Examination of patients with diseases of the gastrointestinal tract (GIT) reveals emaciation, pallor, roughness and a decrease in turgor of the skin with malignant tumors of the stomach and intestines. But in most patients with stomach diseases, there are no visible manifestations. When examining the oral cavity in patients with acute and chronic diseases of the stomach and intestines, a white or brown coating on the tongue is revealed. In diseases accompanied by atrophy of the mucous membrane of the stomach and intestines, the mucous membrane of the tongue becomes smooth, devoid of papillae (“varnished tongue”). These symptoms are nonspecific, but they reflect the pathology of the stomach and intestines.
Inspection of the abdomen begins in the position of the patient lying on his back. The shape and size of the abdomen, respiratory movements of the abdominal wall and the presence of peristalsis of the stomach and intestines are determined. In healthy ones, it is either slightly retracted (in asthenics) or slightly protruded (in hypersthenics). Marked retraction occurs in patients with acute peritonitis. A significant symmetrical increase in the abdomen can be with obesity, bloating (flatulence) and the accumulation of free fluid in the abdominal cavity (ascites). Obesity and ascites differ in some ways. With ascites, the skin on the abdomen is thin, shiny, without folds, the navel protrudes above the surface of the abdomen. With obesity, the skin on the abdomen is flabby, with folds, the navel is retracted. Asymmetric abdominal enlargement occurs with a sharp increase in the liver or spleen.
Respiratory movements of the abdominal wall are well defined when examining the abdomen. Pathological is their complete absence, which often indicates diffuse peritonitis, but can be with acute cholecystitis and appendicitis. Stomach peristalsis can be detected only with pyloric stenosis (cancerous or cicatricial), intestinal motility - with narrowing of the intestine above the site of the obstacle.
Palpation of the abdomen
The abdomen - part of the body, is the abdominal cavity where the main internal organs (stomach, intestines, kidneys, adrenal glands, liver, spleen, pancreas, gall bladder) are located. Two methods of abdominal palpation are used: superficial palpation and methodical deep, sliding palpation according to V.V. Obraztsov and N.D. Strazhesko:
- Superficial (approximate and comparative) palpation reveals the tension of the muscles of the abdominal wall, the localization of pain and an increase in any of the organs of the abdominal cavity.
- Deep palpation is used to clarify the symptoms identified by superficial palpation, and to detect a pathological process in one or a group of organs. When examining and palpating the abdomen, it is recommended to use schemes of clinical topography of the abdomen.
The principle of surface palpation
Palpation is carried out by light pressure with fingers flat on the palpating hand located on the abdominal wall. The patient lies on his back in bed with a low headboard. Arms extended along the body, all muscles should be relaxed. The doctor sits to the right of the patient, who must be warned to let him know about the occurrence and disappearance of pain. Approximate palpation begins with the left inguinal region. Then the palpating hand is transferred 4-5 cm higher than the first time, and further into the epigastric and right iliac regions.
Comparative palpation of the study is carried out in symmetrical areas, starting from the left iliac region, in the following sequence: iliac region on the left and right, umbilical region on the left and right, lateral abdomen on the left and right, hypochondrium left and right, epigastric region on the left and right on the white belly lines. Superficial palpation ends with a study of the white line of the abdomen (the presence of a hernia of the white line of the abdomen, divergence of the abdominal muscles).
In a healthy person with superficial palpation of the abdomen, pain does not occur, the tension of the muscles of the abdominal wall is insignificant. Severe diffuse pain and muscle tension over the entire surface of the abdomen indicates acute peritonitis, limited local pain and muscle tension in this area indicate an acute local process (cholecystitis in the right hypochondrium, appendicitis in the right iliac region, etc.). With peritonitis, a symptom of Shchetkin-Blumberg is revealed - increased pain in the abdomen with a quick removal of a palpating hand from the abdominal wall after light pressure. When tapping the abdominal wall with a finger, local soreness can be established (Mendel symptom). Accordingly, in the painful area, local protective tension of the abdominal wall is often detected (Glinchikov's symptom).
Muscular defense in duodenal and pyloric anthral ulcers is usually determined to the right of the midline in the epigastric region, with an ulcer of lesser curvature of the stomach - in the middle part of the epigastric region, and with a cardiac ulcer - in its highest part in the xiphoid process. Corresponding to the indicated areas of pain and muscle protection, zones of skin hyperesthesia of Zakharyin-Ged are revealed.
Principles of deep sliding palpation
The fingers of the palpating arm, bent in the second phalangeal joint, are installed on the abdominal wall parallel to the organ under investigation and after dialing the surface skin fold, which is necessary for the sliding movement of the arm, carried out in the depth of the abdominal cavity together with the skin and not limited by the tension of the skin, are immersed deeply when exhaling into the abdominal cavity. This must be done slowly without sudden movements for 2-3 inhalation and exhalation, holding the achieved position of the fingers after the previous exhalation. The fingers are immersed to the back wall so that their ends are located inward from the palpable organ. At the next moment, the doctor asks the patient to hold his breath while exhaling and conducts a sliding movement of the arm in a direction perpendicular to the longitudinal axis of the intestine or edge of the stomach. When sliding, the fingers bypass the accessible surface of the organ. Determine the elasticity, mobility, soreness, the presence of seals and tuberosity on the surface of the organ.
The sequence of deep palpation: sigmoid colon, cecum, transverse colon, stomach, pylorus.
Palpation of the sigmoid colon
The right hand is installed parallel to the axis of the sigmoid colon in the left ileal region, the skin fold in front of the finger is collected, and then, during the patient's exhalation, when the abdominal relaxation comes, the fingers gradually sink into the abdominal cavity, reaching its posterior wall. After that, without easing the pressure, the doctor’s hand slides along with the skin in the direction perpendicular to the axis of the intestine, and rolls the hand through the surface of the intestine when holding the breath. In a healthy person, the sigmoid colon is palpated in 90% of cases in the form of a smooth, dense, painless and non-rumbling cylinder 3 cm thick. In pathology, the intestine can be painful, spastically contracted, bumpy (neoplasm), strongly peristaltic (an obstacle below it), immobile during fusion with a mesentery. With the accumulation of gases and liquid contents, rumbling is noted.
Palpation of the cecum
The hand is placed parallel to the axis of the cecum in the right ileal region and palpation is performed. The cecum is palpated in 79% of cases in the form of a cylinder, 4.5–5 cm thick, with a smooth surface; it is painless and hardly displaced. In pathology, the intestine is extremely mobile (congenital lengthening of the mesentery), motionless (in the presence of adhesions), painful (with inflammation), dense, tuberous (with tumors).
Palpation of the transverse colon
Palpation is carried out with two hands, i.e., by bilateral palpation. Both hands are set at the umbilical line along the outer edge of the rectus abdominis muscles and are palpated. In healthy people, the transverse colon is palpated in 71% of cases in the form of a cylinder 5–6 cm thick, easily displaced. In pathology, the intestine is palpated dense, contracted, painful (with its inflammation), tuberous and dense (with tumors), sharply rumbling, increased in diameter, soft, smooth (with narrowing below it).
Palpation of the stomach
Palpation of the stomach presents great difficulties, in healthy people it is possible to palpate a large curvature. Before palpating the greater curvature of the stomach, it is necessary to determine the lower boundary of the stomach by the method of auscult-percussion or by the method of auscult-affection.
- Auscult-percussion is carried out as follows: a phonendoscope is placed over the epigastric region and at the same time, quiet percussion is carried out with one finger in the direction radial from the stethophonendocope or, conversely, to the stethoscope. The border of the stomach is located by listening to a loud sound.
- Auscult-affection - a percussion stroke is replaced by a light intermittent glide on the skin of the abdomen. Normally, the lower border of the stomach is determined 2-3 cm above the navel. After determining the lower border of the stomach using these methods, deep palpation is used: a hand with bent fingers is placed on the lower border of the stomach along the white line of the abdomen and palpated. The greater curvature of the stomach is felt in the form of a “roller” located on the spine. In pathology, the lowering of the lower border of the stomach, pain on palpation of large curvature (with inflammation, peptic ulcer), the presence of a dense formation (tumor of the stomach) are determined.
Palpation of the pylorus
Palpation of the pylorus is carried out along the bisector of the angle formed by the white line of the abdomen and the umbilical line, to the right of the white line. The right hand with slightly bent fingers is set on the bisector of the specified angle, the skin fold is collected in the direction of the white line and palpation is performed. The gatekeeper is palpated in the form of a cylinder, changing its consistency and shape.
Percussion abdomen
The importance of percussion in the diagnosis of diseases of the stomach is small.
Using it, you can determine the Traube space (a section of tympanic sound on the left in the lower chest, due to the air bubble of the bottom of the stomach). It can be increased with a significant increase in the content of air in the stomach (aerophagy). Percussion allows you to determine the presence of free and sedated fluid in the abdominal cavity.
When the patient is on his back, quiet percussion is performed from the navel towards the lateral abdomen. Over the liquid, the percussion tone becomes dull. When the patient turns on his side, free fluid moves to the lower side, and above the upper side, a dull sound changes to tympanic. Osumkovannaya fluid appears with peritonitis limited by commissures. Above it, with percussion, a dull percussion tone is determined, which does not change localization when changing position.
Gastrointestinal auscultation
Auscultation of the gastrointestinal tract should be carried out before deep palpation, since the latter can change peristalsis. Listening is carried out in the position of the patient lying on his back or standing at several points above the stomach, over the large and small intestines. Normally, moderate peristalsis is heard, sometimes rhythmic intestinal murmurs after eating. Above the ascending part of the large intestine, rumbling can be heard normally, above the descending one only with diarrhea.
With mechanical intestinal obstruction, peristalsis increases, with paralytic obstruction, it sharply weakens, with peritonitis disappears. In the case of fibrinous peritonitis during the patient's respiratory movements, the noise of friction of the peritoneum can be heard. By auscultation under the xiphoid process in combination with percussion (auscult-percussion) and light short rubbing movements of the researcher’s finger along the skin of the patient’s abdomen, the lower border of the stomach can be roughly determined using the radial lines to the stethoscope.
Of the auscultatory phenomena that characterize sounds arising in the stomach, one should note the noise of the splash. It is called in the supine position of the patient with the help of quick short strokes with bent fingers of the right hand on the epigastric region. The appearance of splashing noise indicates the presence of gas and liquid in the stomach. This symptom becomes important if it is determined 6-8 hours after a meal. Then, with a reasonable degree of probability, pyloroduodenal stenosis can be assumed.
Palpation of the intestine: features of the procedure and its tasks
Palpation is the most important diagnostic method for examining the intestine. This method can only be carried out by a highly competent doctor who knows all the intricacies and rules of probing the organs of the abdominal cavity.
It is divided into 2 main types: superficial and deep. Each of these species allows you to get quite important data about the internal organs of the patient and their condition.
Palpation allows you to determine the presence of pain in any part of the intestine and make a preliminary diagnosis. Also, using this diagnostic method, the doctor can determine the presence of various diseases. To confirm the diagnosis, it is enough to conduct some additional, instrumental studies and analyzes.
Inspection Tasks
The main objectives of the examination of the patient 3, namely:
- Identification of neoplasms that can be benign and malignant. If any tumors are found in the intestinal region, additional procedures and instrumental studies can be prescribed, among which the most significant is a biopsy.
- Changes in tissue structure. On palpation, the doctor can detect obvious changes in the structures of the intestinal tissues, this may be friability, thickening or thinning of any parts of the organ, which indicates a disease.
- Inflammatory processes are also easily determined by examining the patient by palpation.
- Soreness is the most important sign of an ailment. It is this symptom that can indicate which part of the intestine is affected by the disease and how serious the disease is. When determining the painful area during palpation of the abdominal cavity, the doctor can make a preliminary diagnosis.
Thus, the tasks of this inspection method are many. They also depend on the type of palpation (deep or superficial).
How is intestinal palpation?
Palpation of the intestine involves two types of palpation of the abdominal cavity: superficial and deep.
If the patient has painful areas, an important rule that the doctor observes is the following: in no case should feeling be started from a place that hurts. Usually, the doctor starts from the opposite side of the abdomen.
Most often, palpation begins with the left iliac region and involves palpation of the intestine in a circle and counterclockwise.
Video about intestinal palpation technique:
Surface method
With a superficial palpation method, the doctor needs to relax the patient as much as possible. For this patient, they are placed in a horizontal position with legs slightly bent at the knees. So the muscles of the press relax as much as possible.
If the patient is still too tense, the doctor can distract him from the procedure by forcing him to perform breathing exercises.
Feeling happens very smoothly and accurately. The area that hurts is felt last, because if you start the procedure from the painful area, the muscles of the anterior abdominal wall tighten, which will not allow for a full examination.
Deep
A deep type of palpation is performed to diagnose serious changes in the structure of the intestine. The most important condition for probing the deep type is a clear knowledge by the doctor of the projection of the internal organs on the anterior abdominal wall.
For diagnostic accuracy, when performing deep palpation, the doctor feels not only the intestines, but also other organs of the abdominal cavity.
During deep palpation, the patient should breathe deeply, evenly and measuredly, through the mouth. In this case, breathing should be diaphragmatic. To facilitate the procedure, the doctor artificially creates skin folds on the patient’s stomach and then shifts the palm in the required position.
When palpation of the intestine, the doctor always observes the following sequence of probing organs:
- sigmoid colon;
- cecum;
- ascending and descending;
- colon transverse intestine.
When palpation of a deep type, the doctor must determine the diameter, nature of mobility, rumbling and painful areas of all parts of the intestine.
Small intestine
Pain to the right of the navel most often speaks of a disease of the small intestine. Palpation allows you to determine the condition of the small intestine. Most often, both types of palpation are used, however, it is the deep and sliding type of palpation that is more effective.
With the right approach to the diagnosis and professionalism of the doctor, carrying out this procedure is not difficult.
Colon
Palpation of the large intestine allows you to explore the pathology of the abdominal cavity, to assess their size, position and shape.
So, the conditions for palpation are actually the same as when conducting a study of the surface of the abdomen. However, in this case, the doctor should be extremely focused and attentive so as not to lose sight of important details.
Blind
The cecum is located in the right ileal region and has an oblique passage. In fact, at a right angle, it crosses the umbilical-rest line.
Palpation should be carried out in the right iliac region. The palm of a doctor lies on the anterior superior spine. The fingers are directed towards the navel and are in the projection of the cecum. When palpating, the skin fold is shifted to the direction from the intestine.
According to generally accepted standards, the cecum must be soft and smooth elastic, and also have a diameter of two transverse fingers.
Transverse
The intestine is palpable exclusively in the umbilical region simultaneously with both hands. Palpation is carried out through the rectus abdominis muscles.
To perform palpation, the doctor puts his palms on the front abdominal wall so that the fingertips are located at the level of the navel. The skin fold must be shifted towards the epigastric region.
Normally, the transverse colon has an arched shape that is curved downward. The diameter of the intestine does not exceed 2.5 centimeters. It is painless and easily displaced upon palpation. In the presence of any deviations, you can find some soreness, expansion, compaction, tuberosity.
Sigmoid
The sigmoid colon is located in the left ileal region of the abdomen. It has an oblique stroke and crosses the umbilical-rest line almost perpendicularly. The doctor’s hand should be so that the base of the palm is on the umbilical region. The fingertips should be directed towards the anteroposterior spine of the left ilium.
Thus, the palpating hand should be in the projection of the sigmoid colon.
Feeling painless, the intestine does not rumble and rarely peristalsis. In the presence of deviations, palpation is more difficult and slow.
Straight
The study of the rectum is performed rectally in the knee-elbow position of the patient. It is preferable to carry out inspection after defecation, as this may cause some difficulties.
In a serious condition of the patient, the study is performed lying on the left side with legs pressed to the stomach.
First, the doctor examines the anus and skin of the buttocks of the perineum, as well as the sacrococcygeal region. This helps to detect cracks in the anus, hemorrhoids and more. After this, the patient must be asked to strain.
Then proceed to a digital examination of the intestine. The index finger of the right hand is inserted through the anus into the rectum by rotational movements. Thus, the sphincter tone and the presence of tumor-like formations are determined.
Causes of pain
There can be many causes of pain, but the most common are the following:
The pain can have a different nature, which very often depends on the cause that led to the discomfort.
Norm
Normally, the intestines during palpation of both superficial and deep types do not cause pain. The patient does not feel discomfort, tingling or dull, aching pain. Acute pain syndrome is also absent.
The doctor does not detect any seals or loose sections of intestinal tissue. Inflammatory processes, expressed by severe swelling or an increase in part of the intestine, are not observed.
An important aspect is the location of the intestine. The correct location of all its parts indicates the absence of intestinal inversion or pathological processes. Also, with deep palpation, the doctor does not reveal seals and neoplasms.
In the normal state of the organs, the doctor can feel the blind, sigmoid, transverse colon. The descending and ascending parts of the large intestine are inconsistently palpated.
The norm is that when pressed, the cecum rumbles slightly. The transverse colon has a soft, not friable structure, compaction and any formations are absent.
Palpation of the rectum occurs by rectal-digital examination. Normally, the absence of inflamed tissues, ruptures of tissue structures and hemorrhoidal cones.
Palpation of the abdomen
Palpation is the main method for studying the normal properties and pathological changes of the abdominal cavity, organs and peritoneum located in it.
Depending on the goals that the researcher sets for himself when feeling the abdomen, there are two types of palpation - superficial and deep. Both types of palpation should be applied to each patient, and superficial palpation should be preceded by a deep one.
To feel the abdomen, the examiner sits to the right of the patient in a chair, the seat of which should be approximately at the level of the patient’s bed. The researcher should be in the most comfortable position possible with the least muscle tension. The patient should lie horizontally on a not particularly soft bed with the most relaxed muscles. The head of the subject should rest on a low pillow, and if possible, during the feeling, the pillow should be completely removed from under the head, since this achieves even more relaxation of the abdominal muscles. For the same reason, the patient should not rest his feet on the back of the bed. The stomach of the subject should be widely exposed (from the xiphoid process to the pubis). The hands of the researcher must be warm, the nails should be short-cropped. Touching a cold hand on the skin of the abdomen is extremely unpleasant for the patient and, in addition, causes a reflex contraction of the abdominal muscles, which can give an erroneous idea of \u200b\u200bthe presence of pathological tension, and also makes it difficult to probe the abdominal organs. In addition, feeling with a cold hand significantly dulls the subtlety of tactile sensations. Long nails on the fingers of the examiner cause pain to the patient. The patient should breathe smoothly and calmly, preferably through the mouth, which significantly reduces the tension of the abdominal muscles.
Superficial palpation of the abdomen allows you to:
- determine the degree of tension of the abdominal wall;
- determine the presence of pain throughout the abdominal wall or its individual sections;
- to distinguish the swelling of the abdominal wall from the accumulation of fat in it or from its stress during ascites or flatulence;
- distinguish tumors in the abdominal wall from tumors in the abdominal cavity;
- to probe the seals developed in the abdominal wall, nodes, metastases of malignant tumors, etc.
The most important are the first two points.
With superficial palpation, the examiner puts the flat palm of his right hand on the patient’s stomach and gently, without pressure, palpates the wall of the abdomen with the flesh of the terminal phalanges of the fingers, gradually moving the palm from one place to another. In order to avoid reflex contraction of the abdominal muscles in sensitive subjects, the patient should be diverted by conversation. If it is known in advance which places are painful, palpation should begin from painless places. Normally, subject to these rules, palpating fingers do not encounter any resistance from the side of the abdominal wall, which appears soft and supple. In pathological conditions, two types of increase in the tension of the abdominal wall can be found: resistance of the abdominal wall and its muscle tension (defense musculaire - muscle protection), which should be distinguished from each other due to their different diagnostic value.
Resistance of the abdominal wall, i.e., some resistance to its palpating fingers, is felt in places corresponding to the pathological, most often inflammatory, process in some deep located organ. So, for example, with inflammation of the gallbladder, resistance is felt in the right hypochondrium near the outer edge of the right rectus abdominis muscle, with duodenal ulcer - slightly lower, in the area corresponding to the location of the intestine.
Muscle tension, “muscle protection”, is observed where there is an inflammatory process in the abdominal cavity, in which the peritoneum, especially the parietal, also takes part. Therefore, the general muscle tension of the entire abdominal wall is observed with diffuse peritonitis, and local - with limited peritonitis.
Muscle tension is also observed with chemical irritation of the peritoneum, for example, with hydrochloric acid of gastric juice, with ulcerative perforation of the stomach wall, in which the tension is most severe, or with irritation by its blood, for example, when the spleen ruptures.
Although both resistance and muscle tension are a reflex contraction of the abdominal muscles (the so-called visceromotor reflex), there is a significant difference between them, namely that resistance occurs only during palpation, and muscle tension exists constantly, regardless of it. Irritations entering the corresponding segment of the spinal cord from pathologically altered organs of the abdominal cavity are weaker than irritations originating from the inflamed peritoneum, as a result of which they are unable, like the latter, to maintain a constant reflex contraction of the abdominal muscles receiving motor innervation from the same segment. Therefore, for the appearance of resistance of the abdominal wall, additional irritation upon palpation is required to cause reflex muscle contraction felt by the researcher.
In practice, resistance and muscle tension differ in the following ways: with the latter, the tension of the abdominal wall is much greater than with resistance, sometimes reaching, for example, when a stomach ulcer is pierced, almost stone hardness (plank-like stomach); with muscle tension, even superficial palpation is accompanied by sharp pain, which is not with resistance; in the presence of resistance, it is sometimes possible by distracting the patient's attention and prolonged gentle stroking of the abdominal wall to achieve the disappearance of resistance, which is never the case with muscle tension.
A strong reflex contraction of the abdominal muscles, not associated with inflammation or irritation of the peritoneum, can be observed with tuberculous meningitis, during an attack of lead colic, with tetanus.
Thickening of the muscles of the upper abdomen should not be mixed with muscle tension in people suffering from persistent cough for many years. This thickening is the result of hypertrophy of these muscles due to their continued functioning during coughing.
Soreness of the abdominal wall with superficial palpation of the abdomen (the so-called palpation soreness), as well as spontaneous (spontaneous) soreness of it, is observed with inflammation of the peritoneum. In acute peritonitis, it is much sharper than in chronic. However, if acute purulent peritonitis lasts for some time and is accompanied by a sharp intoxication of the nervous system, then the pain, as well as muscle tension, can weaken or even completely disappear.
With general peritonitis, both palpation and spontaneous soreness are felt throughout the abdomen, with local - in a limited area, corresponding to the lesion site. With peritonitis, which developed due to perforation of the wall of the stomach or intestine, the pain is only localized in the perforation area for the first time; after a short period of time as a result of irradiation and involvement in the inflammatory process of the entire peritoneum, pain is felt throughout the abdomen. Very light superficial palpation in these cases makes it possible to determine the place of the initial occurrence of pain. To do this, by extremely gentle palpation of the symmetrical points of both halves of the abdomen, it is first determined which half is more painful. Then, in the same way, it is determined which quadrant - upper or lower - is more painful in this half of the abdomen. Having determined the most painful quadrant, they finally find the most painful area in it. Sometimes even better results are obtained if, instead of palpation, apply a very light tapping with the pulp of the terminal phalanx of the finger.
Often a painful sensation, weakly expressed during palpation, increases sharply at the time of rapid withdrawal of the palpating finger from the abdominal wall (Shchetkin symptom). The appearance of sharp pain in this case is due to a sudden concussion of the inflamed peritoneum at the time of removal of the finger.
Increased pain sensitivity of the skin (skin hyperalgesia) with superficial palpation can also be observed with diseases of the abdominal organs, not accompanied by inflammation of the peritoneum. This soreness occurs by the mechanism of viscerosensory reflex. It consists in the fact that the stimuli coming from the internal organ into the corresponding segment of the spinal cord pass to the sensory nerves entering the same segment from the corresponding area of \u200b\u200bthe skin.
Deep palpation of the abdomen. Having finished with superficial palpation, they go on to deep palpation of the abdomen, used to study the abdominal organs. She aims:
- topographic differentiation of the abdominal organs from each other;
- determination of the size, shape, position, nature of the surface, soreness and mobility of these organs, and for hollow organs also the properties of their walls and the nature of their contents;
- the location of tumors inside the abdominal cavity, the determination of their properties and connection with one or another organ.
The peculiarity of palpation of the abdominal organs is that their palpation is performed not directly, but through the integument of the abdominal wall. This necessitates a special technique of deep abdominal palpation, based on a number of provisions, namely:
- The more relaxed the abdominal wall, the less it impedes the penetration of the palpating hand to deep-lying organs and the less tangible sensations arising from palpation are distorted.
- When probing a body through some medium (for example, intra-abdominal organs through the abdominal wall), a tactile sensation is obtained only if the density of the palpable body is greater than the density of the medium through which it is probed, and the sensation is clearer, the greater the difference in density.
- It is easier to feel the body, especially if the palpation is done through some medium, when it is inactive or completely motionless.
- It is easier to feel the body, especially through some medium, if it lies on a solid lining or can be pressed against it.
- When probing the body through any medium, the most clear tactile sensation is obtained at the moment of a sudden change in its consistency under the fingering fingers. This is done when the body probed through the medium moves under the fingers or when the fingers slide on it; then at the moment of passing under the fingers the edges of the body, which differs in consistency from the surrounding elements, a clear tactile sensation arises from this edge.
On these positions rests the method of the so-called methodical deep sliding palpation of the abdominal cavity, created by the famous clinician V.P. Obraztsov.
Based on the first position, when applying deep palpation of the abdomen, one should strive for maximum relaxation of the abdominal muscles. To do this, deep abdominal palpation should be performed in the supine position of the patient, since in the standing position the abdominal muscles are tensed. Further, the patient, as already mentioned, should occupy a strictly horizontal position with a low-lying head and maximally relaxed muscles, especially the abdomen. He should breathe smoothly and calmly, best of all through his mouth, since he does not have to strain his abdominal muscles during exhalation. The abdominal muscles tighten during inspiration and relax during exhalation, so the gradual penetration of the tops of the palpating fingers into the abdominal cavity should occur intermittently, occurring only during exhalation, each time by no more than 2-3 cm. During the next inhalation, when the abdominal muscles tighten again, the palpating fingers rest, not trying to penetrate deeper until the next exhalation, but not backing away from the already reached depth. Thus, plunging deeper and deeper with each exhalation together with the abdominal wall, the palpating fingers after 5-6 exhalations reach the posterior wall of the abdominal cavity or the organ lying on it. Hence the name "deep palpation."
The need to reach the posterior wall of the abdominal cavity with palpating fingers follows from the fourth position; this makes it possible to feel the organ lying in the depths, pressing it to a solid lining formed by the spine and pelvic bones. In addition, the farther the probed organ is pushed deeper, the more its mobility is limited (see the third position).
In the lateral parts of the abdomen, the posterior wall of the abdominal cavity is farther from the palpating arm than in the middle part; upon palpation of the ascending and descending parts of the colon located in the flanks, you can bring the back wall of the abdominal cavity closer to the palpating hand, pressing on it with the back with the other hand laid on the lumbar region (bimanual palpation according to the method of V. X. Vasilenko). This simultaneously achieves two more goals: a harder lining is created for palpating segments of the intestine and their mobility is limited.
Based on the fifth position, you should strive to probe the edge of the investigated organ. This is possible if the palpable organ and palpating fingers move relative to each other. It doesn’t matter whether the palpable organ slides under the motionless fingers when it makes its breathing excursions, or whether the palpating fingers glide on the motionless organ. Hence the second name of the Obraztsov method - “sliding palpation”.
It should be noted that all organs lying inside the abdominal cavity have respiratory mobility, and, of course, this mobility is greater the closer the organ is located to the diaphragm and the closer to the horizontal direction of its longitudinal axis. Since the slipping of the palpable organ under the fingers or the sliding of the fingers along the organ is necessary for palpating its edges, palpating fingers should be set so that they slide in the direction transverse to the longitudinal axis of the investigated organ. If respiratory movements are used to feel the edge of an organ, then the direction of the line formed by closed palpating fingers should be perpendicular to the direction of respiratory movement of the organ under investigation. Therefore, when palpating the greater curvature of the stomach or transverse colon, the line formed by the fingers should be horizontal and the fingers should slide up and down. On palpation of the sigmoid colon, the longitudinal axis of which is directed from top to bottom left and right, palpating fingers should slide from top to bottom right and left. The range of motion of the fingers should be such that the movement begins on one side of the palpable body and ends on the other so that the fingers can slip along both of its edges. In this case, the fingers should slide along with the skin.
From the foregoing, it is clear how important it is for the patient to deeply palpate the abdominal organs for proper breathing. It should be smooth, deep and necessarily diaphragmatic. Therefore, the researcher needs to direct the patient’s breathing, to teach him to breathe correctly with his “stomach” and, if necessary, to make deep breathing movements with his diaphragm, offering the patient to follow and imitate.
As for the positions of the palpating hand, where possible, it is advisable to place it flat on the stomach, as this provides less disturbing palpation to the patient than palpation with the fingertips. However, with an unstable abdominal wall, for example, in obese ones, the best results are obtained by feeling with the tips of the slightly bent fingers of the right hand (except for the big one). When feeling the sigmoid and cecum, the so-called "oblique palpation" is convenient. To do this, the hand becomes so that the longitudinal axis of the fingers is not perpendicular to the abdominal wall, but goes obliquely towards it - so that the pulp of the 3rd, 4th and 5th fingers make up one straight line and the angle between the fingers and the abdominal wall is sharp.
There are times when it is not possible to cause the relaxation of the abdominal muscles necessary for successful deep palpation. This happens in people with increased
reflex excitability, with a pronounced chest type of breathing, in patients suffering from severe shortness of breath or sharp pain in the abdominal cavity, accompanied by tension of the abdominal wall, in patients with ascites, severe obesity, severe swelling of the abdominal wall, etc. In some cases, when no measures lead to relaxation of the abdominal press, deep palpation of the abdomen becomes possible when the patient is placed in a warm bath, in which significant relaxation of the muscles of the body, including the abdominal press, is achieved.
To successfully use the method of deep palpation of the abdominal cavity, it is necessary to feel all its organs in a certain, once and for all established, order. According to N. D. Strazhesko, this order is as follows: first, the sigmoid colon is felt, then the blind, the final segment of the ileum, the appendix, the transverse colon, then the stomach, liver, pancreas, spleen and, finally, the kidneys.
In this series, organs are arranged in order of palpability in healthy people, as can be seen from the following data obtained by Obraztsov school. The sigmoid colon is felt in 91% of healthy people, the blind in 79%, the final ileal segment in 75-80%, the transverse colon in 71%, the greater curvature of the stomach in 50-60%, the pylorus in 20-25% , the edge of the liver - in 88%. The pancreas, spleen and kidneys are not normally palpable.
This requirement of constant strict order with deep palpation of the abdomen is the reason for the third name of the Obraztsov method - “methodical palpation”.
Feeling of the stomach
Palpation (palpation) doctors refer to the physical methods of examining the patient. She is preceded by clarification of complaints, anamnesis, general examination. How is palpation of the stomach carried out? What is this or that method used for, and what does the doctor determine in this way?
The quality of the initial examination of the stomach by palpation depends on the skill of the doctor.
General inspection
At this stage, the doctor discovers the following signs of gastrointestinal ailments:
- Weight loss. It is due to the fact that the patient deliberately restricts nutrition to avoid pain after eating. Peptic ulcers, especially men, are often asthenics, that is, excessively thin.
- Pale skin (often clammy, cold sweating) indicate obvious / hidden ulcerative bleeding.
- Gray, earthy skin. This symptom may indicate stomach cancer.
- Scars on the abdomen from previously performed operations on the digestive tract.
They also examine the abdominal wall itself (the condition is the presence of good lighting). For example, if her movement during diaphragmatic breathing is “behind”, this is regarded as a sign of a local inflammatory process of the peritoneum.
Methods of palpation of the stomach
According to medical regulations, abdominal palpation is performed in strict sequence. Its purpose is to assess the condition of the anterior abdominal wall, cavity organs, and identify pathologies. Such an examination is performed on an empty stomach, the intestines should be empty. The patient is laid on his back on the couch.
Surface
This procedure will allow you to determine:
- the size, shape of the palpable part of the stomach, nearby organs;
- muscle tension of the abdominal cavity (at normal, it should be negligible);
- localization of pain, which makes it possible to make a preliminary diagnosis in acute processes (for example, a hard, painful stomach, muscle tension on the right side - appendicitis).
Superficial feeling is carried out by gently pressing flat lying fingers of one hand on the abdominal wall in certain areas. Start on the left, in the groin area, after moving the arm 5 cm above the original point, then move to the epigastric, right iliac region. The patient should lie relaxed, with his hands folded along, to answer the doctor's questions about his feelings. This method is called approximate superficial palpation.
There is also a comparative superficial palpation. It is carried out according to the principle of symmetry, examining the right and left:
- iliac, umbilical region;
- lateral abdomen;
- hypochondria;
- epigastric region.
Also check the white line of the abdomen for the presence of hernias.
Deep (methodical) moving
- fingers slightly bent along the middle phalanx are set in a position parallel to the organ that is being examined;
- form a skin fold
- the hand on the patient's exhale gradually sinks deeper into the abdominal cavity;
- the doctor’s fingertips glide along the back wall of the abdomen, the organ under examination (this sets mobility, soreness, structure).
With this examination, the doctor sequentially feels:
- intestines (sequence - sigmoid, straight, transverse colon),
- stomach;
- the pylorus (sphincter separating the stomach and the ampulla of the 12th duodenum).
Deep sliding palpation is also recommended when the subject is standing. Only in this way can one feel the small curvature, the highly located neoplasms of the pylorus. Deep sliding palpation in half the cases (in patients with a normal position of the organ) allows you to check the greater curvature of the stomach, in a quarter of cases - the pylorus.
Feeling the gatekeeper
This sphincter - "separator" lies in a strictly designated location, a triangle outlined by certain lines of the body. Under the fingers, it feels like an elastic cylinder (changing in accordance with the phases of contraction / relaxation of one's own muscles), now becoming dense, now practically not palpable. Palpating it, one sometimes hears a slight rumbling caused by "flowing" into the 12-finger process of the fluid, gas bubbles.
Auscult-percussion, auscult-affection
The essence of these two methods is similar. The goal is to determine the size of the stomach, to find the lower limit. Normally, the latter is slightly higher than the navel (3-4 cm in men, a couple of cm in women). The examinee is laid on his back, the doctor sets up a phonendoscope in the middle between the lower part of the sternum and the navel. With auscultus-percussion, the doctor with one finger applies superficial strokes in a circular direction with respect to the phonendoscope.
With auscult-affection, the finger is not "beaten", but is carried along the abdominal wall, "scraped" by it. While the finger "goes" above the stomach, a rustling is heard in the phonendoscope. When you go beyond these limits, it stops. The place where the sound disappeared indicates the lower boundary of the organ. From here, the specialist conducts a deep palpation: bending his fingers and setting his hand in this area, he feels his stomach in the midline. The solid formation here is the tumor. In 50% of cases, a large curvature of the organ is felt under the fingers (soft “roller” transversely running along the spine).
Soreness when palpating a large curvature is a signal of inflammation, ulcerative process.
Percussion
The diagnostic value of this method is not considered particularly large. This manipulation is performed with the help of superficial strokes (with a finger on the finger), starting from the navel, moving in the direction of the lateral abdomen (the patient is lying). This method determines the Traube space (gas bubble of the bottom of the stomach). It is better detected on an empty stomach. If the volume on an empty stomach is insignificant, then problems, in particular, pyloric stenosis, are likely.
Splash noise detection
Examination of the stomach by shaking (succus) is done to detect the presence of fluid in the organ. At the same time, the examinee must lie on his back, he is asked for calm, deep breathing, and the stomach must be involved in the respiratory process. The doctor, with four half-bent fingers of his right hand, makes quick, short shocks to the epigastric region. With the left hand, the abdominal muscles in the lower part of the sternum (xiphoid process) are fixed. The presence of fluid in the stomach causes a gurgling sound - the sound of splashing.
Thus determine:
- the lower boundary of the organ is the “extreme”, lower point where this specific sound is still heard;
- tone: the presence of splashing noise on an empty stomach (7-8 hours after the last meal) suggests stagnation of the contents, that is, a failure of the evacuation function or an increase in secretory function (less often); the absence of such already after 60 minutes after eating, on the contrary, can talk about the acceleration of motor-evacuation ability.
Intestinal palpation
On palpation, the examining fingers carefully immerse and press the organ under investigation to the posterior abdominal wall; sliding movements determine the contours, density and possible formations, deviations.
As a rule, when feeling the sigmoid colon gives the impression of a smooth, dense, mobile, non-rumbling and painless cylinder with a finger thickness. Its thickness depends on the state of the walls, filling with gases and fecal masses. With inflammatory infiltration, its walls thicken; when overflowing with solid fecal matter, the sigmoid colon becomes clearly shaped, and deep ulcerative processes make it tuberous and uneven. In an acute inflammatory process in the sigmoid colon, the latter acquires a denser consistency and becomes painful. The density of the gas-filled and liquid contents of the sigmoid colon is reduced; when inflammatory adhesions form around it, normal mobility is lost. With spasm, the intestine is felt in the form of a cord or cord. A rumbling in the sigmoid colon occurs upon receipt of the upper contents of the liquid contents or with a long delay in feces; the latter entails irritation of the walls with the release of a significant amount of mucus (false diarrhea).
The cecum is normally felt in the form of a two-finger-wide smooth, slightly rumbling, painless and moderately mobile (2-3 cm) cylinder. Its mobility can be pathologically increased (mobile cecum - coecum mobile). The consistency is condensed with coprostasis, gas distension, acute and chronic inflammation, but the walls remain smooth and even. In the presence of a tuberous cecum, one should think about ulcers of tuberculous, syphilitic, dysenteric origin, deeply penetrating the wall, about a tumor. The volume and shape of the cecum depend on the quantity and quality of its contents. With a dense content and a normal amount of gas, the intestines do not rumble, with a liquid content in combination with a significant amount of gases, a loud rumbling occurs, most often with enteritis, tiflitis. The presence of pain during palpation of the cecum always indicates its pathological condition.
After palpation of the cecum and very rarely of the appendix, they proceed to palpation of the less accessible parts of the colon - the ascending, transversely open, and descending colon. The transverse colon is felt only with chronic inflammation of it. The consistency, volume and shape depend on the tone and degree of tension of its muscles, as well as the properties of the contents. Any inflammatory process, especially ulcerative, in the presence of inflammatory infiltration causes serious changes in the transverse colon. It changes its shape and consistency, its walls thicken, under the influence of the ulcerative process, the muscles contract more strongly, its configuration changes.
In chronic colitis and pericolitis, the intestine becomes dense, contracted, painful on palpation, sometimes tuberous (at the site of ulcers). With pericolitis, it loses both respiratory, active and passive mobility due to the formation of adhesions.
With palpation of the abdomen, you can feel a tumor of the intestine, which is often mixed with a tumor of neighboring organs. Tumors of the transverse and cecum are known for their mobility. Tumors of the transverse colon and its bends move during the act of breathing, while tumors located below the navel are usually immobile.
With enterocolitis, palpation of the abdomen causes rumbling and splashing noise in the navel.
The small intestines are felt mainly around the navel. With enteritis, painless diarrhea is noted, and with palpation of the small and large intestines, rumbling. With colitis, a mushy mucous stool, abdominal pains are observed, and with palpation a painful, compacted, enlarged and slightly rumbling colon.
Palpation of the abdomen is complemented by a digital examination of the rectum, sigmoidoscopy and x-ray studies. For all diseases of the intestine, a digital examination of the rectum should be carried out so as not to miss cancer of the rectum, syphilitic structures. Finger research in combination with sigmoidoscopy allows you to establish the presence of inflammatory processes, cracks, fistulas, tumors, hemorrhoidal nodes. In addition, it creates an impression of the sphincter tone, the width and filling of the rectal ampoule. In some cases, palpation of neighboring organs — the bottom of the pelvis, Douglas space, neck and bottom of the bladder — in men — the prostate and seminal vesicles, in women — the uterus and its appendages, is very useful. With a digital examination, a tumor of the rectum and sigmoid colon can be found, in women, a uterine tumor and an ovarian cyst that directly adjoin the rectum, squeeze or push it to the side.
Finger research sometimes allows you to find out the nature of constipation. It is known that under normal conditions, the rectal ampoule is empty, and in case of chronic constipation due to a violation of the innervation of the muscle apparatus, it can be crowded and expanded.
Getting started palpating the cecum, you must remember that in normal cases it is located in the right iliac fossa, and the direction of its axis is somewhat indirect - namely, from the right and from the top - down and to the left. Therefore, remembering the mandatory rule for palpating the abdominal organs - to palpate in a direction perpendicular to the axis of the organ - it is necessary to palpate indirectly from left and from top to right and down along the right umbilical osseous line or parallel to it.
Usually with probing it is most convenient to use 4 slightly bent fingers, which we gradually try to immerse in the abdominal cavity to the inside of the location of the cecum. Taking advantage of the relaxation of the abdominal press during exhalation, and reaching the contact of the ends of the palpating fingers with the back wall of the abdominal cavity, we, without relieving pressure, slide along it, with our fingers rolling through the cecum and bypassing it for about 3/4 of its circumference .
Gausman advises when probing coeci to apply oblique palpation with 3 fingers, but I don’t see any particular advantages in this technique and always use the typical 4-finger palpation proposed for the first time by Exemplary. In most cases, with the first movement along the posterior surface of the ileal cavity, we manage to feel the gut. However, with some tension of the abdominal press, it can be useful to transfer the resistance of the abdominal press to another area in the neighborhood in order to reduce the resistance at the site of the study of the cecum.
To this end, on the advice of Obraztsova, Useful with your free left hand, namely the tenar and the outer edge of the thumb, to press near the navel and not to weaken the pressure during the entire study. In other cases, with the cecum located high, when it lies, therefore, in the right flank, it is useful to place the left hand flat under the right lumbar region in order to create a denser wall to which the cecum is pressed during palpation. In other words, you need to apply bimanual palpation.
If at the first sliding the movement of our fingers Since we do not feel the guts, it usually depends on the fact that its walls are in a relaxed state and, therefore, in order to feel, we must wait for their physiological contraction. According to Gausman statistics, a normal blind. Gut is felt in 79%, therefore, quite often, although less frequently than S. R.
I must say that blind gut Glenard first felt 10% in the form of an oval body the size of a chicken egg (boudin coecal) and considered her palpability as a pathological phenomenon, depending on the tension of her walls due to the narrowing of the colon above the blind. Only Samples showed that a perfectly normal cecum is also palpable. When palpating the cecum, we usually find not only the blind sac, but also palpate at the same time some part of the ascending intestine 10-12 cm long, that is, what is commonly called typhlon in the clinic.
According to Obraztsov, longitudinal axis of the cecum it is 5 cm away from spina osis ilei anterior superior, on average, with the lower border of the cecum on average lying slightly higher than the intercostal line in men, and in women at its level. But already Obraztsov drew attention to the fact that the position of coeci is individually different and varies widely.
At present time after work Wandel, Faltin "a and Ekehorn" a, Wilms "a, Klose et al., We know that the position of coeci, its thickness and length, and the ways of attaching it individually are so different that it is difficult to find two identical cases in this regard. Normally we palpate the cecum (typhlon) in the form of a width of two fingers smooth, slightly rumbling, painless on palpation and a moderately mobile cylinder with a small pear-shaped blind extension downward (the cecum itself), which has moderately elastic walls.
I moment of palpation: installation of the doctor’s hands. the right hand is mounted on the anterior abdominal wall in accordance with the topography of the palpable organ.
II moment of palpation: the formation of skin folds. During inhalation of the patient with slightly bent fingers form a skin fold, shifting the skin to the side opposite to the direction of subsequent sliding along the intestine.
III moment of palpation: immersion of the hand deep into the abdomen. During exhalation of the patient, when the muscles of the anterior abdominal wall gradually relax, they try to plunge the fingertips as deep as possible into the abdominal cavity, as far as possible, to its posterior wall.
IV moment of palpation: gliding over the organ. At the end of the exhalation, the organ is felt with a sliding movement of the right hand, pressing it to the back wall of the abdominal cavity. At this moment, they make a tactile impression of the features of the palpable organ.
Normally, the sigmoid colon is probed over 15 cm in the form of a smooth, moderately dense cord with a diameter of the thumb. It is painless, does not rumble, sluggishly and rarely peristalsis, is easily displaced by palpation within 5 cm. With lengthening of the mesentery or the sigmoid colon (dolichosigma), it can be palpated "much more medially than usual.
33. Palpation of the cecum. The sequence of actions of the doctor during its implementation. Characterization of the cecum is normal and its changes in pathology.
I moment of palpation: the doctor places the right hand in the right iliac region so that the tips of the bent fingers are 1/3 of the distance from the spina iliaca anterior superior to the navel.
II palpation moment: during inspiration, a movement of the researcher’s hand towards the navel forms a skin fold.
III moment of palpation: during exhalation, taking advantage of the relaxation of the abdominal muscles, they try to plunge the fingers of the right hand into the abdominal cavity as deep as possible until it reaches its posterior wall.
IV moment of palpation: at the end of exhalation, make a sliding motion e in the direction of the right spina iliaca anterior superior and get a palpation of the cecum.
Normally, the cecum has the form of a smooth, soft-elastic cylinder with a diameter of 2-3 cm. It is somewhat widened downwards, where it blindly ends with a rounded bottom. The intestine is painless, moderately mobile, rumbling with pressure.
34. Palpation of 3 sections of the colon. The sequence of actions of the doctor during its implementation. The characteristic of the colon is normal and its changes in pathology.
The ascending and descending parts of the colon are palpated with bimanual palpation. To create a solid foundation, the left hand is placed on the lumbar region on the right and left. The fingers of the right hand are set perpendicular to the axis of the ascending or descending intestine. Fingers immersed in the abdominal cavity are carried out outwards. Palpation of the transverse colon is carried out 2-3 cm below the found border of the stomach, either with one right hand, first setting it at 4-5 cm to the right of the midline, then - to the left, or bimanually - setting the fingers of both hands to the right and left of the midline . As for palpation of the ascending and descending intestines, throughout their entire length these sections of the large intestines are rarely probed and palpable with difficulty, since they are located on a soft lining, which makes it difficult to feel. However, in those cases when these departments are altered due to any pathological processes in themselves (inflammatory thickening of the walls, ulcers, developed neoplasm, polyposis) or lower, for example, with narrowing in the fl. hepatica or in S. R., which entails hypertrophy and thickening of the wall of these departments, applied by general rules, palpation makes it possible not only to easily palpate these departments of coli, but also to diagnose the corresponding process by characteristic palpation data.
35. Inspection of the liver. Palpation of the liver. The sequence of actions of the doctor with palpation of the liver. Characterization of the edge of the liver and its surface. Changes in the liver in pathology (physically determined). The clinical significance of the changes identified.
The liver is palpated according to the rules of deep sliding palpation according to Obraztsov. The doctor is located to the right of the patient lying on his back with arms extended along the torso and legs bent at the knees, placed on the bed. A necessary condition is maximum relaxation of the muscles of the abdominal wall of the patient with deep breathing. To enhance the excursion of the liver, you should use the palm pressure of the doctor’s left hand on the lower sections of the anterior chest wall on the right. The palpating right hand lies on the anterior abdominal wall below the edge of the liver (which should be predefined percussion); while the fingertips (they should be located along the proposed lower edge) are immersed into the abdomen synchronously with the patient’s breathing and, with the next deep breath, they meet with the falling edge of the liver, from which they slip out.
With severe ascites, normal percussion and palpation of the liver are difficult, therefore, they use the ballot palpation method, identifying the symptom of "floating ice floes". To do this, the right hand is placed in the mesogastric region on the lower right of the umbilicus and the jerky movements of the fingers of the hand move up to the sensation of a dense displaced organ under the fingers. Using this technique, you can get an idea of \u200b\u200bthe features of the edge of the liver and its surface.
With the help of palpation of the liver, its lower edge is first of all assessed - shape, density, presence of irregularities, sensitivity. Normally, the edge of the liver during palpation of a soft consistency, smooth, pointed (thin), painless. Displacement of the lower edge of the liver may be associated with the omission of the organ without its increase; in this case, the upper limit of hepatic dullness also shifts downward.
After carrying out superficial palpation of the abdomen, abdominal organs accessible during deep palpation are examined, determining their position, size, shape, texture, surface condition, and soreness. In this case, additional pathological formations, in particular, tumors and cysts, can also be detected.
The conditions of the study are the same as with superficial palpation of the abdomen. To reduce stress, the abdominal muscles should ask the patient to bend his knees slightly so that the soles are completely on the bed. In some cases, palpation is additionally carried out with the patient upright. To clarify the boundaries of individual organs, along with the palpation method, percussion and auscultation are used. In addition, in order to detect pain in the projection of organs deeply lying in the abdominal cavity and inaccessible to palpation, penetrating palpation is used. In patients with ascites, the ballot palpation method is used to study abdominal organs.
One of the most important conditions for deep palpation of the abdominal organs is the knowledge of their projection on the anterior abdominal wall:
- left hypochondrium: cardial section of the stomach, tail of the pancreas, spleen, left bend of the colon, upper pole of the left kidney;
- epigastric region: stomach, duodenum, pancreas body, left lobe of the liver;
- right hypochondrium: right lobe of the liver, gall bladder, right bend of the colon, upper pole of the right kidney;
- left and right lateral areas (flanks of the abdomen): respectively, the descending and ascending divisions of the colon, the lower poles of the left and right kidneys, part of the loops of the small intestine;
- umbilical region: loops of the small intestine, transverse colon, lower horizontal part of the duodenum, greater curvature of the stomach, head of the pancreas, portal of the kidneys, ureters;
- left iliac region: sigmoid colon, left ureter;
- suprapubic region: loops of the small intestine, bladder and uterus as they increase;
- right iliac region: cecum, terminal ileum, appendix, right ureter.
Usually observe the following sequence of palpation of the abdominal cavity: colon, stomach, pancreas, liver, gall bladder, spleen. The study of the organ, in the projection of which tenderness was revealed during superficial palpation, is carried out last, in order to avoid the diffuse protective reaction of the muscles of the abdominal wall.
When palpating the colon, stomach and pancreas, they use the method, developed in detail by V.P. Obraztsov and called the method of deep, sliding, methodical, topographic palpation. The essence of it is to exhale to penetrate with the brush into the depths of the abdominal cavity and, sliding the fingertips along the back wall of the abdomen, feel for the organ under examination, after which, rolling through it with your fingers, determine its properties.
During the study, the doctor puts the palm of his right hand on the front abdominal wall in the area of \u200b\u200bthe palpable organ in such a way that the tips of the closed and slightly bent fingers are in line and parallel to the longitudinal axis of the part of the intestine or the edge of the palpable organ. Greater palei is not involved in palpation. During the study, the patient should breathe evenly, deeply, through the mouth, using the diaphragmatic type of breathing. In this case, the abdominal wall should rise during inhalation, and lower as it exhaled. After asking the patient to take a breath, the doctor shifts the skin of the abdomen with the fingertips of the palpating hand, forming a skin fold in front of the fingers. The skin reserve thus obtained facilitates further movement of the arm. After this, on exhalation, using lowering and relaxation of the anterior abdominal wall, fingers smoothly immerse into the abdomen, overcoming muscle resistance and trying to reach the posterior wall of the abdominal cavity. In some patients, this can not be done immediately, but within a few respiratory movements. In such cases, during inspiration, the palpating hand must be held in the abdomen at the depth reached, so that with the next exhalation it penetrates even deeper.
At the end of each exhalation, the fingertips glide in the direction perpendicular to the length of the intestine or the edge of the organ under investigation, until it touches the palpable formation. In this case, the fingers should move with the skin lying under them, and not slip on its surface. The discovered organ is pressed against the back wall of the abdomen and, rolling across it with the tips of the fingers, they feel. A fairly complete picture of the properties of the palpable organ can be obtained within 3-5 respiratory cycles.
In the presence of tension of the abdominal muscles, it is necessary to try to cause their relaxation in the area of \u200b\u200bpalpation. To this end, gently press the beam edge of the left hand on the anterior abdominal wall away from the palpable area.
The colon is palpated in the following sequence: first, the sigmoid colon, then the blind, ascending, descending and transverse colon.
Normally, in the vast majority of cases, it is possible to palpate the sigmoid, blind, and transverse colon, while the ascending and descending sections of the colon are palpable. On palpation of the colon, its diameter, density, surface character, mobility (displacement), the presence of peristalsis, rumbling and splashing, as well as pain in response to palpation, are determined.
You can use another method of palpation of the sigmoid colon. The right hand is opened on the left side of the body and positioned so that the palm rests on the anteroposterior spine of the left iliac bone, and the fingertips are in the projection of the sigmoid colon. In this case, the skin fold is displaced inwards from the intestine and is palpated in the direction: from the inside and from above - outwards and downwards (Fig. 45).
Normally, the sigmoid colon is probed over 15 cm in the form of a smooth, moderately dense cord with a diameter of the thumb. It is painless, does not rumble, sluggishly and rarely peristalsis, is easily displaced by palpation within 5 cm. With lengthening of the mesentery or the sigmoid colon (dolichosigma), it can be palpated "much more medially than usual. Cecum located in the right iliac region and also has an oblique passage, crossing almost at right angles to the right umbilical-rest line at the border of its outer and middle thirds. A palpating hand is placed in the right iliac region so that the palm rests on the anteroposterior spine of the right iliac bone, and the fingertips are directed towards the navel and are in the projection of the cecum. On palpation, the skin fold is shifted inwards from the intestine. Palpate in the direction: from the inside and from above - outwards and downwards (Fig. 46).
Normally, the cecum has the form of a smooth, soft-elastic cylinder with a diameter of two transverse fingers. It is somewhat expanded downward, where it blindly ends with a rounded bottom. The intestine is painless, moderately mobile, rumbling with pressure.
In the right iliac region, it is sometimes possible to palpate also terminal ileum, which from the bottom obliquely flows from the inside into the cecum. Palpation lead along the inner edge of the cecum in the direction from top to bottom. If the ileum is reduced and accessible for palpation, it is defined as a smooth, dense, mobile, painless cord 10-15 cm long and with a diameter of no more than the little finger. She periodically relaxes, making a loud rumbling, and at the same time, as it were, disappears at hand.
When feeling the descending colon, the palm of the left hand is moved further beyond the spine and placed in the transverse direction under the left lumbar region so that the fingers are outward from the long muscles of the back. A palpating right hand is wound on the left side of the body and placed in the left flank of the abdomen transverse to the bowel so that the base of the palm is directed outward and the fingertips are 2 cm lateral to the outer edge of the rectus abdominis muscle. The skin fold is displaced more medially than the intestine and is palpated outwardly from the inside, while pressing the lumbar region with the left hand (Fig. 47b).
The ascending and descending sections of the colon, if they can be felt, are mobile, moderately dense, painless cylinders with a diameter of about 2 cm.
Normally, the transverse colon has the shape of a transverse lying and curved downward, moderately dense cylinder with a diameter of about 2.5 cm. It is painless, easily moves up and down. If it was not possible to find the transverse colon, palpation should be repeated after finding a large curvature of the stomach, which is located 2-3 cm above the intestine. At the same time, it must be borne in mind that with severe visceroptosis, the transverse colon often descends to the level of the pelvis.
In the presence of pathological changes in the colon, soreness in one or another of its sections can be detected, as well as a number of other signs characteristic of certain diseases. For example, local expansion, densification and tuberosity of the surface of a limited area of \u200b\u200bthe colon most often indicates its tumor lesion, although it can sometimes be caused by a significant accumulation of solid feces in the intestine. Uneven clearly thickened and densified walls of the colon or terminal ileum are observed with intestinal granulomatosis (Crohn’s disease) and tuberculous lesion of it. The alternation of spasmodically contracted and gas-inflated areas, the presence of loud rumbling and splashing noise is characteristic of inflammatory diseases of the colon (colitis) or functional origin (irritable bowel syndrome).
In the presence of a mechanical obstacle to the promotion of feces, the overlying part of the intestine increases in volume, often and strongly peristalsis. Causes of mechanical obstruction may be cicatricial or tumor stenosis of the intestine or compression of the intestine from the outside, for example during adhesions. In addition, in the presence of adhesions and colon cancer, the mobility of the affected section is often significantly limited.
If there is local pain in the abdomen, but the feeling of a part of the intestine located in this section does not cause pain, this indicates a pathological process in neighboring organs. In patients with ascites, the presence of even a small amount of free fluid in the abdominal cavity significantly complicates palpation of the colon.
Small intestine usually not accessible for palpation, because it lies deep in the abdominal cavity and is extremely mobile, which does not allow it to be pressed against the posterior abdominal wall. However, with inflammatory lesions of the small intestine (enteritis), it is sometimes possible to test its inflated gas and loud noise making loops. In addition, in patients with a thin abdominal wall, deep palpation in the umbilical region makes it possible to detect enlarged mesenteric (mesenteric) lymph nodes during their inflammation (mesadenitis) or cancer metastases.
The process of palpation of the stomach and intestines is important in terms of a diagnostic study of the human body. Digestive organs are monitored as follows: at the first stage, a qualified specialist carefully probes the sigmoid colon - this is the most common landmark and the most accessible organ for palpation. Next, the doctor proceeds to study the condition of the cecum and transverse. The ascending and descending sections of the suction organ are probed quite problematically.
In practice, in the process of palpation, the fingers must be carefully immersed on the surface of the body area and gently pressed down on the organ under investigation (towards the posterior abdominal wall). With the help of sliding movements, you can clearly determine the contours, density, the presence of various neoplasms and deviations. When the sigmoid colon is touched (felt), it gives the impression of a smooth, dense, and mobile cylinder in the human body. The size of such a "geometric figure" does not exceed the thickness of the human thumb. The formation parameters are directly related to the state of the walls, which are densely filled with gases and decay products (fecal / fecal masses).
With the inflammatory process of the infiltrating walls, a significant thickening of the membrane occurs. Ulcerative manifestations form a tuberous and uneven surface of the suction organ. Acute inflammation of the sigmoid colon is accompanied by the formation of a dense texture of the painful manifestation. Due to the dense overflow of gases and liquid contents, inhibition of motility occurs. A spasm is felt in the form of a cord and a cord. The patient experiences a systematic rumbling + false urge to defecate (false diarrhea).
In the normal state, the cecum is palpated easily. A specialist can detect a moderately active cylinder with movements up to 3 cm. Its mobility with a pathological disorder is significantly increased. The internal consistency is significantly condensed with coprostasis and chronic inflammation. The volume and shape of the cecum directly correlates with the contents. In the normal functional state, the intestines do not rumble.
The patient should remember that the presence of pain during palpation in the cecum indicates the development of a pathological process. The digestive organ requires a systematic and comprehensive treatment.
In practice, after examining the cecum (+ appendix), it is possible to examine less accessible sections of the large intestine. Palpation is carried out from the ascending to the lateral and descending intestines. The transverse part of the suction organ is qualitatively felt only in the case of chronic inflammation. Tone, consistency, volume, shape depend on the tone and degree of muscular tension. For example, the inflammatory process of the ulcer type forms serious prerequisites for the transformation of the transverse intestine. At the same time, the musculature of the organ significantly thickens, its configuration changes.
Today, chronic colitis and perekolit are quite common. With these ailments, the wall of the suction organ begins to contract painfully. Due to the rough surface, palpation is accompanied by sharp pain. So, for example, with pericolitis, respiratory and active mobility is lost.
Palpation of the abdomen allows palpation of a tumor of the intestine, which is often confused with the pathology of various organs. Oncology of the cecum and transverse colon is distinguished by the already known mobility. The pains are activated during the act of breathing (tumors below the navel are immobile). Feeling the abdomen with enterocolitis is accompanied by rumbling in the navel. The disease has specific signs and symptoms: painful diarrhea (grueling mucous stools, abdominal pain, tightened colon). Palpation of the abdomen is carried out in combination with a digital examination of the rectum (sigmoidoscopy + radiography). These actions allow us to predict the formation of colorectal cancer and the formation of various syphilitic structures. It will also be possible to clearly determine the presence of inflammatory processes, cracks, fistulas, hemorrhoids and all kinds of tumors. A specialist can get a clear vision of the sphincter tone, the level of filling of the colon ampoule. In some cases, it is rational to palpate adjacent organs (the bottom of the bladder, prostate gland, uterus with appendages). This will reveal an ovarian cyst, a tumor of the genital organs, the degree of constipation, etc.
The mechanism of the procedure
Palpation is the last stage of a full and objective examination of the abdomen. The patient will need to cough vigorously before the procedure. In practice, a person with developed peritonitis manages to do this only superficially (holding the abdomen with his hands). It is allowed to make a small force hit on the couch, on which the patient is in a lying position. Vibration impulse will provoke the manifestation of pain in the digestive tract. Thus, it is fairly easy to establish a diagnosis of peritonitis without touching the hand. To identify symptoms of peritoneal irritation, it is allowed to gently shake the patient, having previously grasped the crests of the ileum (or jumping on one leg).
The palpation procedure begins with the fact that the patient is asked to clearly indicate the area where the first pains formed (primary localization of the disease). The specialist needs to carefully monitor the actions of the patient. This is how the causes of peritoneal irritation can be identified. Visceral type diffuse pains in the abdomen are easily determined by circular movements of the palm. Hands should be warm.
The procedure begins as far as possible from the main focus of pain. This helps to avoid unplanned pain at the very beginning of the study. Children, and sometimes adult patients, sometimes do not give a quality examination due to pain.
First of all, the doctor must perform gentle and accurate palpation (superficial). An experienced specialist moves gently, methodically and consistently. The fingers make the minimum number of movements. It is strictly forbidden to palpate your stomach randomly! Pressure on the surface of the body should not be high. Otherwise, protective tension of the abdominal muscles will occur. Touching a sore spot should be carried out until the patient says that it really hurts.
A qualified specialist can always determine the degree of muscle tension in the anterior abdominal wall. A physician must distinguish between voluntary and involuntary muscle tension. To clearly determine this factor during palpation, a person takes a deep breath and exhale. If muscle activity persists, then this indicates the development of peritonitis.
It is rational to produce deeper palpation if peritonitis was not detected by a surface examination. This allows you to detect various tumor formations, hepatosplenomegaly, aortic aneurysm. It is very important for a physician to remember the optimal sizes for normal structures, so as not to confuse them with malignant ones. Pain on palpation of the abdomen and intestines are of two types:
- immediate local pain - the patient experiences sharp pain at the study site;
- indirect (reflected soreness) - pain is formed in another place when feeling. For example, with acute appendicitis, pain accumulates at the Mc Burney point on the left side of the iliac fossa. This symptom is called "Roving" and acts as a reliable sign of peritoneal irritation.
Comparative palpation of the patient with tense muscles of the abdominal cavity is easy. For this patient, who is in a supine position, he is asked to carefully raise his head above the pillow.
The classic symptom of parietal peritoneal irritation is easy to identify. To do this, at the time of the study, the doctor must sharply remove his hand from the surface of the body and observe the patient's reaction. In most cases, patients have a significant increase in pain. This classical method of examination is rather crude; some scholars attribute it to a barbaric method of study.
With the development of various pathologies in the digestive organs (for example, acute appendicitis), hyperesthesia of the skin in the abdominal region is observed. For this reason, if you pinch or prick the patient easily, a painful reaction of the body will instantly arise. This is a fairly common clinical symptom, but its establishment is not enough for a solid diagnosis of acute appendicitis and other diseases of the abdominal cavity.
An integral part of the palpation study is the accurate striking of the lumbar region (+ side of the abdomen) to determine the degree of pain in these areas. Quite often, pyelonephritis and urolithiasis correlate with sharp pains in the abdomen (region of the rib-vertebral).
In dubious clinical situations, inspection alone is not enough. An accurate assessment of the dynamics of the disease is established with repeated palpation of the abdomen by the same doctor.
Varieties of pain
Causes of pain in women
Today, medicine distinguishes two types of fundamental causes that affect pain when palpating. Organic factors include:
- inflammatory processes in the genitourinary system (cyst, endometritis, myoma);
- the use of the spiral as a contraceptive;
- the formation of various pathological formations;
- the presence of inflammation in the gallbladder (including appendicitis, pyelonephritis);
- sharp pain during pregnancy (detachment of the placenta, miscarriage).
Functional reasons are as follows:
- systematic malfunctions in cycles during menstruation;
- uterine bleeding;
- ovulation + bending of the uterus.
Inflammatory processes are the main reason for the occurrence of pain during palpation of the stomach and intestines. The ailment begins with classic acute manifestations and is supplemented by various signs of intoxication of the body, namely:
- Endometritis is accompanied by aching pain in the abdomen. Their manifestation can be established with a slight feeling. The patient experiences severity in the area of \u200b\u200bthe appendages + uterine compaction;
- Endometriosis is a pathological disorder that affects the uterus and appendages. Severe pain is observed during palpation of the middle abdomen;
- Ovarian apoplexy correlates with ovulation. In this case, part of the blood penetrates into the abdominal cavity due to strong physical exertion;
- Uterine fibroids. Pain syndrome is localized in the lower abdomen (compression of adjacent organs);
- Appendicitis requires prompt medical attention. Palpation pain in the area of \u200b\u200bthe appendix;
- Cholecystitis is an inflammatory process of the gallbladder. Pain gives clearly to the lumbar region and back;
- Cystitis - damage to the bladder. Pain is observed both on palpation and during urination.
Causes of pain in men
Pain on palpation in men is preceded by a number of factors. It can be both inflammation of the appendages, and prostatitis, cystitis, various formations. Doctors highlight some signs of pain in which it is necessary to hospitalize a person. If the pain is concentrated in the area of \u200b\u200bthe formation of the appendix, then this indicates the occurrence of appendicitis. Inguinal hernia and its pinching are also dangerous. In this case, the organ simply bulges outward and has a hard cover. The patient experiences severe pain. Abdominal pain is also a consequence of poor-quality food. Thus, peptic ulcer is formed. The main causes of pain in men are: diverticulitis, genitourinary disease, cystitis, pyelonephritis and excessive hypothermia.
In some cases, sharp pains are localized not only on the right side, but also on the left. Quite often, the main reason lies in the spread of intestinal infection. In this case, the main symptoms of appendicitis are observed, which have a paroxysmal manifestation. Pain is often aggravated during meals.
