Auscultation of the abdominal cavity. Methods for examining the abdomen: inspection, palpation, percussion, auscultation. Increased bowel sounds are established when

Tympanic sound zone of the stomach its shape resembles a bull's horn, with its wider part facing upward and located in the chest area, being bounded above by the lungs, on the left by the spleen, on the right by the left lobe of the liver - this area of tympanitis is called the semilunar space of Traube; the other part, approximately equal in area, is located in the epigastric region.

Of course, the size area Tympanitis of a normal stomach varies over an extremely wide range, depending primarily on the degree of filling of the stomach itself with gases and the condition and position of the organs bordering the stomach. For this reason, it cannot have any particular clinical significance.

But large fluctuations in magnitude area tympanitis can still provide some data for diagnosis; a sharp increase occurs when the stomach expands, and a decrease occurs when it shrinks, for example, with cirrhosis of the stomach or scyrous cancer. But when assessing an increase or decrease in tympanitis, you should always remember that an increase in the area of tympanitis may depend on a decrease in the volume of the left lobe of the liver, a high position of the diaphragm or wrinkling of the left lung, and a decrease in the area of tympanitis from compression of the stomach by neighboring enlarged organs, for example, an enlarged left lobe liver or spleen, or, finally, a lowered diaphragm with left-sided pleurisy.

It is also necessary to pay attention that the right border of the tympanic zone, when the stomach expands, deviates significantly to the right, sometimes going beyond the right nipple line, as indicated by another 3 and vert.

In the same way, it is still necessary to note the abnormal position right upper border of gastric tympanitis with perigastric adhesions in the area of the pyloric part of the stomach. In this case, one often notices a lifting upward of the right part of the zone of gastric tympanitis onto the costal arch, and then between the right nipple line and the median line a clear tympanic sound is noticed on the right costal arch. spreading upward by 4-5 cm.

If this, so to speak, additional area tympanitis is observed as a constant phenomenon, then along with tension of the right rectus muscle in its upper part and pain on palpation, it indicates perigastric adhesions or, if this phenomenon occurs suddenly, after severe pain with a stomach or duodenal ulcer, then perforation of the ulcer with consistent release of gases from the stomach.

If the specified area is located during percussion additional tympanic tone on the lower ribs between the mamillary and midline, we notice that the lower percussion border of the liver appears as if pressed upward between these lines,

Moving on to auscultation of the stomach, we must say that it provides extremely little for diagnosis. True, if you listen to the stomach under the xiphoid process while swallowing water, then according to Meltzer"y and Ewaldy you can hear two peculiar noises following each other at a certain distance - exactly after 10-12 seconds.

The first of them (Durchspritzgerausch) is clearer, more definite, consists as if of smaller bubbles, the second (Durchpressgerausch) is more dull, barely audible, occurs as if from the bursting of larger bubbles. When the entrance to the stomach is narrowed, the second noise is always delayed and follows the first by 50 - 70 seconds, and if you force the patient to take an empty sip, then according to Rewidzoffy, you can cause a new noise from pushing - the peristalsis of the esophagus drives the lingering over the cardia through the narrowed place liquid.

For my part, however, I must add that everything these acoustic phenomena are expressed so often unclearly that it is unlikely that any clinician will decide to base their diagnosis of narrowing of the esophagus on these noises.

Methods of physical examination of patients with diseases of the gastrointestinal tract - examination, palpation of the abdomen, percussion, auscultation.

Examination of the patient

Examination of patients with diseases of the gastrointestinal tract ( Gastrointestinal tract) allows you to identify emaciation, pallor, roughness and decreased turgor of the skin in malignant tumors of the stomach and intestines. But most patients with stomach diseases do not have any visible manifestations. When examining the oral cavity in patients with acute and chronic diseases of the stomach and intestines, a white or brown coating is detected on the tongue. 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.

Examination of the abdomen begins with 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 people, it is either slightly retracted (in asthenics) or slightly protruded (in hypersthenics). Severe retraction occurs in patients with acute peritonitis. Significant symmetrical enlargement of the abdomen can occur with bloating (flatulence) and accumulation of free fluid in the abdominal cavity (ascites). Obesity and ascites differ in several ways. With ascites, the skin on the abdomen is thin, shiny, without folds, the navel protrudes above the surface of the abdomen. In obesity, the skin on the abdomen is flabby, with folds, and the navel is retracted. Asymmetrical enlargement of the abdomen occurs with a sharp enlargement of the liver or spleen.

Respiratory movements of the abdominal wall are well determined when examining the abdomen. Their complete absence is pathological, which most often indicates diffuse peritonitis, but can also occur with appendicitis. Stomach peristalsis can be detected only with pyloric stenosis (cancerous or scar), intestinal peristalsis - with narrowing of the intestine above the obstruction site.

Palpation of the abdomen

The abdomen is a part of the body that is the abdominal cavity, where the main internal organs are located (stomach, intestines, kidneys, adrenal glands, liver, spleen, pancreas, gall bladder). Two methods of palpation of the abdomen are used: superficial palpation And methodical deep, sliding palpation according to V.V. Obraztsov and N.D. Strazhesko:

Superficial (approximate and comparative) palpation allows us to identify tension in the muscles of the abdominal wall, localization of pain and enlargement of any of the abdominal organs.
Deep palpation is used to clarify symptoms identified during 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 clinical topography diagrams of the abdomen.

The principle of the superficial palpation method

Palpation is carried out by applying gentle pressure with the fingers of the palpating hand placed flat on the abdominal wall. The patient lies on his back on a bed with a low headboard. Arms are 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 from the left groin area. Then the palpating hand is moved 4-5 cm higher than the first time, and further into the epigastric and right iliac regions.

For comparative palpation, studies are carried out in symmetrical areas, starting from the left iliac region, in the following sequence: iliac region left and right, periumbilical region left and right, lateral abdomen left and right, hypochondrium left and right, epigastric region left and right of the white belly lines. Superficial palpation ends with examination of the linea alba (the presence of a hernia in the linea alba, separation of the abdominal muscles).

In a healthy person, upon superficial palpation of the abdomen, pain does not occur, and tension in the muscles of the abdominal wall is insignificant. Severe diffuse soreness and muscle tension over the entire surface of the abdomen indicates acute peritonitis, limited local soreness 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, the Shchetkin-Blumberg symptom is detected - increased abdominal pain when the palpating hand is quickly removed from the abdominal wall after light pressure. When tapping the abdominal wall with a finger, local pain can be detected (Mendelian symptom). Accordingly, local protective tension of the abdominal wall is often detected in the painful area (Glinchikov’s symptom).

Muscular protection in duodenal and pyloroantral ulcers is usually determined to the right of the midline in the epigastric region, in case of an ulcer of the lesser curvature of the stomach - in the middle part of the epigastric region, and in case of a cardiac ulcer - in its uppermost section at the xiphoid process. According to the indicated areas of pain and muscle protection, zones of Zakharyin-Ged skin hyperesthesia are identified.

Principles of deep sliding palpation

The fingers of the palpating hand, bent at the second phalangeal joint, are placed on the abdominal wall parallel to the organ being examined and, after the formation of a superficial skin fold, which is subsequently necessary for the sliding movement of the hand, carried out in the depths of the abdominal cavity along with the skin and not limited by the tension of the skin, they sink deeply when exhaling into the abdominal cavity. This must be done slowly without sudden movements over 2-3 inhalations and exhalations, maintaining the achieved position of the fingers after the previous exhalation. The fingers are immersed to the back wall in such a way that their ends are located inward from the palpated organ. The next moment, the doctor asks the patient to hold his breath as he exhales and performs a sliding movement of the hand in a direction perpendicular to the longitudinal axis of the intestine or the edge of the stomach. When sliding, the fingers bypass the accessible surface of the organ. Elasticity, mobility, pain, the presence of compactions and lumpiness on the surface of the organ are determined.

The sequence of deep palpation is: sigmoid colon, cecum, transverse colon, stomach, pylorus.

Palpation of the sigmoid colon

The right hand is placed parallel to the axis of the sigmoid colon in the left iliac region, a skin fold is collected in front of the finger, and then, during the patient’s exhalation, when the abdominal muscles relax, the fingers gradually sink into the abdominal cavity, reaching its posterior wall. After this, without weakening the pressure, the doctor’s hand slides along with the skin in a direction perpendicular to the axis of the intestine, and rolls the hand over the surface of the intestine while 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, lumpy (neoplasm), strongly peristaltic (obstruction below it), motionless during fusion with 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 iliac 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 slightly displaceable. In pathology, the intestine can be extremely mobile (congenital elongation of the mesentery), immobile (in the presence of adhesions), painful (in inflammation), dense, lumpy (in tumors).

Palpation of the transverse colon

Palpation is carried out with both hands, i.e. using the method of bilateral palpation. Place both hands at the level of the umbilical line along the outer edge of the rectus abdominis muscles and palpate. 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 inflammation), lumpy and dense (with tumors), sharply rumbling, increased in diameter, soft, smooth (with narrowing below it).

Palpation of the stomach

Palpation of the stomach is very difficult; in healthy people it is possible to palpate the greater curvature. Before palpating the greater curvature of the stomach, it is necessary to determine the lower border of the stomach using the ausculto-percussion method or the ausculto-affriction method.

Ausculto-percussion is carried out as follows: a phonendoscope is placed over the epigastric region and, at the same time, quiet percussion is performed with one finger in a direction radial from the stethofonendoscope or, conversely, to the stethoscope. The border of the stomach is located by listening to a loud sound.
Ausculto-affriction- the percussion blow is replaced by a light intermittent glide over 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 area of the lower border of the stomach along the white line of the abdomen and palpation is performed. The greater curvature of the stomach is felt in the form of a “roller” located on the spine. Pathology reveals prolapse of the lower border of the stomach, pain on palpation of the greater curvature (with inflammation, peptic ulcer), and the presence of a dense formation (stomach tumor).

Palpation of the pylorus

Palpation of the pylorus is carried out along the bisector of the angle formed by the linea alba and the umbilical line, to the right of the linea alba. The right hand with slightly bent fingers is placed on the bisector of the indicated angle, a skin fold is collected in the direction of the white line and palpation is performed. The pylorus is palpated in the form of a cylinder, changing its consistency and shape.

Percussion of the abdomen

The value of percussion in the diagnosis of gastric diseases is small.

Using it, you can determine Traube's space (the area of tympanic sound on the left in the lower part of the chest, caused by the air bubble of the fundus of the stomach). It can be increased when there is a significant increase in the air content in the stomach (aerophagia). Percussion allows you to determine the presence of free and encysted fluid in the abdominal cavity.

With the patient positioned on his back, quiet percussion is performed from the navel towards the lateral abdomen. Above 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 the dull sound changes to tympanic. Encapsulated fluid appears with peritonitis limited by adhesions. Above it, during percussion, a dull percussion tone is determined, which does not change localization when changing position.

Auscultation of the gastrointestinal tract

Auscultation of the gastrointestinal tract should be carried out before deep palpation, since the latter can change peristalsis. Listening is carried out with the patient lying on his back or standing at several points above the stomach, above the large and small intestines. Normally, moderate peristalsis is heard, and sometimes rhythmic bowel sounds are heard after eating. Above the ascending part of the large intestine, rumbling can be heard normally, above the descending part - only with diarrhea.

With mechanical intestinal obstruction, peristalsis increases, with paralytic obstruction it sharply weakens, and with peritonitis it disappears. In the case of fibrinous peritonitis, a peritoneal friction sound may be heard during the patient's respiratory movements. By auscultation under the xiphoid process in combination with percussion (ausculto-percussion) and light short rubbing movements of the researcher's finger on the skin of the patient's abdomen along the radial lines to the stethoscope, the lower border of the stomach can be approximately determined.

Among the auscultatory phenomena that characterize the sounds occurring in the stomach, the splashing noise should be noted. It is caused with the patient in a supine position using quick short blows with the bent fingers of the right hand on the epigastric region. The appearance of a splashing noise indicates the presence of gas and liquid in the stomach. This sign becomes significant if it is detected 6-8 hours after eating. Then, with a reasonable degree of probability, pyloroduodenal stenosis can be assumed.

Auscultation is the next stage of an objective examination of the abdomen. First of all, warm up the stethoscope, because the touch of a cold instrument to the skin can cause a protective reaction in adult patients and especially in children. Some authors believe that auscultation of the abdomen should be performed for at least 5 minutes in order to adequately assess the state of intestinal motility. The absolute time during which auscultation of the abdomen is recommended seems to many doctors to be too high. A significant part of this time should be devoted to assessing intestinal motility (absence or presence and nature of bowel sounds). As with cardiac auscultation, as the physician gains experience, the time required to listen and adequately interpret peristalsis decreases. Sometimes the doctor makes a general conclusion about the presence or absence of peristaltic sounds in all four quadrants of the abdomen. This conclusion has little clinical significance.

A truly “silent stomach” (i.e., complete absence of peristaltic noise) indicates the development of an intra-abdominal catastrophe with diffuse peritonitis. However, there may be exceptions to this rule. If peristaltic sounds are heard, the doctor should note their frequency and nature. Is the frequency of peristaltic sounds normal, decreased or increased? By auscultation of the abdomen and determining the nature of peristaltic sounds, mechanical intestinal obstruction can often be differentiated from intestinal paresis. In the early stage of intestinal paresis, the frequency of peristaltic sounds is usually reduced, but peristalsis does not disappear completely. Peristaltic noises have a peculiar, gurgling character (the so-called splashing noise appears), which reflects the accumulation of gas and liquid in the intestinal lumen. Peristaltic sounds can vary from weak to loud and loud. In the later stages of intestinal paresis, the frequency of peristaltic sounds is significantly reduced, but peristalsis completely disappears quite rarely.

In the early stages of development of mechanical intestinal obstruction, the frequency of peristaltic sounds may be increased. Peristalsis is activated simultaneously with the appearance of cramping pain. The intensity and high tones of peristaltic noises are approximately the same as with resolving intestinal paresis. With mechanical intestinal obstruction, intestinal peristalsis varies from moderate to very loud, as a rule, it becomes more frequent, and its intensity steadily (sometimes quickly) increases. With intestinal paresis, peristaltic sounds are less frequent, usually gurgling, although it is difficult to differentiate these two pathological conditions. In the later stages of mechanical intestinal obstruction, the motor activity of the intestine weakens (the intestine “gets tired”), the periodicity of peristaltic noises is lost and it becomes impossible to distinguish them from peristaltic noises with advanced intestinal paresis.

In addition to mechanical intestinal obstruction, an increase in the frequency and amplitude of peristaltic noises (hyperperistalsis, rumbling) is observed in patients with gastroenteritis, bleeding from the upper gastrointestinal tract (due to irritation of the intestine with blood spilling into its lumen) and after eating. Peristaltic sounds have a normal tone, but their frequency and duration are increased.

If the doctor hears breath sounds or heart sounds during auscultation of the abdomen, this means that the entire space between the diaphragm and the anterior abdominal wall is filled with loops of intestine. For this auscultatory phenomenon to occur, it is necessary that the intestinal loops be sufficiently overstretched, which is most typical for intestinal paresis, and can also be observed in patients with small bowel obstruction if the obstruction is located in the distal parts of the intestine.

When auscultating the abdomen, you can also hear a specific murmur resulting from turbulent blood flow in the renal or mesenteric arteries, as well as from an abdominal aortic aneurysm. A friction noise heard over the liver appears with perihepatitis in patients with hepatoma and in women with pelvic inflammatory diseases, but in general this auscultatory phenomenon is not common. When auscultating the abdomen, you can use a stethoscope to apply significant pressure on the anterior abdominal wall, which is a kind of palpation of the abdomen. This method is recommended for use in faking patients who complain of severe abdominal pain, especially on palpation, while no other pathological symptoms are detected. The most active malingerers often do not realize that the doctor does much more than just listen to peristaltic sounds. This technique is also recommended for use when examining children to detect the area of maximum pain. Children with abdominal pain upon palpation are usually very tense, which greatly complicates the identification of local pain. In such cases, distracting the children's attention with his actions, the surgeon can palpate the abdomen with a stethoscope.

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Inspection, percussion, auscultation of the abdomen

Plan

1. Examination of the abdominal organs with the patient in an upright position
1.1 Abdominal examination
1.2 Percussion of the abdomen
1.3 Auscultation of the abdomen
2. Examination of the abdominal organs with the patient in a horizontal position
2.1 Abdominal examination
2.2 Percussion of the abdomen
2.3 Auscultation of the abdomen

1. Examination of the abdominal organs with the patient in an upright position

1.1 Abdominal examination

Examination of the abdomen with the patient in an upright position begins with inspection.

The doctor sits on a chair, and the patient stands in front of the doctor, facing him, exposing his stomach.

For precise localization of symptoms detected during an objective examination, abdominal cavity conditionally divided into several regions(Fig. 1.)

Rice. 1. Clinical topography of the abdomen (region): 1, 3 - right and left hypochondrium; 2 - epigastric; 4, 6 - right and left flanks; 5 - umbilical; 7.9 - right and left iliac; 8 - suprapubic

On the anterior abdominal wall there is three departments, located one below the other: epigastric, mesogastric and hypogastric. They are separated by two horizontal lines: the first connects the tenth ribs, the second connects the anterior superior iliac spines.

Two vertical lines carried out along the outer edges of the rectus abdominis muscles, each section is divided into three oblusty:

- epigastric: by two subcostal areas (right and left) And epigastric (epigastric), located in the middle;

- mesogastric: on two lateral flank and on umbilical;

- hypogastric: on two located on the sides iliac regions 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 his constitution. With an asthenic physique, the stomach is somewhat retracted in the upper part and slightly protruded in the lower part. With a hypersthenic physique, the stomach is evenly protruded anteriorly.

You should pay attention to the symmetry of changes in the abdomen.

In pathological cases, retraction or significant protrusion of the abdomen is detected. Uniform retraction of the abdomen is associated with increased tone of the muscles of the anterior abdominal wall in patients with acute peritonitis, as well as with general exhaustion. Asymmetrical retraction of the abdomen may be a consequence of the adhesive process.

Uniform protrusion of the abdomen is caused by obesity, flatulence, and ascites.

With obesity, the folding 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 symmetrical increase in volume of the entire abdomen, small ones - only protrusion of the lower part.

Bulging of the abdomen in the lower part may be associated with pregnancy, large uterine fibroids, ovarian cysts, or an enlarged bladder due to obstruction of the outflow of urine.

Stenosis of the distal parts of the large intestine (sigmoid or rectum) is 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 peristalsis can be visible only with 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 site of the obstruction and are easily caused by a slight shaking of the anterior abdominal wall.

Normally, the skin of the abdomen is smooth and pale- pink with matte tint.

In multiparous and thin women, it is wrinkled with whitish jagged stripes. Reddish-bluish stripes on the lower lateral parts of the abdomen with transition to the thighs are found in Itsenko-Cushing's disease. The nature and location of postoperative scars make it possible to fairly accurately determine 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 surface of the skin.

If there is difficulty in blood circulation in the portal or inferior vena cava system, dilated veins on the anterior abdominal wall. Disturbance of outflow in the system portal vein with cirrhosis of the liver, thrombophlebitis of the portal vein, pressure on it from 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 convoluted veins on the anterior abdominal wall in the navel area is called " Medusa heads"(caput Medusae).

Examination of the abdomen in an upright position ends with examination beloy line, inguinal and femoral canals where hernias are found. The outer inguinal ring usually allows the index finger to pass freely, 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 an upright position of the patient, the divergence of the rectus abdominis muscles can be recognized by palpation of the white line of the abdomen.

1.2 Percussion of the abdomen

Percussion of the abdomen with the patient in an upright position used to detect normal or increased gas filling of the intestines, as well as free fluid in the abdominal cavity (ascites) and determine its level.

Percussion is carried out from top to bottom along the midline from the xiphoid process to the pubis and on both sides along the flanks from the r ethe arch of the spine to the iliac bones. The pessimeter finger is installed horizontallynin detail(Fig. 2.).

With a vertical fingerpercussion is performed from the navel to the right and left flanks(Fig. 3.).

The normal amount of gas in the intestines is characterized by a certain quality of tympanic sound over different parts of the abdominal cavity.

A pronounced tympanic sound is heard during percussion in the umbilical and epigastric regions (above the small intestine, gas bubble of the stomach).

Rice. 2. Percussion of the abdomen with the patient in an upright position

Tympanic sound in the left flank and left iliac region should be shorter than the tympanic sound over the corresponding right sections.

Violation of this ratio of the severity of the tympanic sound with its intensification in areas 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

Auscultation abdomen in a standing position of the patient is carried out to determine the friction noise of the peritoneum in the right and left hypochondrium 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. The delay or absence of the second noise associated with the passage of fluid through the cardia indicates an obstruction in the lower third of the esophagus or in the cardia of the stomach.

2. Examination of the abdominal organs with the patient in a horizontal position

During the examination, the patient should lie on his back, on a semi-rigid bed with a low headboard, with his stomach completely exposed, legs extended and arms placed 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 it.

2.1 Abdominal examination

abdomen topography percussion auscultation

At inspection pay attention to the changes that occurred when the patient’s body position changed. In a horizontal position, hernias visible to the eye usually disappear.

In the presence of free fluid in the abdominal cavity, the abdomen becomes flattened, which extends in the lateral directions (the fluid spreads over the posterior surface of the abdominal cavity) and takes on a “frog” shape.

Asymmetrical bulges appear more prominently, caused by enlargement of the liver, spleen, the formation of cysts or tumors, and the presence of flatulence.

Local flatulence or protrusion of a limited area of the intestine during intestinal obstruction (Val's symptom) is accompanied by intense peristalsis above the site of obstruction.

Abdominal bloating in the epigastric region in combination with visible peristalsis indicates the appearance of an obstacle to gastric emptying (pyloric stenosis).

In patients with pancreatitis, examination reveals bright red spots (aneurysms of small vessels) on the skin of the abdomen, chest and back (S.A. Tuzhilin’s symptom), ecchymoses around the navel (Grunwald’s symptom) and a strip of atrophy of the subcutaneous fat layer according to the topographic position of the pancreas ( Grotta's sign).

A complete lack of abdominal mobility during deep breathing may 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 and focal peritonitis.

2.2 Percussion of the abdomen

With the patient in a horizontal position percussion abdomen is carried out along the same lines as in the vertical position of the patient. In addition, with the patient in the supine position, and then on the side, they percussion from the navel to the flanks, placing the plessimeter finger vertically (Fig. 3).

With ascites, the localization of the dull sound obtained by percussion in the vertical position of the patient changes. Its horizontal level disappears, now a dull sound is detected 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 on its side, the dull sound zone in the lower flank increases due to additional fluid from the other flank. Tympanitis is detected in the opposite flank (Fig. 3). Turning the patient to the other side completely changes the percussion picture - a tympanic sound appears in place of the former dull sound and vice versa.

By using percussion- palpation technique- causing fluid fluctuations also determine the presence of ascites. To do this, the palmar surface of the left hand is applied to the right half of the abdomen in the area where dullness is detected. With the right hand, single-finger percussion according to V.P. Obraztsov is given light blows to the left half of his abdomen at the same level as the applied left hand (Fig. 4.). If there is a significant amount of free fluid in the abdominal cavity, the palm of the left hand clearly perceives fluctuations - jerky vibrations of the fluid. To prevent the transmission of oscillatory movements along the anterior abdominal wall, you can place your hand or a book with its edge along the white line of the abdomen.

Using percussion, you can determine local pain in the epigastric region during exacerbation of gastric or duodenal ulcers (Mendel's symptom). Abruptly strike the upper sections of the rectus abdominis muscles with the middle finger of the right hand. Due to the increased sensitivity of the parietal layer of the peritoneum in the projection of the diseased organ, the blow is painful.

Rice. 3. Percussion of the abdomen in a horizontal (on the back and right side) position of the patient

Rice. 4. Percussion-palpation technique for determining free fluid in the abdominal cavity (side view and top view)

2.3 Auscultation of the abdomen

To listen to intestinal peristalsis, a stethoscope is installed at the site of the projection 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 umbilicus and the anterior superior iliac spine on the left.

Rice. 5. Auscultation of the abdomen: 1) sigmoid colon; 2) cecum; 3) small intestine

The point of auscultation of the cecum is between the outer and middle thirds of the line connecting the umbilicus and the anterior superior iliac spine on the right.

The auscultation point 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 sounds over the large intestine is about 4-6 per minute, over the small intestine - 6-8 per minute.

Increased peristalsis is detected with enteritis, colitis, and accelerated movement of liquid contents through the intestines.

Lack of peristalsis is a sign of intestinal paresis, peritonitis.

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