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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 2  |  Page : 275-279

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


1 Departement of Pediatrics, Faculty of Medicine, Liver Institute, Menoufia University, Menufia, Egypt
2 Departement of Pediatrics, Liver Institute, Menoufia University, Menufia, Egypt

Date of Submission12-Jun-2014
Date of Acceptance15-Aug-2015
Date of Web Publication18-Oct-2016

Correspondence Address:
Moatseem Bedin Allah F Elemy
Kotour, Gharbiah, 31562
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.192417

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  Abstract 

Objectives:
The aim of the study was to determine liver and spleen span in normal Egyptian school children of 12–18 years of age in El-Gharbiah governorate using the ultrasonographic method.
Background:
A sound measurement of the liver and spleen size in children of different age groups is necessary to help the pediatrician exclude hepatomegaly and splenomegaly.
Patients and methods:
This study included 300 healthy Egyptian school children from El-Gharbiah governorate — Kotour district. The age of the children ranged from 12 to 18 years (156 boys and 144 girls). The children were divided into six groups (12 up to 13 years, 13 up to 14 years, 14 up to 15 years, 15 up to 16 years, 16 up to 17 years, and 17 up to 18 years). The age, weight, and height were assessed, and the BMI was calculated. The clinical liver span was estimated by percussion and palpation and compared with ultrasonography; in addition, the spleen size was obtained by ultrasound (US).
Results:
Normal liver and spleen length and range were obtained sonographically. There was strong positive correlation between clinical liver span and age, weight, height, BMI, and US liver longitudinal at midclavicular line and at midline diameters. In addition, there was strong positive correlation between US liver at midclavicular line and age, weight, height, BMI, US liver longitudinal at midline, and US spleen diameters (P<0.001).
Conclusion:
The study provides the normal values of clinical liver span and ultrasonography of liver and spleen size in healthy children from 12 to 18 years of age.

Keywords: children, clinical method, liver size, spleen size, ultrasonography


How to cite this article:
EL Shafie AM, Elnemr FM, Allam AA, Elemy MF. Correlation between clinical examination and ultrasound of liver and spleen span in normal children between 12 and 18 years. Menoufia Med J 2016;29:275-9

How to cite this URL:
EL Shafie AM, Elnemr FM, Allam AA, Elemy MF. Correlation between clinical examination and ultrasound of liver and spleen span in normal children between 12 and 18 years. Menoufia Med J [serial online] 2016 [cited 2019 Nov 20];29:275-9. Available from: http://www.mmj.eg.net/text.asp?2016/29/2/275/192417


  Introduction Top


The clinical assessment of liver size remains an important part of physical examination, and knowledge of its normal values at different ages is essential in children and adolescents. Such a 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 [1].

Anatomically, the liver lies in the right upper quadrant of the abdomen, just below the diaphragm. Clinical evaluation of liver size is generally practiced by palpating the lower border of the liver. However, the better way to describe the liver size is liver span. This assessment is performed by percussion from the upper to lower edge of the liver. Although percussion provides a physical measure of liver size, it remains only gross estimation. In fact, the liver size may be overestimated due to the pleural effusion or lung consolidation or underestimated due to tympani in the right upper abdomen [2].

Liver and spleen size vary widely according to age. Many diseases can affect their size, ranging from infective processes to malignant disorders. Palpation and percussion are the standard bedside techniques to document liver and spleen size but are far from accurate to detect small increase in size [3].

Clinical assessment of hepatomegaly by palpation and percussion has also been shown to lack both accuracy and reliability [4].

The spleen has to be enlarged two to three times its normal size to be clinically palpable [5].

Ultrasonography is a noninvasive, established, safe, quick, and accurate method for measurement of liver and spleen size [6].

Ultrasound (US) is an important imaging for evaluation of the liver size in children. It is easy to use, providing real-time image without anesthesia and ionizing radiation. However, few ultrasonic data are available for assessment of the liver span in children under 2 years of age [7].

This study aimed to determine liver and spleen span in normal Egyptian school children of 12–18 years of age in El-Gharbiah governorate using the ultrasonographic method. Liver measurement by ultrasonography was compared with clinical method and correlation was performed between mean liver sizes and age as well as BMI.


  Patients and Methods Top


Three hundred normal Egyptian school children were selected from preparatory and secondary school from El-Gharbiah – Kotour district. The age of the children ranged from 12 to 18 years, 52.0% boys and 48.0% girls. They were divided into six age groups: 12 up to 13 years, 13 up to 14 years, 14 up to 15 years, 15 up to 16 years, 16 up to 17 years, and 17 up to 18 years; each group included 17.3, 17.3, 16.0, 16.6, 16.0, and 16.6% children, respectively. This study has been approved by ethical committee; informed consent was taken from the caregivers of the included children. All children were examined by a pediatrician, and only healthy children were included in this study. Clinical exclusion criteria were acute or chronic hepatitis, jaundice, fever, macular or maculopapular rash, lymphadenopathy, children with altered clinical examinations, children bearing any chronic or acute diseases, and children with special stress on exclusion of blood transfusion.

The age, weight, and height were assessed, and the BMI was calculated. The liver span was obtained by percussion of the upper border and palpation/percussion of the lower border along midclavicular line (MCL) while the child was lying supine with knee slightly flexed. Liver sonography was performed at the same visit by the radiologist who was blind to the clinical result using Acuson computed sonography (mountain view, CA, US) 128 × F 13 (a sector 5 MHz probe). The liver length was measured with the child in the supine position and the section level along the MCL was determined by simultaneous demonstration of the right kidney as per standard methodology. The upper and lower points of the measurement of the liver span were marked and then measured from the sonographic image. The measurements were made during quiet breathing in younger children and during breath-holding in older children. The measurement of spleen length was the optically maximal distance at the hilum on the longitudinal coronal view (between the most superomedial and the most inferolateral points) as the spleen length at the hilum is considered the most reproducible linear measurement.

Statistical analysis

Analysis of data was carried out using an IBM computer utilizing statistical program for social science (version 18.0; SPSS Inc., Chicago, Illinois, USA). Description of quantitative variables was given as mean, SD, and range. The χ2-test was used to compare qualitative variables between groups. The unpaired t-test was used to compare quantitative variables in parametric data. The Mann–Whitney test was used instead of the unpaired t-test for nonparametric data. The analysis of variance test was used for comparison of quantitative data among different time points in the same group. P values less than 0.05 were considered significant and P values less than 0.01 were considered highly significant [8].


  Results Top


Measurements of weight, height, BMI, clinical liver span, US liver span at MCL and midline (ML), and US spleen span in age groups are shown in [Table 1].
Table 1: Clinical and ultrasonographic data of the studied groups

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There was statistically highly significant difference between age groups in weight, height, and BMI (P < 0.01).

There was statistically highly significant difference between age groups in clinical liver span, US liver at MCL, and US spleen (P < 0.01).

There was strong positive correlation between clinical liver span and age, weight, height, BMI, and US liver longitudinal at MCL and at ML diameters (P < 0.001) ([Table 2] and [Figure 1] and [Figure 2]).
Table 2: Correlation of variables in the studied groups

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Figure 1: Pearson correlation between clinical liver span and US liver longitudinal axis at midclavicular line (MCL) among studied children. US, ultrasound

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Figure 2: Pearson correlation between clinical liver span and US liver longitudinal axis at midline (ML) among studied children. US, ultrasound

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There was positive correlation between clinical liver span and US spleen longitudinal axis (P < 0.05) ([Table 2]).

There was strong positive correlation between US liver at MCL and age, weight, height, BMI, and US liver longitudinal at ML and US spleen diameters (P < 0.001) ([Table 2] and [Figure 3]).
Figure 3: Pearson correlation between US liver longitudinal axis at midclavicular line (MCL) and BMI among studied children. US, ultrasound

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There was positive correlation between US liver longitudinal at ML and age, weight, and BMI (P < 0.05) ([Table 2]).

There was 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 positive correlation between US spleen longitudinal axis and BMI and clinical liver span (P < 0.05) ([Table 2]).

There was no statistically significant difference between boys and girls regarding mean value of US liver longitudinal axis at ML. However, there was statistically significant difference between boys and girls regarding mean value of clinical liver span, US liver longitudinal axis at MCL, and US spleen span, being higher among female children than in male ones (P < 0.001) ([Table 3]).
Table 3: Comparison of liver and spleen spans in boys and girls

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  Discussion Top


In different countries, the liver spans were different in size. The results of this study differed with those of Mac Sween et al. [9] who studied 394 children of 1 week to 19 years of age, where both the upper and lower borders were determined by percussion, and this is the cause that the mean liver span was about 3 cm less than ours in comparable age groups.

The results of this study differed also with those of El-Mouzan et al. [0] who concluded that mean liver span increases from 7.9 cm at 12 years to 9.3 cm at 18 years.

In this study, there was strong positive correlation between clinical liver span and age, weight, height, BMI, and US liver longitudinal at MCL and at ML diameters (P < 0.001). There was positive correlation between clinical liver span and US spleen longitudinal axis (P < 0.05) and this agreed with the study by Safak et al. [1] in which 700 children aged 7–15 years were examined for sonographic measurement of liver and spleen size and they found that there was significant correlation between liver size and body parameters especially body weight.

This study also coincided with the study by Konus et al. [2] in which 307 children aged from 5 days to 16 years were examined sonographically for liver and spleen size measurement and there was also significant correlation between liver span and body parameters (weight, height, BMI).

This study also coincided with the study by Assadamongkol et al. [3] who found a significant correlation between liver span and BMI of children.

This study also agreed with the study by Tarawneh et al. [4] in which 517 adult Jordanian populations were examined for US liver span measurement and there was correlation between body weight and liver size.

There was strong positive correlation between US spleen longitudinal axis and age, weight, height, and US liver longitudinal at MCL diameters (P < 0.001). There was positive correlation between US spleen longitudinal axis and BMI and clinical liver span (P < 0.05).

The results of this study coincided with those of Megremis et al. [6] who studied 512 healthy children between the age of 1 day and 17 years and found that the mean longitudinal diameters of spleen span by US for children were 10.2 ± 0.81 in boys 12 up to 14 years, 9.8 ± 1.02 in girls 12 up to 14 years, 10.7 ± 0.90 in boys 14 up to 17 years, and 10.3 ± 0.69 in girls 14 up to 17 years.

The results of this study coincided also with those of Konus et al. [2] who found that the mean longitudinal diameters of spleen span by US were 9.7 ± 0.97 cm at 11 up to 13 years of age, 10.1 ± 1.17 cm at 13 up to 15 years of age, and 10.1 ± 1.03 cm at 15 up to 17 years of age.

In this study, the US longitudinal diameters of spleen span were studied with respect to sex, and the results revealed statistically significant difference between boys and girls regarding mean value of spleen longitudinal axis; this differed with the results of Safak et al. [1] and also with that of Konus et al.[12].

Conflicts of interest

There are no conflicts of interest.[14]

 
  References Top

1.
Kratzer W, Fritz V, Mason RA, Haenle MM, Kaechele VRoemerstein Study Group. Factors affecting liver size: a sonographic survey of 2080 subjects. J Ultrasound Med 2003; 95:1155–1156.  Back to cited text no. 1
    
2.
Seidel HM, Ball JW, Dains JE, Benedict GW. In: Dains JE, Benedict GW, eds. Abdomen. Mosby's guide to physical examination. 6th ed. Amsterdam: Mosby: Elsevier; 2006. 521–578.  Back to cited text no. 2
    
3.
Zhang B, Lewis SM. A study of the reliability of clinical palpation of the spleen. Clin Lab Haematol 1989; 95:7–10.  Back to cited text no. 3
    
4.
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 Gastroenterol 2004; 95:171–174.  Back to cited text no. 4
    
5.
French J, Camitta BM. In: Behrman RE, Kliegman RM, Jenson HB, eds. Splenomegaly. Nelson textbook of pediatrics. 17th ed. Philadelphia, Pa: Saunders 2004; 1675.  Back to cited text no. 5
    
6.
Megremis SD, Vlachonikolis LG, Tsilimigaki AM. Spleen length in childhood with US: normal values based on age, sex and somatometric parameters. Radiology 2004; 95:129–134.  Back to cited text no. 6
    
7.
Kaya S, Ramazan K, Cengiz Y, Yasar D, Taner B, Unsal O. Sonographic evaluation of liver and spleen size in school-age children. Turk J Med Sci 2000; 95:187–190.  Back to cited text no. 7
    
8.
Kirkwood BR. Essentials of medical statistics. 2nd ed. San Francisco, USA: Blackwell Scientific Publications; 2003.  Back to cited text no. 8
    
9.
MacSween R, Scothorne, R. In: Mac Sween RNM, Burt AD, Portman BCeds. Clinical estimation of liver span in infants and children. Pathology of the liver. 4th ed. London: Churchill Livingstone; 1–66.  Back to cited text no. 9
    
10.
El Mouzan MI, Al Salloum AA, Al Herbish AS, AlQureshi MM, Al Omar AA. Liver size in Saudi children and adolescents. Saudi J Gastroenterol 2009; 95:35–38.  Back to cited text no. 10
    
11.
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; 95:1359–1364.  Back to cited text no. 11
    
12.
Konus OL, Ozdemir A, Akkaya A, ErbaÛs G, Celik H, IÛsik S. Normal liver, spleen, and kidney dimensions in neonates, infants, and children: evaluation with sonography. Am J Roentgenol 1998; 95:1693–1698.  Back to cited text no. 12
    
13.
Assadamongkol K, Phuapradit P, Varavithya W. Liver size and serum alkaline phosphatase in normal Thai school-aged children. J Med Assoc Thai 1989; 95:89–91.  Back to cited text no. 13
    
14.
Tarawneh ES, Hadidy AM, Haroun AA, et al. Liver span by ultrasound. J Med J 2009; 95:197–204.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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