, 331 normal Egyptian school children were selected from preparatory and secondary schools from the Dakahliah, Aga district. The age of the children ranged from 12 to 18 years, of both sexes: 67.7% male and 32.3% female. They were divided into six age groups: 12-13, 13-14, 14-15, 15-16, 16-17, and 17-18 years; each group included 21.15, 18.73, 21.15, 12.08, 11.78, and 15.11% children, respectively. All children underwent a full assessment of history, anthropometric measurements (weight, length/height, and BMI), and a complete physical examination. Consent was taken from the children and the study was approved by the ethical committee.

Inclusion criteria

All healthy children ranging in age from 12 to 18 years whose parents provided consent for their children to participate in the research were included in this study.

Exclusion criteria

Exclusion criteria were children with altered clinical or ultrasound examinations, children with any chronic or acute diseases, and those with history of blood transfusi special stress on exclusion of blood transfusion.

Methods

Clinical liver span determinations

Abdominal examination was performed systemically for all children by routine local abdominal examination of inspection, palpation, percussion, and auscultation. All liver span determinations were performed along the midclavicular line (MCL). The lower border of the liver was gently palpated in an upward direction, starting from the right iliac fossa, with the hand with fingers perpendicular to palpated edges. The upper border was defined by percussion in a downward direction and marked at the middle of the incident finger when a distinct change of tone to dullness was noted. The lower border was then lightly percussed, starting in the right lower quadrant, percussing upward and marked in the middle of the incident finger when change in dullness was noted. Then, span was measured using standard paper tapes.

Sonographic determinations of liver and spleen diameters

The children underwent an US scan with a portable log book unit (General Electrical Medical Systems), convex, multifrequency 3-7 MHz transducer. The equipment settings were standardized according to the protocol for pediatric abdomen. The measurements of the liver were performed in the right (MCL) and in the midsternal line (ML). The spleen was viewed along its longitudinal diameter in the midaxillary line; the margin between the lung and the spleen served as the upper limit of the spleen [7] .

Statistical analysis

The data collected were tabulated and analyzed using the statistical package for the social sciences (SPSS, version 17; SPSS Inc., Chicago, Illinois, USA) software, where quantitative data were expressed as mean and SD (X ± SD). The measurements of liver and spleen span were correlated with the age of the children, evaluated using Pearson's correlation coefficient. The independent Student t-test was used to compare measurements between the female and male groups. The significance level set was 0.05 [8] .


  Results Top


Measurements of clinical liver span, ultrasound liver span ML, ultrasound liver span MCL, and ultrasound spleen span in all age groups of our assay are listed in [Table 1].
Table 1 Mean clinical liver span, ultrasound liver span midsternal line, ultrasound liver span midclavicular line, and ultrasound spleen span in all age groups

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There was a strong positive correlation between age groups, BMI, clinical liver span, ultrasound liver span MCL, and ultrasound spleen span (P < 0.01) [Table 2].
Table 2 Spearman's correlation matrix between the variables studied

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There was a strong positive correlation between BMI and clinical liver span, ultrasound liver span ML, ultrasound liver span MCL, and ultrasound spleen span (P < 0.01) [Table 2].

There was a strong positive correlation between clinical liver span and ultrasound liver span ML and ultrasound liver span MCL, and ultrasound spleen span (P < 0.01) [Table 2].

There was no significant difference in clinical liver span and US liver span MCL between males and females [Table 1].

There was a strong positive correlation between US spleen longitudinal axis and age, weight, height, and US liver longitudinal at MCL diameters (P < 0.001) [Table 2].

There was a positive correlation between US spleen longitudinal axis and BMI and clinical liver span (P < 0.05) [Table 2] and [Figure 1] [Figure 2] [Figure 3] [Figure 4] [Figure 5] [Figure 6] [Figure 7]).
Figure 1: Scattered diagram showing the correlation between ultrasound liver span midclavicular line (MCL) measurement and clinical liver span

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Figure 2: Scattered diagram showing the correlation of clinical liver span measurement according to age

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Figure 3: Scattered diagram showing the correlation of ultrasound liver span midclavicular line (MCL) measurement according to age

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Figure 4: Scattered diagram showing the correlation of ultrasound liver span midsternal line (ML) measurement according to age

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Figure 5: Scattered diagram showing the correlation of ultrasound spleen span measurement according to age

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Figure 6: Scattered diagram showing the correlation between clinical liver span measurement and BMI

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Figure 7: Scattered diagram showing the correlation between ultrasound liver span midsternal line (ML) measurement and clinical liver span

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  Discussion Top


Accurate assessment of the size of the liver is very important in detecting and evaluating changes in liver size in a given patient and may also provide information on the diagnosis and course of many gastrointestinal diseases [6] .

Hepatomegaly is a frequent clinical finding in children, and may be caused by intrinsic liver diseases or by systemic alterations, and in case of clinical suspicion, US is generally the method of choice for initiating diagnostic investigations in pediatric patients [9] .

Determination of liver size is an important aspect of the clinical skills of medical students and physicians. Measurement of the liver span is essential and clinical evaluation of the liver size by palpation of the lower liver edge is a widespread practice. However, palpation alone is an unreliable index of the liver size because of variations in liver axis, the presence of a Reidel's lobe, and the position of the diaphragm [10] .

In this study, the mean liver span for 331 healthy children ranging in age from 12 to 18 years was established by percussion of the upper and lower border or percussion of the upper border and palpation of the lower border along the MCL; El Mouzan et al. [11] , used the same clinical methods for the detection of liver span by percussing the upper and percussing or palpating the lower border along the MCL in 18 112 healthy newborns, infants, and children up to 18 years of age.

Of the studies providing normative data on both liver and spleen size, Safak et al. [12] , studied 712 children 7-15 years of age and they reported data according to the body weight of groups. Konus et al. [13] studied liver and spleen sizes for 307 children and reported the data in height range and age group categories. Our results are comparable with these studies.

In our study, clinical liver span values were found to be related to age, ranging from 8.5 cm in 12 years to 11.1 cm in 18 years; these findings are consistent with the normal size reported in pediatric textbooks. Our results are almost similar to those found by El Mouzan et al. [11] in corresponding age groups.

Using ultrasound, longitudinal scans of the liver were obtained where longitudinal diameters both in the MCL and in the ML were measured. In this study, the mean MCL diameters of liver span by ultrasound for children aged from 12 to 18 years were detected and tabulated. The results of this study are similar to those of Assadamongkol et al. [14] , who found that the mean US MCL diameters of liver span for children were 9.88 cm at the age of 6-12 years.

The results of our study are also in agreement with those of another study of Silva [15] , where there was a good correlation between liver size obtained by clinical examination and ultrasound method; the mean value of clinical liver span was 8.8 ± 2 cm.

In our study, there was a strong positive correlation between ultrasound spleen span and weight, height, and BMI, and this was in agreement with the study of Safak et al. [12] , in which there was a significant correlation between ultrasound spleen span and weight (P < 0.001).


  Conclusion Top


The results of this study showed that liver measurement obtained by clinical examination correlates well with the ultrasound method in children ranging in age from 12 to 18 years. The estimation of liver and spleen span in healthy children of the same age in Egypt could be used as a normalized reference that can enable a physician interpreting liver and spleen size. Clinical liver span remains a simple practical measurement of liver size. The clinical estimation of liver span should help to prevent unnecessary costs in the use of US during routine evaluation of children.

Recommendations

Our study reports a highly significant correlation between clinical examination and ultrasound of liver span in healthy children between 12 and 18 years of age and that is a good indicator to depend on clinical method instead of ultrasound to preserve our resources and cost saving to people.

The values of liver and spleen span in our study can be used as normalized references for normal children between 12 and 18 years of age that may enable a physician to interpret liver and spleen size.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.
Demetris, AJ. Functional anatomy of the normal liver. 6th ed. Philadelphia: Lippincott Williams and Wilkins 2005;7-27.  Back to cited text no. 1
    
2.
Joshi R, Singh A, Jajoo N, Pai M, Kalantri SP. Accuracy and reliability of palpation and percussion for detecting hepatomegaly: a rural hospital based study. Indian J Gastroentero1 2004; 23 :171-174.  Back to cited text no. 2
    
3.
Kirmi E, Tuncer O, Atas B, et al. Correlation between clinical and radiological methods in estimation of liver span in neonates. Tohoku J Exp Med 2002; 197 :27-33.  Back to cited text no. 3
    
4.
Dittrich M, Milde S, Dinkel E, Baumann W, Weitsel D. Sonographic biometry of liver and spleen size in childhood. Pediatr Radiol 1983; 13 :206-211.  Back to cited text no. 4
    
5.
Lawson EE, Grand RJ, Neff RK, Cohen LF. Clinical estimation of liver span in infants and children. Am J Dis Child 1978; 132 :474-476.  Back to cited text no. 5
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6.
Radtke A, Schroeder T, Sotiropoulos GC. Estimation of liver size by percussion in normal individuals. Am Intern Med 2005; 70 :1183.  Back to cited text no. 6
    
7.
Chang S, Kim SH, Lim HK, Lee WJ, Choi D, Lim JH. Ultrasound of digestive diseases. AM J Roentgenol 2005; 80-85.  Back to cited text no. 7
    
8.
Morton, et al. In: Morton RF, Hebel JR, McCarter RJ, editors. Medical statistics. A study guide to epidemiology and biostatistics. 5th ed. Gaithersburg, Maryland: Aspen Publication 2006;71-74.  Back to cited text no. 8
    
9.
Laying F. Ultrasonography of the liver coated from alimentary tract radiology. 5th ed. Toronto: C.V.; 2000. 11.  Back to cited text no. 9
    
10.
MacSween R, Scothorne R. In: MacSween RNM, Burt AD, Portmann BC, editors. Clinical estimation of liver span in infants and children. Pathology of the liver. 4th ed. London: Churchill Livingstone; 2001. 166.  Back to cited text no. 10
    
11.
El Mouzan MI, Al Salloum AA, Alherbish AS, Al Qureshi MM, Omar AA. Liver size in Saudi children and adolescents. Saudi J Gastroenterol 2009; 15 :35-38.  Back to cited text no. 11
    
12.
Safak AA, Simsek E, Bahcebasi T. Sonographic assessment of the normal limits and percentile curves of liver, spleen, and kidney dimensions in healthy school-aged children. J Ultrasound Med 2005; 24 :1359-1364.  Back to cited text no. 12
    
13.
Konus OL, Ozdemir A, Akkaya A. Normal liver, spleen, and kidney dimensions in neonates, infants, and children: evaluation with sonography. Am J Roentgenol 1998; 171 :1693-1698.  Back to cited text no. 13
    
14.
Assadamongkol K, Phuapradit P, Varavithya W. Liver size and serum alkaline phosphatase in normal Thai school-aged children. J Med Assoc Thai 1989; 72 :89-91.  Back to cited text no. 14
    
15.
Silva RM, Pereira RB, Siqueira MV. Correlation between clinical evaluation of liver size versus ultrasonography evaluation according to body mass index and biotypes. Rev Med Chil 2010; 13:1495-1501.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Participants and...
Results
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Acknowledgements
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