Strengthening of intestinal noise is established at. Methods for examining the stomach
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Examination, percussion, auscultation of the abdomen
Plan
- 1. Examination of the abdominal organs in an upright position of the patient
- 1.1 Examination of the abdomen
- 1.2 Abdominal percussion
- 1.3 Auscultation of the abdomen
- 2. Examination of the abdominal organs in the horizontal position of the patient
- 2.1 Examination of the abdomen
- 2.2 Abdominal percussion
- 2.3 Auscultation of the abdomen
1. Examination of the abdominal organs in an upright position of the patient
1.1 Examination of the abdomen
Examination of the abdomen in an upright position of the patient begins with inspection.
The doctor sits on a chair, and the patient stands in front of the doctor, facing him, exposing his stomach.
For accurate localization of symptoms detected by physical examination, abdominal cavity conventionally divided into several areas (fig. 1.)
Figure: 1. Clinical topography of the abdomen (area): 1, 3 - right and left subcostal; 2 - epigastric; 4, 6 - right and left flanks; 5 - umbilical; 7.9 - right and left iliac; 8 - suprapubic
On the anterior abdominal wall, three departmentslocated below each other: epigastric, mesogastric and hypogastric... They are separated by two horizontal lines: the first connects the tenth ribs, the second - the anterior superior spine of the ilium.
Two vertical lines, held along the outer edges of the rectus abdominis muscles, each of the sections is divided into three aboutblusty:
- epigastric:for two hypochondrium (right and left) and epigastric (epigastric) located in the middle;
- mesogastric: on twolateral flank and on umbilical;
- hypogastric:on two located on the sides iliac area and suprapubic.
At the very beginning of the inspection, it is determined belly shape.
In a healthy person, the shape of the abdomen largely depends on its constitution. With an asthenic physique, the abdomen is somewhat retracted in the upper section and slightly protruded in the lower. With a hypersthenic constitution, the abdomen is evenly protruded anteriorly.
Attention should be paid to the symmetry of the abdominal changes.
In pathological cases, a retraction or significant protrusion of the abdomen is revealed. Uniform retraction of the abdomen is associated with an increase in the tone of the muscles of the anterior abdominal wall in patients with acute peritonitis, as well as in general exhaustion. Asymmetric retraction of the abdomen may be a consequence of the adhesion process.
Uniform protrusion of the abdomen is due to obesity, flatulence, ascites.
With obesity, the wrinkling of the skin remains, the navel is always retracted.
The skin of the anterior abdominal wall with ascites is thinned, shiny, without folds, the navel is often protruded. Huge ascites cause a significant symmetric increase in the entire abdomen in volume, small - only protrusion of the lower part.
Lower abdominal swelling may be associated with pregnancy, large uterine fibroids, ovarian cysts, or enlargement bladder in violation of the outflow of urine.
Stenosis of the distal colon (sigmoid or rectum), accompanied by flank flatulence, manifested by a clear smoothing of the lateral lines of the abdominal waist.
Asymmetrical protrusion of the abdomen occurs with a significant increase in individual organs: liver, spleen, tumors of the stomach, intestines, omentum, kidneys.
Physiological peristalsiscan be seen only with a pronounced thinning of the anterior abdominal wall or divergence of the rectus abdominis muscles, pathological - if there is an obstacle to the passage of food through the stomach or intestines. In this case, peristaltic waves arise above the place of the obstacle, are easily caused by a slight concussion of the anterior abdominal wall.
Normal abdominal skin is smooth, pale- pink with a matte shade.
In multiparous and thin women, it is wrinkled with whitish jagged stripes. Reddish-cyanotic stripes on the lower-lateral parts of the abdomen with the transition to the thighs are found in Itsenko-Cushing's disease. Character and localization postoperative scars make it possible to quite accurately establish the organ on which the operation was performed.
Under normal conditions, saphenous veins are visible in individuals with thin skin. The detected veins do not protrude above the skin surface.
If blood circulation is obstructed in the portal or inferior vena cava system, dilated veins on the anterior abdominal wall. System churn disturbance portal vein with cirrhosis of the liver, thrombophlebitis of the portal vein, pressure on it of a tumor, enlarged lymph nodes, compression or thrombosis of the inferior vena cava is manifested by tortuosity of the saphenous veins of the abdomen protruding above the surface.
A significant expansion of the convoluted veins on the anterior abdominal wall in the navel area is called " medusa's head"(caput Medusae).
Examination of the abdomen in an upright position ends with an examination beloy line, inguinal and femoral canalswhere a hernia is found. The outer inguinal ring usually freely passes the index finger, the inner one - only its tip.
Umbilical hernias and hernias of the white line of the abdomen are located above the navel. To detect hernias, it is necessary to palpate the hernial rings with the index finger, the expansion of which contributes to the formation of hernias.
In the upright position of the patient, it is possible to recognize the divergence of the rectus abdominis muscles by palpation of the white line of the abdomen.
1.2 Abdominal percussion
Percussion of the abdomen in the upright position of the patient is used to detect normal or increased intestinal gas filling, as well as free fluid in the abdominal cavity (ascites) with the determination of its level.
Percussion is carried out from top to bottom along the midline from xiphoid process to the pubis and on both sides along the flanks from p eberry arch to the ilium. The finger plessimeter is installed horizontallyntally(fig. 2.).
With a vertically mounted fingerpercussion is performed from the navel to the right and to the left flanks(fig. 3.).
The normal amount of gas in the intestine is characterized by a certain quality of the tympanic sound over different parts of the abdominal cavity.
A pronounced tympanic sound is heard during percussion in the umbilical and epigastric regions (above small intestine, gas bladder of the stomach).
Figure: 2.Percussion of the abdomen in the upright position of the patient
The tympanitis in the left flank and left iliac region should be shorter than the tympanic sound above the corresponding right parts.
Violation of this ratio of the severity of the tympanic sound with its amplification in the sections with dull tympanitis indicates metheorism.
In the presence of ascites (more than 1 liter) along all three lines, we obtain a horizontal level between the tympanic and the underlying dull sound (at the border between the loops of the small intestine that have floated upward and the fluid that has shifted downward). The difference in sounds is most clearly captured when using direct percussion according to V.P. Obraztsov.
1.3 Auscultation of the abdomen
Auscultationabdomen in a standing position of the patient is carried out to determine the rubbing noise of the peritoneum in the right and left hypochondria with perihepatitis and perisplenitis.
When a healthy person swallows liquid, listening to the epigastric region below or above the xiphoid process allows you to hear two noises: the first - immediately after swallowing, the second after 6-9 seconds. A delay or absence of a second murmur associated with the passage of fluid through the cardia indicates an obstruction in the lower third of the esophagus or in the cardiac region of the stomach.
2. Examination of the abdominal organs in the horizontal position of the patient
During the study, the patient should lie on his back, on a semi-rigid bed with a low headboard with a completely naked stomach, extended legs and arms along the body. The doctor should sit on the right side of the patient on a chair, the level of which is close to the level of the bed, turning sideways to her.
2.1 Examination of the abdomen
abdomen topography percussion auscultation
When inspection pay attention to the changes that occurred at the time of the change in the position of the patient's body. In a horizontal position, hernias visible to the eye usually disappear.
In the presence of free fluid in the abdominal cavity, the abdomen is flattened, which is distributed in lateral directions (the fluid spreads over the posterior surface of the abdominal cavity) and takes the form of a "frog".
Asymmetric bulging caused by an enlargement of the liver, spleen, the formation of cysts or tumors, and the presence of flatulence are more pronounced.
Local flatulence or protrusion of a limited section of the intestine with intestinal obstruction (Valya's symptom) is accompanied by intense peristalsis above the site of the obstruction that has arisen.
Bloating in the epigastric region, combined with visible peristalsis, indicates an obstruction to gastric emptying (pyloric stenosis).
In patients with pancreatitis, upon examination, bright red spots (aneurysms of small vessels) are revealed on the skin of the abdomen, chest and back (symptom of S.A. Tuzhilin), ecchymosis around the navel (Grunwald's symptom) and a strip of atrophy of the subcutaneous fat layer, according to the topographic position of the pancreas ( Grott's symptom).
The complete lack of mobility of the abdomen during deep breathing can be a sign of widespread peritonitis in patients with abdominal breathing. Local restriction of respiratory movements of the anterior abdominal wall occurs with severe pain syndrome, focal peritonitis.
2.2 Abdominal percussion
In the horizontal position of the patient percussion the abdomen is drawn along the same lines as in the vertical position of the patient. In addition, in the position of the patient on the back, and then on the side, percussion is performed from the navel to the flanks, setting the plessimeter finger vertically (Fig. 3.).
With ascites, the localization of a dull sound obtained by percussion in an upright position of the patient changes. Its horizontal level disappears, now a dull sound is defined above the lateral parts of the abdomen, and in the middle, above the floating intestines, we get a tympanic sound.
When the patient's body is turned to the side, the zone of dull sound in the flank located below increases due to additional fluid from the other flank. Tympanitis is revealed in the opposite flank (Fig. 3.). Turning the patient to the other side completely changes the percussion picture - in place of the former dull sound, a tympanic sound appears and vice versa.
Through percussion- palpation - Inducing fluid fluctuations also determine the presence of ascites. For this, the palmar surface of the left hand is applied to the right half of the abdomen in the dullness detection zone. With the right hand, one-finger percussion according to V.P. Obraztsov inflict light blows on the left half of the abdomen at the same level as the attached left hand (Fig. 4.). In the presence of a significant amount of free fluid in the abdominal cavity, the palm of the left hand clearly perceives fluctuation - jerky fluctuations of the fluid. To prevent the transmission of oscillatory movements along the anterior abdominal wall, you can place a hand or a book along the white line of the abdomen with an edge.
With the help of percussion, you can determine local pain in the epigastric region with an exacerbation of gastric ulcer or duodenum (Mendel's symptom). Briskly hit with the middle finger of the right hand on upper divisions rectus abdominis muscles. because of hypersensitivity of the parietal sheet of the peritoneum in the projection of the diseased organ, the blow is painful.
Figure: 3. Percussion of the abdomen in the horizontal (on the back and right side) position of the patient
Figure: 4. Percussion-palpation method for determining free fluid in the abdominal cavity (side view and top view)
2.3 Auscultation of the abdomen
To listen to intestinal motility, a stethoscope is installed at the projection site of the sigmoid, cecum and small intestine (Fig. 5.).
The point of auscultation of the sigmoid colon is between the outer and middle thirds of the line connecting the navel and the anterior superior iliac spine on the left.
Figure: 5. Auscultation of the abdomen: 1) sigmoid colon; 2) the cecum; 3) small intestine
The point of auscultation of the cecum is between the outer and middle thirds of the line connecting the navel and the anterior superior iliac spine on the right.
The point of auscultation of the small intestine is 2 cm from the navel along the line between the left costal arch and the navel.
In a healthy person, peristaltic sounds (rumbling) are heard, alternating with periods of absence of peristalsis.
The frequency of peristaltic murmurs above the large intestine is about 4-6 per minute, above the small intestine - 6-8 per minute.
Strengthening of peristalsis is detected with enteritis, colitis, accelerated movement of liquid contents through the intestines.
Lack of peristalsis is a sign of intestinal paresis, peritonitis.
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The position of the lower edge of the liver in the epigastrium in hypersthenics and asthenics is very different. (fig. 427).In hypersthenics, the lower edge from the nipple line stretches obliquely to the left and up, crossing the midline at the level between the upper and middle third of the distance from the base of the xiphoid process to the navel. Sometimes the edge of the liver lies at the apex of the xiphoid process.
In asthenics, the liver occupies most of the epigastrium, its lower edge along the midline lies at the level of the middle of the distance between the xiphoid process and the navel.
To the left, the liver extends 5-7 cm from the midline and reaches the parasternal line. In rare cases, it is located only in the right half of the abdominal cavity and does not go beyond the midline.
The anterior projection of the liver on the right is mostly covered by the chest wall, and in the epigastrium - by the anterior abdominal wall. The liver surface behind the abdominal wall is the most accessible part for direct clinical examination.
The position of the liver in the abdominal cavity is quite fixed due to two ligaments that attach it to the diaphragm, high
Figure: 427.The position of the lower edge of the liver in the epigastrium, depending on the type of constitution.
intra-abdominal pressure and the inferior vena cava, which runs along the posterior surface of the liver, grows into the diaphragm and thereby fixes the liver.
The liver is closely adjacent to adjacent organs and bears their imprints: on the bottom right - the hepatic corner of the colon, behind which is the right kidney and adrenal gland, in the front below - the transverse colon, gall bladder. Left lobe the liver covers the lesser curvature of the stomach and most of its anterior surface. The ratio between the listed organs can change with the vertical position of a person or developmental anomalies.
The liver is covered by the peritoneum on all sides, except for the hilum and part of the posterior surface. The parenchyma of the liver is covered with a thin, strong fibrous membrane (Glisson's capsule), which enters and branches into the parenchyma. The anterior lower edge of the liver is sharp, the posterior edge is rounded. When looking at the liver from above, you can see its division into right and left lobes, the border between which will be the falciform ligament (the transition of the peritoneum from the upper surface to the diaphragm). On the visceral surface, 2 longitudinal grooves and a transverse groove are determined, which divide the liver into 4 lobes: right, left, square, tail. The right longitudinal depression in front is designated as the fossa of the gallbladder, behind there is a groove of the inferior vena cava. In a deep transverse groove on the lower surface of the right lobe, there is a gate of the liver, through which the hepatic artery and portal vein enter with their accompanying nerves, the common hepatic duct and lymphatic vessels exit. In the liver, in addition to the lobes, 5 sectors and 8 segments are distinguished.
Above the abdominal cavity in healthy people, intestinal motility (rumbling) is usually heard. It is listened to with a phonendoscope (stethoscope) or directly with the ear.
Loud rumbling occurs with stenosis (narrowing) of the intestine, inflammatory processes in it (enteritis, colitis), accelerating the movement of liquid contents through the intestines, with diarrhea, etc.
The absence of sound phenomena above the abdominal cavity can serve as a sign of intestinal paresis and occurs with peritonitis.
When the sheets of the peritoneum become inflamed, a characteristic sound called the rubbing noise of the peritoneum is detected. It occurs when the rough sheets of the peritoneum are rubbed as a result of displacement of the abdominal organs during breathing. Most often, it is heard over the liver with perihepatitis, pericholecystitis, or over the spleen with perisplenitis.
Palpation of the stomach:
a, b - large curvature in the usual way and the "double hand" method;
c - by palpation auscultation;
d - percussion method;
e - in the upright position of the patient.
The accuracy of finding the greater curvature is checked by comparing palpation data with the results obtained using other methods of examining the lower border of the stomach.
Palpation:
Palpation of the pancreas
The pancreas is detected by palpation only when it is enlarged and compacted. Palpation (Fig. 62) should be done on an empty stomach, with an empty stomach. First, it is necessary to palpate the greater curvature of the stomach and the transverse colon in order to exclude the possibility of mistaking them for the pancreas and to determine the localization of the latter. The fingers of the palpating right hand are placed horizontally, parallel to the longitudinal axis of the pancreas, 2-3 cm above the greater curvature of the stomach. Their upward movements during inhalation create a skin fold. Then, with each exhalation, the fingers gradually sink into the abdominal cavity to its back wall and slide from top to bottom.
Normally, the pancreas is palpated through the stomach in the form of a soft, horizontally located, painless, motionless cylinder with indistinct contours with a diameter of 1.5-2 cm.
In chronic pancreatitis, the pancreas enlarges, thickens, becomes painful and therefore easily palpable. With tumors, cysts, it also increases, becomes lumpy, painful, often changes the shape of the abdomen, which already on examination makes it possible to detect its changes. It should be noted that tumors of the head and tail of the pancreas are easier to palpate than tumors of the body
Palpation of the gallbladder
The gallbladder is normally not palpable, since it is soft and almost does not protrude from under the liver (no more than 1 cm). With an increase (dropsy, purulent inflammation, the presence of stones, etc.) or thickening of its walls, it becomes palpable. However, palpation of the gallbladder must be carried out in all cases without exception, since there is a number of palpation signs (soreness, etc.) indicating its change, even if it is not palpable itself.
Palpation of the gallbladder is performed in the area of \u200b\u200bits projection (the point of intersection of the outer edge of the rectus abdominis muscle and the costal arch, or somewhat lower if there is an increase in the liver), in the same position of the patient and according to the same rules as with palpation of the liver.
An enlarged gallbladder can be palpated as a pear-shaped or ovoid formation, the nature of the surface of which and the consistency depend on the state of the bladder wall and its contents.
In the case of blockage of the common bile duct with a stone, the gallbladder relatively rarely reaches large sizes, since the resulting prolonged sluggish inflammatory process limits the extensibility of its walls. They become bumpy and painful. Similar phenomena are observed with a tumor of the gallbladder or the presence of stones in it.
You can feel the bladder in the form of a smooth elastic pear-shaped body shape in case of obstruction of the exit from the bladder (for example, with a stone or with empyema, with dropsy of the gallbladder, compression of the common bile duct, for example, with cancer of the head of the pancreas - Courvoisier-Guerrier symptom).
Much more often, palpation allows you to detect not the gallbladder, but pain points and symptoms characteristic of the inflammatory process in itself or in the bile ducts. For example, an inflammatory lesion of the gallbladder is evidenced by Ortner's symptom (the appearance of pain when lightly tapping with the edge of the palm along the costal arch in the area of \u200b\u200bits localization). In this case, you can also identify the symptoms of Zakharyin (sharp pain when tapping in the gallbladder), Vasilenko (sharp pain when tapping in the gallbladder at the height of inspiration), Obraztsov - Murphy (after a slow and deep immersion of the hand in the right hypochondrium on while exhaling, the patient is asked to take a deep breath; at this moment, pain arises or sharply increases).
In diseases of the gallbladder, soreness is detected in other points (Fig. 61). Often it is noted when pressing to the right of the X-XII thoracic vertebrae, as well as when tapping the edge of the hand or pressing a little to the right of the spine at the level of IX-XI thoracic vertebrae. You can also identify the phrenicus symptom (pain when pressing between the legs of the right sternocleidomastoid muscle).
Percussion gallbladder, as a rule, is also not defined. This is possible only with a significant increase in it (very quiet percussion is used).
Palpation of the liver
Before palpating the liver, it is recommended to determine its borders by percussion. This makes it possible not only to judge the size of the liver, but also to determine where to start palpation. The liver gives a dull sound during percussion, but since the lower edge of the lung partially covers it, then two upper boundaries of hepatic dullness can be determined: relative (true) and absolute. In practice, as a rule, the boundaries of absolute dullness, upper and lower, are determined.
When palpating the liver, certain rules and technique of execution must be observed. The patient should lie on his back with his head slightly raised and legs straightened or slightly bent at the knee joints. His hands should lie on his chest (to limit the mobility of the chest during inhalation and to relax the abdominal muscles). The examiner sits to the right of the patient, facing him, the palm of his right hand with slightly bent fingers is placed flat on his stomach, in the area of \u200b\u200bthe right hypochondrium, 3-5 cm below the border of the liver, found percussion, and with his left hand covers the lower section of the right half of the chest, moreover, 4 fingers position it behind, and the thumb - on the costal arch (Fig. 59, a). This limits the mobility (expansion) of the chest during inhalation and increases the downward movement of the diaphragm. When the patient exhales, the researcher pulls the skin down with a superficial movement, plunges the tips of the fingers of his right hand into the abdominal cavity and asks the patient to take a deep breath. In this case, the lower edge of the liver, descending, falls into an artificial pocket, bypasses the fingers and slips out from under them. The palpating hand remains motionless all the time. If it was not possible to feel the lower edge of the liver, the manipulation is repeated by moving the fingertips 1-2 cm up. This is done until, rising higher and higher, until the lower edge of the liver is palpated or the right hand reaches the costal arch.
Palpation of the lower edge of the liver is usually performed along the right mid-clavicular line or along the outer edge of the right rectus abdominis muscle. However, if necessary, it can be palpated along all 5 lines, starting with the right anterior axillary and ending with the left parasternal.
When a significant amount of fluid accumulates in the abdominal cavity, palpation of the liver becomes difficult.
In this case, it can be felt by jerky ballot palpation (Fig. 59, b). With closed 2, 3, 4 fingers of the right hand, jerky blows are applied to the anterior abdominal wall from bottom to top to the costal arch, until a dense body is found - the liver. With a push, it first moves away into the depths of the abdominal cavity, and then comes back and hits the fingers, that is, it becomes palpable (a symptom of "floating ice").
Normally, the liver is palpable in 88% of cases. Its lower edge is located at the edge of the costal arch, along the right mid-clavicular line. It is soft, sharp or slightly rounded, even, painless, easily tucked up on palpation.
The location of the liver below the edge of the costal arch indicates its increase or displacement. This issue can be resolved only when determining the position of its boundaries, which is done percussion.
If the size of the liver does not change, then the displacement of the lower border of hepatic dullness, occurring simultaneously with the unidirectional displacement of its upper border, speaks only of the prolapse of the liver. With an increase in the liver, only its lower border shifts downward. This is observed with stagnation of venous blood in the liver (congestive liver), inflammatory processes in the liver and biliary tract, with some acute infectious diseases (dysentery, typhoid fever, cholera, malaria), in the initial stage of liver cirrhosis, etc.
Displacement of only the lower border of the liver upward can be caused by a decrease in the size of the liver (for example, in the final stage of its portal cirrhosis).
Displacement of the upper border of the liver (up or down) is relatively rarely caused by damage to the liver itself (the upper border can move up in cancer or echinococcosis of the liver). Most often this happens for other reasons (high standing of the diaphragm with flatulence, ascites, pregnancy; low - with emphysema, pneumothorax, enteroptosis; displacement of the liver from the diaphragm in cases of gas accumulation under the diaphragm). With right-sided exudative pleurisy, pneumonia, pulmonary infarction, wrinkling of the lower lobe of the right lung, an apparent displacement of the upper border of hepatic dullness upward is possible.
In some cases, it is possible to palpate not only the lower edge of the liver, but also part of it (fingers are placed immediately under the right costal arch and, easily pressing on the abdominal wall, slide along the surface of the liver). At the same time, they find out the features of its surface (smooth, even, bumpy), consistency (soft, dense), reveal the presence of pain, etc.
A smooth, even, soft surface of the liver with a rounded edge, tenderness on palpation is observed in inflammatory processes in the liver and intrahepatic biliary tract, as well as in acute stagnation of blood due to heart failure.
A bumpy surface, unevenness and compaction of the lower edge is noted with syphilitic liver damage, echinococcosis. Especially sharp density ("wood") is detected in case of liver cancer.
Compaction of the edge of the liver occurs with hepatitis, cirrhosis (an uneven surface is also noted).
Soreness of the liver on palpation is observed with an inflammatory process or stretching it (for example, congestive liver).
The size of the liver is determined by the Kurlov method (Fig. 60). To do this, measure the distance between the upper (found percussion) and lower (found percussion and palpation) borders of the liver along the right median-clavicular and anterior median lines, as well as along the left costal arch (the distance between the set point along the left costal arch and the conditional upper border liver along the anterior midline - oblique size). The normal size of the liver along the mid-clavicular line is on average 9 ± 1-2 cm, along the anterior median line - 8 ± 1-2 cm, along the left costal arch - 7 ± 1-2 cm.
Liver percussion
The liver gives a dull sound during percussion, but since the lower edge of the lung partially covers it, then two upper boundaries of hepatic dullness can be determined: relative (true) and absolute. In practice, as a rule, the boundaries of absolute dullness, upper and lower, are determined.
With liver percussion, the patient should be in a horizontal position. The finger plessimeter is placed parallel to the desired boundary.
The upper limit of absolute hepatic dullness can be determined along all lines that are used to find the lower edge of the lungs, but are usually limited to percussion along the right parasternal, midclavicular and anterior axillary lines. At the same time, they use quiet percussion. Percussion from top to bottom, from clear to dull sound. The found border is marked with dots on the skin along the upper edge of the plessimeter finger, that is, from the side of a clear sound. Normally, the upper limit of the absolute dullness of the liver is located on the peri-sternal and mid-clavicular lines, respectively, on the upper and lower edges of the VI rib and on the anterior axillary line on the VII rib. The upper limit of relative dullness lies on the edge above. To determine it, use percussion of medium strength.
The lower limit of absolute hepatic dullness is determined along the anterior axillary, midclavicular and peri-sternal lines on the right, along the anterior midline, on the left - along the peri-sternal line. Percussion from bottom to top from tympanic sound to dull.
The found border is marked on the skin with dots along the lower edge of the plessimeter finger, that is, from the side of tympanitis.
In a healthy person of normosthenic constitution, the lower border of hepatic dullness on the left peri-sternal line is located along the lower edge of the left costal arch, on the anterior median - on the border between the upper and middle thirds of the distance from the xiphoid process to the navel, on the right periosternal line - by 1.5-2 cm below the lower edge of the right costal arch, on the mid-clavicular - along the lower edge of the right costal arch, on the anterior axillary line - along the lower edge of the X rib.
In persons of asthenic constitution, the lower edge of the liver is located somewhat lower, and hypersthenic - higher than in normosthenics, but this mainly concerns only the border located along the anterior midline. In the upright position of the patient, the lower edge of the liver shifts downward by 1-1.5 cm.
The boundaries of the liver can also be determined by the Kurlov method. For this purpose, along the mid-clavicular line on the right, the upper border of the absolute dullness of the liver is found, as well as its lower edge (Fig. 58, b, c), and the lower border is determined along the anterior midline (Fig. 58, a). The upper limit on this line is conditional (it is impossible to establish it, since here the liver borders on the heart, which, when percussed, also gives a dull sound). To determine this border through a point located on the mid-clavicular line and corresponding to the level of the upper border of absolute hepatic dullness, draw a horizontal line until it intersects with the anterior midline (Fig. 58, e). The intersection will be the upper border of hepatic dullness along the anterior midline.
Then the borders of the liver are determined along the left costal arch. To do this, the plessimeter finger is installed perpendicular to the lower edge of the left costal arch, somewhat inward from the anterior axillary line (Fig. 58, e). Percussion is carried out along the costal arch until a dull sound appears and a point is put. This will be the border of the liver in the region of the left costal arch.
It is possible to determine the size of the liver only after palpation of its lower edge, which makes it possible to clarify its localization, as well as to get an idea of \u200b\u200bits outlines, shape, consistency, soreness and features of the surface of the liver itself.
Abdominal percussion
Percussion of the abdominal cavity is mainly used to detect free fluid in the abdominal cavity, determine the size and location of the liver and spleen, etc. When percussion of the abdomen (finger on the finger) normally reveals a tympanic percussion sound, higher above the intestine than above the stomach ... However, it is rarely possible to determine this difference, since in this case the corresponding skill is required.
If there is free fluid in the abdominal cavity, if the patient is in a horizontal position, it is placed along the back wall, filling the flanks. In such cases, a dull sound is detected over the lateral parts of the abdomen. In the middle of the abdomen, a tympanic sound is detected due to the intestines floating above the fluid. When the patient is turned on the side, a dull sound in this side is replaced by a tympanic one. It is also provided by the gas-filled intestines at the top. In the upright position of the patient, the tympanic sound above the intestine is replaced by a blunt sound above the liquid.
The presence of fluid in the abdominal cavity can also be detected using the fluctuation method (Fig. 57, a). For this, the left hand brush is applied with the palmar surface to the right half of the abdomen. With the fingers of the right hand, short light pushes are applied to the left half of the abdomen, in the dullness detection zone, which, if there is a large amount of free fluid in the abdominal cavity, are clearly felt with the palm of the left hand. To exclude the possibility of transmission of shocks in a wave-like manner along the abdominal wall, it is necessary that the patient (or the assistant investigator; put his palm on the midline of the abdomen with an edge, vertically (Fig. 57, b).
Above superficially located tumors of large sizes and inflammatory infiltrates in a limited area with percussion, a dull and dull sound can be detected.
With the help of one-finger percussion with the pulp of the terminal phalanx of the middle or index finger of the right hand according to the Yanovsky method, it is possible to determine local soreness in the epigastric region that occurs during exacerbation of gastric ulcer and duodenal ulcer.
Palpation of the gatekeeper
The gatekeeper should be palpated (Fig. 56, e) in the area of \u200b\u200bthe rectus abdominis muscle, in the triangle formed by the costal arch, the midline of the abdomen and a horizontal line passing 3-4 cm above the navel or at the location of the greater curvature of the stomach. On palpation, the slightly bent fingers of the right hand are set parallel to the longitudinal axis of the pyloric stomach along the bisector of the right angle of the above triangle. During the inhalation of the patient, a skin fold is formed by a superficial movement of the palpating fingers upward. In the exhalation phase, the fingertips of the right hand are immersed deep in the abdomen and with a sliding motion directed perpendicular to the longitudinal axis of the pylorus from top to bottom and to the right, they are rolled over the pyloric section of the stomach. The latter is palpated in the form of a thin cylindric that changes its shape and consistency in accordance with the phases of contraction and relaxation of its muscles. This is the so-called peristaltic play of the gatekeeper. In the contraction phase, which lasts 40-50 s, the gatekeeper is felt in the form of a dense elastic cylinder with a diameter of about 3 cm; when relaxing - in the form of a sluggish, flattened, sedentary, painless strand 3-5 cm wide.
On palpation of the gatekeeper, you can hear a faint rumbling caused by the movement of liquid and small gas bubbles from it into the duodenum due to pressure. The mobility of the gatekeeper is 2-3 cm up and down. Normally, it is palpable only in 20-25% of cases. The gatekeeper is more accessible to palpation during contraction (pylorospasm). This is observed in gastric ulcer, duodenal ulcer, with increased acidity of gastric juice. With tumors, the pylorus is dense, inactive, painful, its surface is bumpy.
Palpation of the stomach
The stomach is palpated in the epigastric region with four folded together bent fingers of the right hand. They are installed 3-5 cm below the xiphoid process parallel to the position of the greater curvature of the stomach (Fig. 56, a). A superficial movement of the fingers up to the xiphoid process first creates a skin fold. Then, during the exhalation of the patient, the fingertips are immersed in depth and, upon reaching the spine, slide them from top to bottom. As long as the fingers are over the stomach, a rumbling can be felt. It is caused by the movement of fluids and gases in the stomach due to deep sliding palpation.
Breathing excursions contribute to better palpation of the stomach. Therefore, the patient should be offered to calmly and deeply "breathe in the stomach." In the expiratory phase, the greater curvature of the stomach goes up, and the examiner's fingers make a downward movement and slide off a small elevation in the form of a step formed by a duplicate of the greater curvature, which is felt at this moment as a soft elastic arcuate roller located on both sides of the spine.
To find the greater curvature, you can use the "double hand" palpation method (Fig. 56, b). For this purpose, the fingertips of the left hand are placed on the terminal phalanges of the right hand and deep sliding palpation is performed with them. Normally, the greater curvature of the stomach in men is 3-4 cm, in women it is 1 - 2 cm above the navel and is palpable in 50-60% of cases. When the stomach is lowered, it may lie below the navel.
When palpating the stomach, in addition to determining its localization, one should pay attention to the consistency, surface and shape, as well as the presence of pain. In healthy people, the surface of the stomach is smooth.
Thickening of the greater curvature and soreness during palpation are observed with gastritis, peptic ulcer disease. In the case of the development of a tumor of the stomach, its shape and consistency change, the surface becomes bumpy. It is better revealed by palpation of the stomach in the upright position of the patient (Fig. 56, e).
To determine the lower border of the stomach, percussion palpation according to Obraztsov is used (according to the splash noise; Fig. 56, d). A splashing noise can be caused if there is liquid and air in the stomach and if the latter is located in front of the liquid. To detect splash noise with the ulnar edge of the slightly bent left hand, press in the area of \u200b\u200bthe xiphoid process. In this case, the air of the gas bubble will be distributed over the surface of the liquid. Then, with four bent fingers of the right hand, short blows are made in the epigastric region, slightly below the xiphoid process, and, gradually descending downward, cause a splash noise until the fingers slide off the greater curvature of the stomach. The termination of the lapping noise indicates the lower border of the stomach.
In healthy people, splash noise is triggered shortly after eating. If a loud splash noise is caused on an empty stomach or 6-7 hours after eating, then motor function the stomach is reduced or impaired its evacuation ability. This can be with spasm or pyloric stenosis.
In addition to deep sliding and percussion palpation, palpation auscultation can be used to determine the lower border of the stomach (Fig. 56, c). It boils down to the following. The stethoscope is placed over the stomach area. With the index finger of the right hand, light rubbing movements are made along the abdominal wall from top to bottom towards the navel. While the finger is over the stomach, a rustling sound is heard in the stethoscope, which disappears or weakens when the finger extends beyond the stomach. This simple method can establish the position of the greater curvature of the stomach, but sometimes it gives incorrect results.
The location of the lower border of the stomach in normal conditions can vary depending on the degree of filling of the stomach and intestines, the body condition of a person, changes in intra-abdominal pressure and other reasons. Significant displacement of the lower border of the stomach during its expansion and prolapse acquires diagnostic value.
Palpation of the hepatic and splenic curvature of the large intestine
For palpation of the hepatic and splenic curvature of the large intestine, the method of bimanual palpation is used. The hepatic curvature is more often palpated; the splenic is very rarely palpable, since it is located much higher and is hidden under the ribs.
The palpation technique is as follows. The left hand is tightly pressed with the palmar surface to the corresponding lumbar region perpendicular to the spine and, pressing it, the curvature is pressed against the right hand. The tips of the bent fingers of the right hand are placed horizontally 2-3 cm below the edge of the costal arch, outward from the rectus abdominis muscle and a skin fold is created with a superficial movement towards the costal arch. During the exhalation of the patient, the fingertips of the right hand are smoothly immersed in the abdominal cavity until they touch its back wall and, as it were, with the fingers of the left hand, which exert pressure from below. Then, with a sliding movement of the fingertips of the palpating right hand down, one feels an oval-shaped elastic formation of a soft consistency, painless and non-purring. With enteroptosis, shortening of the ascending intestine, the frequency of detection of hepatic curvature increases. Possible changes in the hepatic curvature of the colon are identical to changes in the transverse colon. The splenic curvature of the intestine is normally not palpable and can only be determined when a cancer tumor develops in it.
Palpation of the transverse colon
The transverse colon is palpated (Fig. 55, g) with both hands on both sides of the midline of the abdomen after determining the lower boundary of the greater curvature of the stomach, which serves as a reference point for its location. To do this, slightly bent fingers of both hands are placed on the sides of the white line, parallel to the desired intestine, 2-3 cm below the greater curvature of the stomach, that is, horizontally. Then, with a superficial movement of the fingers during inhalation, the patient pushes the skin upward, and during exhalation, the fingers are gradually immersed in the abdominal cavity until they touch its back wall and slide along it from top to bottom, as far as the size of the skin fold allows. When sliding, the fingers of one or both hands roll over the transverse colon. If the intestine cannot be palpated, then the palpation is repeated slightly lower, gradually shifting the fingers up to the hypogastric region.
With a sharp descent, the transverse colon acquires a U-shape. Its right side can be adjacent to the cecum, and the left - to the sigmoid colon. In this case, it is necessary to conduct a study in the lateral parts of the abdomen.
Normally, the transverse colon is palpable in 70% of cases. It has the shape of a cylinder of moderate density. Its thickness is 2-2.5 cm. It easily moves up and down, is painless, does not hum.
In contrast to the greater curvature of the stomach, the transverse colon is easier to bend around with the fingers from above. On palpation of the intestine, you can trace its direction to the right and left until the transition to the hepatic or splenic curvature of the large intestine. Sometimes, on palpation of this part of the intestine, a rumbling is heard, which indicates the presence of gases and liquid contents in it. In ulcerative colitis, tuberculous lesions of the intestine, rumbling is accompanied by pain and immobility. In case of spastic colitis, the transverse colon is felt in the form of a cord, and in atony, in the form of a soft cylinder. In the case of a significant accumulation of gases, the transverse colon can reach a thickness of 3-4 fingers. The tuberosity and deformation of the transverse colon gives reason to assume the presence of a tumor in it.
Palpation of the ascending and descending colon
The ascending colon is palpated in the initial part, which is a direct continuation of the cecum; descending - in the final part, passing into the sigmoid colon. First, the ascending part is palpated, then the descending part. In this case, the hand of the left hand with the palmar surface is first placed under the right half of the lower back, and then under the left (to increase the density of the posterior abdominal wall, since the palpable sections of the colon lie on soft tissues). The left hand should be pressed against the corresponding half of the lumbar region and directed towards the palpating right hand (this is the so-called bimanual palpation). The fingers of the right hand, bent at the joints and closed together, are placed in the area of \u200b\u200bthe right and left flanks, along the edge of the rectus abdominis muscle, parallel to the intestine, at the place of its transition into the cecum (or sigmoid colon). During the patient's inhalation, a skin fold is created by a superficial movement of the fingers of the right hand towards the navel. During exhalation, at the moment of relaxation of the abdominal press, the fingers are immersed in the abdominal cavity up to the posterior abdominal wall, until there is a sensation of contact with the left hand. Then, by sliding the fingers of the right hand outwards perpendicular to the axis of the intestine, they are rolled over the ascending (or descending) segment (Fig. 55, e, f). In terms of properties, these segments in many ways resemble the cecum and sigmoid colon, since they are their continuation, only they are more limited in mobility.
In healthy people, especially in lean people with a thin and flaccid abdominal wall, it is often possible to palpate the ascending and descending sections of the colon with the help of bimanual palpation. This possibility increases with inflammatory changes in one segment or another and with the development of partial or complete obstruction of the underlying sections of the large intestine, since in such cases the intestinal walls become denser and rumbling and soreness appear in them.
Palpation of the terminal segment of the ileum
The end segment of the ileum is palpable in 75-85% of cases. This is the only section of the small intestine accessible to palpation at the place where it flows into the cecum due to its low mobility, relatively superficial location, and most importantly, the possibility of fixation to the dense posterior wall of the abdominal cavity and pelvic bones. The reference point for determining the position of this section of the small intestine is the border between the outer right and middle third of the line connecting the anterior superior spine of the ilium. The end segment of the ileum in this place has a somewhat oblique direction (from the inside out and from the bottom up, from the small pelvis to the large one) and flows into the cecum, slightly above its end
On palpation of the final segment of the ileum (Fig. 55, d), the fingers of the right hand, slightly bent at the joints and folded together, are set parallel to the length of this segment. During the inhalation of the patient, a skin fold is created by a superficial movement of the fingers up to the navel. During exhalation, fingers are immersed in the abdominal cavity, the final segment of the ileum is pressed against the posterior abdominal wall and slid off it. If it was not possible to palpate the indicated segment immediately, the palpation should be repeated. In this case, the intestinal wall from a relaxed state under the influence of irritation also goes into a state of tension and becomes denser.
Normally, the final segment of the ileum is palpated as a smooth, dense, moderately mobile, painless, rumbling, changing the consistency of a cylinder as thick as a little finger (about 1 - 1.5 cm), peristalting under the arm. With a spastic state of the ileum, it is dense, thinner than normal; with enteritis - painful, characterized by a loud rumbling when probing; with atony or impaired patency, it increases in size, overflows with intestinal contents and gives a splash noise on palpation. With inflammation, the final segment of the ileum thickens, becomes painful, its surface is somewhat uneven. With typhoid fever, tuberculous ulcers in the intestine, its surface is bumpy.
Palpation of the appendix of the cecum
The appendix of the cecum is palpable only in 10% of cases, just above or below the final segment of the ileum and parallel to it, in the form of a thin painless cylinder 1 - 1.5 cm thick, with a smooth surface, does not rumbling, does not change its consistency. In a chronic inflammatory process, the appendix thickens, becomes denser, becomes painful, inactive, and then the possibility of palpation increases. In acute appendicitis, it is not possible to feel the appendix due to the tension of the muscles of the anterior abdominal wall.
Palpation:
a, b - the sigmoid colon, respectively, with four fingers and the ulnar edge of the little finger;
c, d - the blind and ileum, respectively.
Palpation of the cecum
Palpation of the cecum. Palpable in 78-85% of people, in the right iliac region. Its longitudinal axis is located obliquely (from top to bottom right and left) on the border of the middle and outer third of the line connecting the navel and the right upper anterior spine of the ilium.
Palpation:
a, b - the sigmoid colon, respectively, with four fingers and the ulnar edge of the little finger;
c, d - respectively, the blind and ileum
The technique of palpation of the cecum (Fig. 55, c) is similar to that of palpation of the sigmoid colon. The cecum is palpated with four bent fingers of the right hand folded together. They are installed parallel to the length of the intestine. A superficial movement of the fingers towards the navel creates a skin fold. Then, gradually immersing the fingers into the abdominal cavity, during exhalation, they reach the posterior abdominal wall, slide along it, without unbending the fingers, perpendicular to the intestine, towards the right anterior iliac spine and roll over the cecum. If it was not immediately possible to palpate it, the palpation should be repeated. In this case, the wall of the cecum from a relaxed state under the influence of irritation goes into a state of tension and becomes denser (due to contraction of the muscular layer of the intestine). With the tension of the abdominal press, you can press with the thenar and thumb of your free left hand near the navel on the anterior abdominal wall and continue the study of the cecum with the fingers of your right hand. With this technique, the tension of the abdominal wall in the caecum region is transferred to the adjacent one.
Normally, the cecum is palpated in the form of a smooth, painless, slightly rumbling cylinder, 3-5 cm wide, moderately elastic and weakly mobile, with a slight pear-shaped expansion downward. The mobility of the cecum is normally 2-3 cm. With its excessive mobility, attacks of sudden pain with symptoms of partial or complete obstruction due to kinks and volvulus can be observed. A decrease in the mobility of the intestine or its complete immobility can be caused by adhesions that have arisen after an inflammatory process in this area.
The cecum, more than the sigmoid colon, is subject to various changes. The consistency, volume, shape, tenderness on palpation and acoustic phenomena (rumbling) of the cecum depend on the condition of its walls, as well as on the quantity and quality of the contents. Soreness and loud rumbling on palpation of the cecum are observed in the case of inflammatory processes in it and are accompanied by a change in its consistency. In some diseases (tuberculosis, cancer), the intestine can acquire a cartilaginous consistency and become uneven, bumpy and inactive. The volume of the intestine depends on the degree of filling it with liquid contents and gas. It increases with the accumulation of feces and gases in case of constipation and decreases with diarrhea and spasm of her muscles.
Palpation of the sigmoid colon
The sigmoid colon is palpable in 90-95% of cases, in the left iliac region, with four slightly bent fingers of the right hand folded together, or with the ulnar edge of the little finger (Fig. 55, a, b). To do this, the fingers are placed on the anterior abdominal wall at the border of the middle and outer third of the line connecting the navel with the anterior superior iliac spine, parallel to the longitudinal axis of the sigmoid colon (located from the top to the left and to the right). Then, during the patient's inhalation, a skin fold is created with a superficial movement of the fingers of the right hand towards the navel for free sliding. During the exhalation of the patient, when, as noted, relaxation of the abdominal muscles occurs, the fingers are smoothly immersed in the abdominal cavity. Having reached the posterior abdominal wall, slide along it perpendicularly to the longitudinal axis of the sigmoid colon in the direction from the navel to the anterior superior spine of the ilium (palpating fingers roll over the sigmoid colon).
Palpation:
a, b - the sigmoid colon, respectively, with four fingers and the ulnar edge of the little finger;
c, d - the blind and ileum, respectively.
With such a palpation, the thickness, consistency, nature of the surface, soreness, peristalsis, mobility and rumbling of the sigmoid colon are determined. Usually, it is normally palpated in the form of a smooth, dense, painless, non-rumbling cylinder 2-3 cm thick.Its mobility varies within 3-5 cm.The presence of rumbling indicates the accumulation of gases and liquid contents in the intestine during its inflammatory process (sigmoiditis, dysentery), which causes pain on palpation. The sigmoid colon can enlarge, becomes lumpy, dense, inactive, for example, with cancer. It can be dense, have an uneven surface and with a retention of feces, but this passes after an act of defecation or a cleansing enema.
Palpation of the abdomen
When palpating the abdomen, certain rules should be followed. The patient should lie on his back on a hard bed with a low pillow, his legs and arms should be stretched out, his stomach is exposed. He should breathe evenly and calmly, preferably through the mouth. The researcher sits on the right side of the patient, facing him, on the same level as the bed. His hands should be warm and dry, nails cut short.
Distinguish between superficial (approximate) and deep palpation.
With superficial palpation, the examiner puts his right hand with slightly bent fingers on the patient's abdomen and carefully, without penetrating deeply, proceeds to palpation of all parts of the abdomen. They start from the left groin area and, gradually going up the left flank to the left hypochondrium, epigastric region, move to the right hypochondrium, going down the right flank to the right groin area. Thus, palpation is carried out as if counterclockwise. Then, the middle part of the abdomen is palpated, starting from the epigastric region and going down to the pubis (it is not recommended to start palpation from the painful area of \u200b\u200bthe abdomen).
Superficial palpation reveals the degree of tension (judged by the resistance) of the abdominal wall and its pain. Normally, it should be soft, pliable, painless. The tension of the abdominal wall is observed mainly in inflammatory processes in the abdominal cavity. It can be general and local.
According to the severity of the general tension, the resistance of the abdominal wall arising from palpation is distinguished, and muscle tension - the rigidity of the muscles of the abdominal press. With the latter, the tension of the abdominal wall increases significantly, reaching a "board-like hardness". The “board-shaped stomach”, or “muscle defense”, signals a “catastrophe” in the abdominal cavity - the development of diffuse peritonitis, which may be the result of perforated stomach and intestinal ulcers, perforated (perforated) appendicitis, cholecystitis.
Local tension of the abdominal press is noted with limited peritonitis, which develops as a result of an attack acute appendicitis, cholecystitis, etc. In this case, even superficial palpation can cause pain. Sometimes painful sensation, moderately pronounced on palpation, sharply increases with quick withdrawal hands from the anterior abdominal wall (Shchetkin-Blumberg symptom). It is caused by the concussion of the inflamed peritoneal sheet in patients with diffuse or limited peritonitis.
With superficial palpation, it is possible to reveal swelling of the skin of the abdomen by the characteristic dents on the skin, which remain from the fingers after feeling. With a well-developed subcutaneous fatty tissue, this is not observed.
Superficial palpation also allows you to detect seals, nodes, hernias, tumors in the abdominal wall. If, during palpation, ask the patient to strain his stomach, then the formations in the abdominal wall continue to be palpated well, and intra-abdominal neoplasms are no longer felt.
Deep sliding methodical palpation is carried out according to the Obraztsov-Strazhesko method. It is called deep because the examiner's fingers penetrate deeply into the abdominal cavity, sliding - because the fingers get a tactile sensation of the palpable organ at the moment of "sliding" from it, methodical - because it involves palpation of the abdominal organs in a certain sequence. With the help of such palpation, the abdominal organs are examined. Beginning with the sigmoid colon, then alternately palpate the cecum with the process, the final part of the ileum, the ascending and descending parts of the colon, the transverse colon *, stomach, liver, pancreas, spleen. Then the kidneys are palpated.
* V.P. Obraztsov believes that for a better orientation in determining the location of the transverse colon, palpation should be carried out after establishing the lower border of the stomach.
Examination of the abdomen
You should pay attention to the shape of the abdomen, skin color, the presence of general or local protrusion, flatulence, the state of the navel, and visible peristalsis.
The shape of the abdomen depends on the constitution of the patient. Asthenics have a small stomach. In persons with a hypersthenic body type, it is increased in size.
The protrusion of the abdomen can be uneven and even.
Uneven protrusion of the abdomen is observed with an increase in the liver, spleen, tumors in the abdominal cavity, with large cysts emanating from the ovaries, pancreas.
Uniform protrusion occurs with excessive deposition of fat in the subcutaneous tissue (with obesity), with increased gas formation in the intestine (flatulence) and the presence of free fluid in the abdominal cavity (ascites; Fig. 54, a), during pregnancy, etc.
With obesity, the abdomen is enlarged, its wall is thickened, the navel is retracted.
With flatulence, the abdomen is also enlarged and does not change shape when the patient changes from horizontal to vertical, the navel is smoothed or slightly protruded.
With ascites in the supine position, the abdomen is flattened in the umbilical region, protrudes in the flanks and takes on the characteristic shape of a "frog belly". A significant accumulation of fluid and air in the abdominal cavity, large tumors can lead, due to an increase in intra-abdominal pressure, to a strong protrusion of the abdomen and navel, as well as to the divergence of the umbilical ring
In case of difficulty in blood circulation in the portal vein (with cirrhosis of the liver, compression by a tumor or enlarged lymph nodes of the portal vein, with its blockage, compression or thrombosis of the inferior or superior vena cava), a vascular network is clearly visible on the anterior abdominal wall, formed by significantly dilated convoluted saphenous veins (Fig. . 54, c). It is called the "jellyfish head". To determine the direction of blood flow in an expanded vessel, it is necessary to squeeze blood out of it by placing two fingers, and then, alternately lifting them, observe from which end it begins to fill with blood. If the blood flow is directed from the bottom up, it means that the blood moves into the superior vena cava system, if downward - into the inferior vena cava system.
Abdominal skin discoloration can be limited or diffuse. In the first case, red-brown spots ("tiger skin") appear on it, due to the frequent use of heating pads. In the second, the color of the skin is pale, red, with a bluish tint, icteric, bronze. There may be a rash on the sides of the abdomen
With swelling of the subcutaneous tissue, the abdominal wall becomes tense, shiny, a mark remains on it when pressed. This is observed with circulatory disorders as a result of heart disease, kidney disease.
When examining the abdomen, umbilical and inguinal hernial protrusions, as well as protrusions of the white line, can be detected. (When straining the patient and changing the horizontal position to vertical, these protrusions increase.) In such cases, the examination must be supplemented with a study (index finger) of the hernial rings.
With flatulence caused by coprostasis (fecal stones in the intestine), or with narrowing of the intestine, in addition to its bloating, peristalsis is often noted, especially intense above the place of obstruction.
With the narrowing of the pylorus of ulcerative and cancerous etiology, when the tone of the muscular part of the stomach has not yet been lost, peristalsis and protrusion of the intestine are observed in the epigastric region.
When tuberculous meningitis, sometimes with diffuse peritonitis, there may be a sharply sunken (scaphoid) abdomen.
In the horizontal position of the patient with a thin abdominal wall, pulsation in the epigastric region can be detected. Better visible aortic pulsation, aneurysm pulsation abdominal aorta, especially with a soft abdominal press.
It should be noted that the stomach takes part in the act of breathing. Restriction of respiratory movements of the abdominal wall is observed with local inflammation of the peritoneum, acute inflammation of the gallbladder, with appendicitis, severe pain syndrome, etc. The complete lack of mobility of the abdominal muscles during deep breathing can signal diffuse peritonitis.
The percussion method, along with other described areas of its application in the study of the abdominal organs, is important for determining the cause of the abdominal enlargement and, in particular, for identifying signs of ascites. Above the places of accumulation of free fluid in the abdominal cavity during percussion, instead of tympanitis, a dull sound is determined, and, depending on the position of the body, the dullness zone quickly shifts. Therefore, to detect ascites, abdominal percussion is performed in various positions of the patient: lying on the back and on the side, standing, as well as in the knee-elbow position. Percussion is carried out from the area of \u200b\u200bthe tympanic sound. At the same time, the finger-plessimeter is placed parallel to the expected liquid level. Quiet percussion strikes are used.
With abdominal percussion in the supine position of the patient, the finger-pessimeter is placed longitudinally along the anterior midline so that its middle phalanx lies on the navel. Percussion along the umbilical line alternately in the direction of the right and left lateral sections (flanks) of the abdomen until the transition of tympanitis into a dull sound (Fig. 64a).
Normally, on both sides, the border of the transition of the tympanic sound to the blunt one runs along the anterior axillary lines. A more medial location of such a border indicates the accumulation of free fluid in the abdominal cavity. In this case, when performing percussion in the same way in the patient's position lying on both the right and left sides (Fig.64b), the border of the dull sound above the fluid in the lower abdominal flank will shift in the medial direction, and the border of the dull sound in the overlying flank will correspond to its normal position.
When the patient moves to an upright position, the fluid will move to lower part abdominal cavity. Therefore, tympanitis will be detected in the lateral parts of the abdomen, and percussion along the vertical identification lines in the direction from top to bottom in the lower abdomen will reveal an area of \u200b\u200bdull sound with a horizontal upper border (Fig.65a).
When the patient moves to the knee-elbow position, the dull sound section will move to the umbilical region, while tympanitis will be determined in the rest of the abdomen. In this case, percussion is carried out towards the navel, starting it sequentially from the right and left lateral flanks of the abdomen, the xiphoid process and the pubis (Fig. 65b).
The method of percussion in the knee-elbow position reveals even a small amount of free fluid in the abdominal cavity. When applying the described method, it is necessary to keep in mind the following. In patients with severe ascites, sometimes such a significant amount of transudate accumulates in the abdominal cavity that a dull percussion sound is detected in any position of the patient over all parts of the abdomen. In these cases, the examination data are taken into account: the size of the abdomen, its shape depending on the position of the patient, changes in the skin of the anterior abdominal wall and the navel (p. 172).
In some pathological conditions, inflammatory effusion (exudative peritonitis) or blood (ectopic pregnancy, rupture of the spleen or liver, etc.) may accumulate in the abdominal cavity. In such patients, with a change in body position, the fluid in the abdominal cavity is mixed much more slowly than with ascites. Moreover, in the presence of an enclosed exudate in the abdominal cavity, for example, in patients with tuberculous adherent peritonitis, the dullness border above the fluid will not change with a change in position.
When a large cyst forms in the abdominal cavity, as a rule, it is localized in the mid-abdomen, where the dull area is determined, regardless of the position of the patient's body, while tympanitis persists in the lateral abdomen. These cysts most often come from the pancreas or ovaries.
In addition to these reasons, an increase in the abdomen can also be caused by flatulence and obesity. In the presence of flatulence over all parts of the abdomen, a tympanic sound is determined during percussion.
In patients with severe obesity over all parts of the abdomen, a moderate dullness of the percussion sound is revealed, which does not depend on a change in position. However, there is no such pronounced increase in the size of the abdomen, as with ascites with a similar percussion picture. There is also no protrusion of the navel and thinning of the skin of the abdominal wall. On the contrary, there is a significant thickening of the subcutaneous fat layer of the abdomen and common features obesity.
In doubtful cases, along with percussion, it is necessary to additionally use the swelling (fluctuation) method to detect ascites. The study is carried out with the patient lying on his back. The doctor puts his left palm on the right flank of the abdomen, and with the closed fingers of his right hand makes quick jerky movements along the symmetrical area of \u200b\u200bthe left flank of the abdomen. If there is free fluid in the abdominal cavity, the left hand shoots fluid fluctuations in the form of waves of ripple passing from the left half of the abdomen to the right.
To distinguish swelling from transmission vibrations of a strained abdominal wall, ask the assistant to press the elbow edge of the palm on the abdomen along the midline in the navel and repeat the study (Fig. 66). If the swelling persists, then there is an effusion in the abdominal cavity, and if the vibrations have disappeared, then they were of a transmission nature.
Auscultation of the abdomen is used to identify physiological and pathological noises that occur in the abdominal cavity (Fig. 388). In a healthy person, the constantly arising peristaltic waves of the stomach and intestines contribute to the movement of their contents, which generates intestinal noises.The intensity of these noises is individual and depends on the mode of food intake, the nature of the food, the state of the secretory function.
onion, pancreas, intestines, severity of fermentation processes, timely bowel emptying, etc. It is carried out for:
- detection of normal and pathological sounds of the stomach and intestines;
- detecting the noise of friction of the abdomen over the liver, spleen, omentum;
- detection of splash noise in the stomach and intestines, provoked by percussion.
The noises arising in the abdomen are often not audible at a distance, they can only be heard with the help of a phonendoscope. But sometimes their sonority is significant and they can be heard without an instrument. In some cases, the diagnostic value of auscultatory data can be very high.
When auscultation of the abdomen, the phonendoscope is installed on the
divided area of \u200b\u200bthe abdominal wall. Listening is carried out when the patient holds his breath at half-expiration for 15-20 s.
It is best to stick to the main topographic lines from top to bottom. The position of the patient can be different, but more often auscultation is performed in the supine or lateral position.
Normally, a slight rumbling, fluid transfusion, and a slight squeak are usually heard in the abdomen. Most of these sounds are heard over the thin
\
by the cervix, that is, in the umbilical region and especially below the navel to the pubic articulation. Above the large intestine, intestinal noises are heard less and mainly above the cecum 5-7 hours after eating.
Auscultation of each section of the digestive tube is described in detail in the description of methods for examining the esophagus, stomach, and intestines.
A brighter and more varied auscultatory picture when listening to the abdomen in a healthy person is observed in violation of the diet: untimely food intake, excessive consumption of carbonated drinks, carbohydrate foods and foods with high content fiber, especially gas-forming products - cabbage, legumes, rye bread, potatoes, grapes, etc.
In pathological conditions, the auscultatory picture of the abdomen can change in the following options:
- a sharp increase in intestinal noise;
- weakening of intestinal noise;
- the disappearance of intestinal noise;
- the appearance of a friction noise of the peritoneum.
A sharp increase in peristalsis occurs with mechanical obstruction, with narrowing of the lumen of the intestinal tube at any level (spasm, cicatricial narrowing, external compression, swelling, worms, intussusception).
The weakening or disappearance of intestinal murmurs, if they were heard earlier, is of great diagnostic value. This indicates the developed paresis or even paralysis of the intestinal muscles, which leads to a violation of peristalsis. The absence of intestinal noises in the clinic was called "gro
bovy "or" grave silence ", which is observed with diffuse peritonitis.