Ix. determination of the boundaries of absolute hepatic dullness and liver size
First way. The percussion method allows you to determine the boundaries, size and configuration of the liver. Percussion determines the upper and lower boundaries of the liver. There are upper limits of two types of hepatic dullness: relative stupidity, which gives an idea of the true upper limit of the liver and absolute dullness, i.e. the upper border of the section of the anterior surface of the liver, which is directly adjacent to the chest and is not covered by the lungs. In practice, they are limited to determining only the boundaries of absolute dullness of the liver, since the position upper limit relative dullness of the liver is not constant and depends on the size and shape chest, height of the right dome of the diaphragm. In addition, the upper edge of the liver is very deeply hidden under the lungs, and the upper limit of the relative dullness of the liver is difficult to determine. Finally, in almost all cases, liver enlargement occurs predominantly downward, as judged by the position of its lower edge.
The upper limit of absolute liver dullness. Quiet percussion is used. Percuss from top to bottom along vertical lines, as when determining the lower boundaries right lung. The boundaries are found by the contrast between the clear pulmonary sound and the dull sound from the liver. The found border is marked with dots on the skin along the upper edge of the pessimeter finger along each vertical line. Normal upper limit of absolute liver dullness is located along the right parasternal line at the upper edge of the VI rib, along the right midclavicular line on the VI rib and along the right anterior axillary line on the VII rib, i.e., the upper limit of absolute dullness of the liver corresponds to the position of the lower edge of the right lung. In the same way, you can determine the position of the upper border of the liver and the back, but usually they are limited to determining only along these three lines.
Definition lower limit absolute liver dullness presents some difficulty due to proximity hollow organs(stomach, intestines), giving high-pitched tympanitis upon percussion, concealing the hepatic sound. Taking this into account, you should use the quietest percussion, or even better, use direct percussion with one finger according to the Obraztsov method. Percussion of the lower limit of absolute liver dullness according to Obraztsov-Strazhesko begins in the area right half abdomen along the right anterior axillary line in horizontal position sick. The pessimeter finger is installed parallel to the expected position of the lower edge of the liver and at such a distance from it that when a blow is applied, a tympanic sound is heard (for example, at the level of the navel or below). Gradually moving the finger-pessimeter upward, they reach the border of the transition of the tympanic sound to an absolutely dull one. In this place, along each vertical line (right midclavicular line, right parasternal line, anterior midline), and with significant enlargement of the liver and along the left parasternal line, a mark is made on the skin, but the lower edge of the pessimeter finger
When determining the left border of absolute dullness of the liver, a finger-pessimeter is installed perpendicular to the edge of the left costal arch at the level of the VIII-IX ribs and percussed to the right directly under the edge of the costal arch to the point where the tympanic sound (in the area of Traube's space) transitions to dull.
Normally, the lower limit of absolute dullness of the liver in a horizontal position of a patient with a normosthenic chest shape runs along the right anterior axillary line on the X rib, along the midclavicular line along the lower edge of the right costal arch, along the right parasternal line 2 cm below the lower edge of the right costal arc, along the anterior midline 3-6 cm from the lower edge of the xiphoid process, on the border upper third distance from the base of the xiphoid process to the umbilicus, on the left does not extend to the posterior midline. The position of the lower edge of the liver can normally vary depending on the shape of the chest and the constitution of the person, but this is reflected mainly only at the level of its position along the anterior midline. Thus, with a hypersthenic chest, the lower edge of the liver is located slightly above the indicated level, and with an asthenic chest, lower, approximately in the middle of the distance from the base of the xiphoid process to the navel. A downward displacement of the lower edge of the liver by 1–1.5 cm is noted in vertical position sick. When the liver is enlarged, the location of its lower edge is measured from the edge of the costal arch and the xiphoid process; the border of the left lobe of the liver is determined along the right parasternal line down from the edge of the costal arch and to the left of this line (along the course of the costal arch).
The obtained data from liver percussion make it possible to determine the height and size of hepatic dullness. To do this, measure the distance between the two corresponding points of the upper and lower boundaries of absolute liver dullness along vertical lines. This height is normally 10–12 cm along the right anterior axillary line, 9–11 cm along the right midclavicular line, and 8–11 cm along the right parasternal line. It is difficult to determine the percussion zone of dullness of the liver from behind (it merges with the dull sound zone formed by thick layer of lower back muscles, kidneys and pancreas), but sometimes it is possible in the form of a strip 4-6 cm wide. This makes it possible to avoid the erroneous conclusion that the liver is enlarged in cases where it is lowered and extends from under the right costal arch, and is also somewhat rotated anteriorly around its axis, then the band of dull sound behind becomes narrower.
The second method (according to Kurlov). To assess the size of the liver, M.G. Kurlov proposed measuring hepatic dullness along three lines.
The first measurement is carried out along the right midclavicular line. Along the midclavicular line, the finger-pessimeter is installed parallel to the intercostal spaces, above the known lung tissue, and percuss downwards. The place where the clear pulmonary sound transitions into a dull one corresponds to the upper border of the liver. Having marked the border of the liver along the upper edge of the finger, the pessimeter finger is moved down (to the level of the ridge ilium) and percuss upward along the midclavicular line. The place where the tympanic percussion sound transitions to a dull sound corresponds to the lower border of the liver. The normal size of the liver along this line is 9-10 cm.
In the next two measurements, the upper point of hepatic dullness is conventionally taken to be the intersection of a perpendicular drawn from the upper border of the liver along the right midclavicular line to the midline of the body.
When determining the second size of the liver, a finger-pessimeter is installed at the level of the navel (or below) along the midline and percussion upward from tympanitis until the percussion tone becomes dull. The second size of the liver according to Kurlov is 8-9 cm.
The third size of the liver is determined along the left costal arch. The plessimeter finger is installed perpendicular to the costal arch at the level of the VIII-IX ribs and is percussed to the right directly under the edge of the costal arch to the point where the tympanic sound (in the area of Traube's space) transitions into a dull one. U healthy person this size is 7-8 cm.
Determining the percussion boundaries of the liver and its size has diagnostic value. Systematic observation of the percussion boundaries of the liver and changes in the height of hepatic dullness allows us to judge the increase or decrease of this organ during the course of the disease.
Shift the top border up more often associated with:
Extrahepatic pathology - high position of the diaphragm (ascites, flatulence), paralysis of the diaphragm, pneumosclerosis of the right lung.
Hepatic pathology - only with echinococcosis and liver cancer can its upper border shift upward.
Shift the top border down occurs with extrahepatic pathology - low position of the diaphragm (prolapse of organs abdominal cavity), emphysema.
Shift the bottom border up indicates a decrease in its size (terminal stage of liver cirrhosis).
Shift bottom border down observed, as a rule, when the organ enlarges as a result of various pathological processes(hepatitis, cirrhosis, cancer, echinococcus, blood stasis in heart failure, etc.).
On the liver shadow, dots indicate the boundaries of absolute hepatic dullness; the difference between relative and absolute hepatic dullness is 1-2 cm (one or two ribs), which depends on the type of constitution.
Liver position in the abdominal cavity is such that it is adjacent to the chest wall only with part of the upper anterior surface. Its upper part, like the dome of the diaphragm, extends deeper from the chest wall chest cavity, partially covered by the lung. The proximity of the liver, as a dense organ, with air (gas) carrying organs (lungs above, intestines and stomach below) creates favorable conditions for percussion determination of its boundaries, size and configuration.
With liver percussion The usual topographical landmarks are used - ribs and conventional vertical lines of the chest. First, the upper and then the lower boundaries of the liver are determined.
Relative and absolute limit of hepatic dullness
From above, there are two boundaries of hepatic dullness - relative and absolute.
Relative limit of hepatic dullness
Relative liver dullness- this is the boundary between a clear pulmonary sound and dullness due to the deep-lying dome of the diaphragm. This border is close to the true one; it often coincides with the border determined using ultrasound and computed tomography. However, this boundary is not always easy to find with percussion due to the depth of its location, especially in obese patients and hypersthenics. Therefore, in practice they are often limited to defining only absolute hepatic dullness, that is, the upper border of the liver, not covered by the edge of the lung, which corresponds to the lower lung boundaries. In our opinion, when assessing the size of the liver, it is necessary to constantly focus on absolute hepatic dullness with a certain correction and caution. There are many examples in the clinic when the lower edge of the lung is “in place”, and the dome of the diaphragm is significantly raised upward. This is observed during relaxation of the diaphragm, subphrenic abscess, liver echinococcosis, liver cancer. In these cases, the error in determining liver size can be significant.
Relative liver dullness is determined, first of all, along the right midclavicular line, then along the middle axillary and scapular lines. Mediocre loud percussion is used. The impact force depends on physical development person: the larger it is, the stronger the blow on the pessimeter finger should be, up to strong palpation percussion. This achieves penetration of the percussion wave to a depth of 7-9 cm. Percussion begins from the II-III intercostal space along the midclavicular line with sequential movement of the finger down by 1-1.5 cm, you just need to take into account some difference in sound above the ribs and intercostal spaces, as well as that the transition from a clear pulmonary sound to a dull one will be gradual. The first noticeable dullness against the background of a clear pulmonary sound will correspond to the border of relative hepatic dullness. For accuracy, it is better to repeat percussion 2-3 times. Along the axillary line, percussion begins from the IV-V rib, along the scapular line - from the middle of the scapula.
Upper limit of relative hepatic dullness along the midclavicular line during quiet breathing in a healthy person, it is located at the level of the 5th rib; it is marked along the upper edge of the pessimeter finger. The upper border along the midaxillary line is at the level of the VII rib, along the scapular line - at the IX rib.
Absolute limit of hepatic dullness
To determine the upper limit of absolute hepatic dullness Quiet percussion is used on the principle of determining the lower edge of the lung.
The border of the upper absolute hepatic dullness along the midclavicular line is on the VI rib (lower edge of the VI or upper edge of the VII rib), along the middle axillary line - on the VIII rib, along the scapular line - on the X rib. The difference between relative and absolute hepatic dullness lies within 1-2 ribs.
Percussion of the lower limit of absolute hepatic dullness from the front and side presents certain difficulties due to the close proximity of the hollow organs, giving a high tympanitis that conceals the dull sound.
With percussion from behind difficulties are caused by the fusion of hepatic dullness with the dull sound of thick lumbar muscles, right kidney. It is impossible to distinguish them. Tympanitis of the abdominal cavity during percussion of the liver from the front and side can significantly (by 2-3 cm) “reduce” the true size of the liver, especially if the swollen loops of intestines rise between the costal arch and the liver, which also helps to push the liver back. Therefore, the results of liver percussion should be assessed with some caution.
To determine the lower border of the liver On the front and side surfaces, only quiet or quiet percussion is used. You can use the direct percussion method, applying light blows with the flesh of the terminal phalanx of the middle finger directly to the abdominal wall (F.G. Yanovsky’s method). With percussion in the usual way the pessimeter finger is positioned horizontally parallel to the expected edge of the liver.
The study usually starts from the level of the navel and is carried out along vertical topographic lines:
- along the right midclavicular;
- along the right parasternal;
- on the anterior axillary right;
- along the middle axilla;
- along the anterior median;
- along the left parasternal.
Moving the finger upward during percussion should be no more than 1-1.5 cm until the tympanic sound becomes completely dull. Along each line, a mark is made along the outer edge of the pessimeter finger, that is, from the bottom. By connecting the dots, you can get an idea of the position of the lower edge of the liver and its configuration.
In a healthy normosthenic, the lower edge of the liver is located:
- along the right midclavicular line - at the edge of the costal arch;
- along the right parasternal line - 2 cm below the edge of the costal arch;
- along the anterior axillary line on the right - on the IX rib;
- along the midaxillary line on the right - on the X rib;
- along the anterior midline - 3-6 cm below the edge of the xiphoid process,
- along the left parasternal line - at the edge of the costal arch (VII-VIII rib).
For asthenics the lower edge of the liver along the midline is located in the middle of the distance from the base of the xiphoid process to the navel, in hypersthenics with a wide chest - at the level of the upper third of this distance, and sometimes at the top of the xiphoid process. With a large gas bubble of the stomach, a swollen intestine, as well as with a marginal position of the liver (the liver is turned backward along the frontal axis), the lower edge of the liver is sometimes impossible to find.
Method for assessing liver size according to M.G. Kurlov
Most widespread V clinical practice received a method for assessing liver size according to M.G. Kurlov (Fig. 430). Using conventional moderate percussion, three sizes of the liver are determined:
- the first size is midclavicular; percussion is carried out along the midclavicular line from above to relative and absolute hepatic dullness and from below; it reflects the size (thickness) of the right lobe of the liver;
- the second size is the middle size; the upper point is not determined by percussion due to the fusion of cardiac and hepatic dullness.
Percussion determination of the boundaries and size of the liver according to M.G. Kurlov
A. The drawing reflects position of the finger during percussion, place of beginning and end of percussion.
Mid-clavicular size:
- the beginning of percussion from the II-III intercostal space on the right,
- the upper limit of relative hepatic dullness is on the V rib, absolute
- on the VI rib,
- the lower border of the liver is located at the edge of the costal arch
Average size:
- for top level the base of the xiphoid process (the level of the dome of the diaphragm) is taken from the liver;
- the beginning of percussion from below the level of the navel;
- the lower border of the liver is located just above the middle of the distance from the xiphoid process to the navel (depending on the type of constitution).
Oblique size:
- the upper point is the base of the xiphoid process;
- the beginning of percussion from the left mid-clavicular line, percussion along the costal arch;
- the lower limit of dullness is at the intersection of the left parasternal line and the costal arch.
B. The picture reflects
A-B- midclavicular size, from relative hepatic dullness is 12 cm, from absolute hepatic dullness (A, -B) is 10 cm. This size reflects the thickness of the right lobe.
V-G- the median size is 9 cm, reflecting the thickness of the left lobe.
V-D- oblique size is 8 cm, reflects the length of the left lobe.
Formula for liver size according to M.G. Kurlov
Formula for liver size according to M.G. Kurlov:
- for men = 12(10), 9, 8
- for women - 1-2 cm less than for men.
It is found by drawing a perpendicular from the point of relative hepatic dullness to its intersection with the midline; this most often corresponds to the base of the xiphoid process (diaphragm level); the lowest point of the second size is determined by percussion from the level of the navel to the hepatic dullness.
Second size reflects the thickness of the liver in its middle part - that is, the thickness of the left lobe;
Third size- percussion begins with determining the lower border of the liver at the edge of the left costal arch, the finger-pessimeter is installed perpendicular to the costal arch at the level of the midclavicular line and percusses along the costal arch upward until hepatic dullness appears; the measurement is made from the found point to the base of the xiphoid process; this size reflects the length of the left lobe of the liver.
For a normosthenic person with average height, the size of the liver according to M.G. Kurlov are approximately equal to:
- the first - 12 cm when measured from relative hepatic dullness;
- 10 cm when measured from absolute hepatic dullness;
- second - 9 cm;
- third - 8 cm.
In women, the liver size is 1-2 cm smaller than in men. For high and low stature, an adjustment is made by 2 cm for every 10 cm deviation from average height.
There is an option for determining the size of the liver according to M.G. Kurlov, with it only percussion is determined top point Size I The lowest points of all three sizes are established by palpation. Such a modification in some cases can provide more accurate results, especially with bloating.
Results of a study of liver size according to M.G. Kurlov can be written as a formula.
Percussion indicators of liver size and true liver size
Percussion indicators of liver size may differ significantly from normal due to true liver pathology, leading to an increase or decrease in the organ. However, in a number of cases when in good condition liver percussion data may be overestimated or underestimated (false deviation). This happens with pathology of neighboring organs, producing a dull sound that merges with the hepatic one, or a tympanic sound, “absorbing” the hepatic dullness.
True increase in all three liver sizes more often associated with diffuse damage liver with hepatitis, hepatocellular liver cancer, echinococcosis, amyloidosis, fatty degeneration, sudden disruption of bile outflow, cirrhosis, abscess formation, as well as heart failure. It should be emphasized that liver enlargement is always accompanied by a shift mainly in its lower border, while the upper border almost always remains at the same level.
False increase in the size of hepatic dullness observed when compaction occurs in the lower lobe of the right lung, fluid accumulation in the right pleural cavity, with encysted diaphragmatic pleurisy, subphrenic abscess, relaxation of the diaphragm, as well as with a significant enlargement of the gallbladder, an abdominal tumor located in the right hypochondrium.
True reduction in liver size occurs with acute liver atrophy and the atrophic version of liver cirrhosis.
False reduction of liver dullness noted when the liver is covered by swollen lungs (emphysema), swollen intestines and stomach, with pneumoperitoneum, with the accumulation of air over the liver due to perforation of a stomach ulcer and duodenum, as well as in the marginal position (“throwing back”) of the liver.
The disappearance of liver dullness may be due to the following reasons:
- pneumoperitoneum;
- pneumoperitonitis with perforation of the abdominal wall, perforation of the stomach and intestines;
- extreme degree of yellow liver atrophy (“wandering liver”);
- pronounced rotation of the liver around the frontal axis - marginally up or down.
Their upward shift may be due to high intra-abdominal pressure during pregnancy, obesity, ascites, abdominal cyst is very large sizes, as well as with a decrease in the volume of the right lung (wrinkling, resection) and relaxation of the right dome of the diaphragm.
Simultaneous downward displacement of the upper and lower boundaries is possible with severe pulmonary emphysema, visceroptosis, and right-sided tension pneumothorax.
Percussion of the gallbladder
Percussion of the gallbladder (Fig. 431) with its normal size is not very informative. This is due to the fact that it protrudes below the edge of the liver by no more than 0.5-1.2 cm. Only with enlargement of the gallbladder can a zone of dull (blunted) sound be obtained above the place of its projection onto abdominal wall: intersection of the edge of the costal arch with the outer edge of the right rectus abdominis muscle.
For percussion, the pessimeter finger is placed horizontally on the abdominal wall at the level of the navel so that the middle of the second phalanx is at the outer edge of the rectus muscle. Using soft or gentle percussion, the finger is slowly moved upward towards the costal arch. The coincidence of the level of dullness with the border of the lower edge of the liver indicates normal sizes gallbladder. If, before percussion of the gallbladder, the lower edge of the liver was already determined along topographic lines, and it turned out to be smooth. then there is no point in percussing the gallbladder. If the edge of the liver is deformed with bulging down the midclavicular line or slightly to the right or left, then there is reason to assume an enlarged gallbladder.
An increase in the volume of the gallbladder occurs due to impaired outflow of bile with poor patency biliary tract in the area of the cystic or common bile duct (stone, compression, scars, tumor).
The volume of the gallbladder increases with its atony, as well as with its dropsy. Dropsy develops against the background of prolonged blockage by a stone or compression cystic duct, gallbladder bile is absorbed, and the bladder is filled with transudate.
An enlarged gallbladder is palpable as an elastic round or pear-shaped formation, often easily displaced to the sides. Only with a tumor does it acquire irregular shape, tuberosity and dense consistency.
Pain on palpation of the gallbladder observed when it is overstretched, inflammation of its wall, including inflammation of the peritoneum covering it (pericholecystitis). Pain is often noted in the presence of stones or gallbladder cancer.
There are several pain-provoking palpation techniques used to diagnose gallbladder pathology. 1. Penetrating palpation to identify Ker’s symptom (Fig. 438) and Obraztsov-Murphy’s symptom (Fig. 439). The doctor's hand is placed on the stomach so that the terminal phalanges of the II and III fingers are above the point of the gallbladder - the intersection of the costal arch and the outer edge of the right rectus muscle. Next, the patient is asked to take a deep breath. At the height of inhalation, the fingers plunge into the depths of the hypochondrium.
The appearance of pain indicates a pathology of the gallbladder - a positive Kehr's symptom, the absence of pain - a Kehr's symptom (-). The doctor's hand is placed flat along the rectus abdominis muscles so that the terminal phalanx of the thumb is at the point of the gallbladder. Next in the background calm breathing The patient's finger is carefully immersed in the hypochondrium by 3-5 cm. Then the patient is asked to take a calm, deep breath, during which thumb The doctor should remain in the hypochondrium, applying pressure to the abdominal wall. During inhalation, the gallbladder “bumps” into the finger. With its pathology, pain occurs, the Obraztsov-Murphy symptom is positive, the absence of pain is a symptom (-).
Here we must mention that with local peritonitis, developing around the pyloric part of the stomach, duodenum, gallbladder and colon, there is often a peculiar change in liver dullness. Thanks to the adhesions developing between the listed organs, the swelling of the stomach, which in such cases is pushed to the right and upward, and the swelling of the right colic curvature, the liver should rise upward and rotate around the transverse axis.
But, however, this movement is hindered by adhesions it with the indicated organs and the parietal peritoneum, and therefore it cannot occupy a marginal position. It is mainly the more pliable and less massive part of the liver that moves upward, i.e. left lobe and the part of the right lobe lying closer to the ligamentum suspensorium, while the rest of the right lobe remains in place.
This circumstance, due to the closer fit of the stomach, as if soldered to the liver, and sometimes the colon, which in some cases moves onto the lower edge of the liver, cause deformation of hepatic dullness and the appearance of an impression at the lower border of dullness between the right sternum and mammillary lines. These changes configurations of the lower limit of liver dullness are very valuable clinical signs local peritonitis in this area (perigastritis, periduodenitis, pericholecystitis).
Returning to disappearance of liver dullness, it should be mentioned that it can be caused not only by colossal flatulence of the intestines, but also by the interposition of intestinal loops between the liver and the diaphragm.
This phenomenon is observed quite rarely and only under certain conditions. In order for the intestinal loops to enter, it is necessary that the liver be reduced in volume and compacted; if the liver is normal, you need to relax the abdominal muscles and increase the mobility of the liver and intestines. Such conditions occur, on the one hand, with atrophic cirrhosis and yellow atrophy, on the other, with acquired splanchnoptosis.
In a normal relationship, when intestinal loops during flatulence they put pressure on the liver; they will not be able to get between the liver and the diaphragm for the reason that the soft normal liver easily adapts to spatial relationships. She not only turns, but also, as it were, spreads out and all the time convex surface remains in contact with the diaphragm. But if the liver is reduced, and especially if it has also become dense, then when the intestinal loops are pressed, it does not fit so tightly to the diaphragm, and the intestines can get between it and the diaphragm.
Especially favors advancing on the liver of the intestines is a sharp descent of the liver during splanchnoptosis, when, moreover, due to the sluggishness of the abdominal press, there is no complete close contact with the abdominal wall, and the intestines, due to stretching of the ligaments and mesentery, become more mobile. I had to observe most cases of intestinal loops on the liver in acquired splanchnoptosis. This type of intestinal loops (most often flexura hepatica, colon ascendens, and sometimes a loop) small intestines) can happen with perforated peritonitis and when gases escape into the free abdominal cavity, since in this case the gas can push the liver away from the abdominal wall and diaphragm to the midline; Loops of intestines can enter the space that appears and even become fixed there with adhesions.
2. Determination of liver dullness
Liver percussion (Fig. 429)
The position of the liver in the abdominal cavity is such that it is adjacent to the chest wall only with part of the upper anterior surface.
Rice. 429. Percussion boundaries of the liver along topographic lines. On the liver shadow, dots indicate the boundaries of absolute hepatic dullness; the difference between relative and absolute hepatic dullness is 1-2 cm (one or two ribs), which depends on the type of constitution.
tee. Its upper part, like the dome of the diaphragm, extends from the chest wall deep into the chest cavity, partially covering the lung. The proximity of the liver, as a dense organ, to air (gas) carrying organs (lungs above, intestines and stomach below) creates favorable conditions for percussion determination of its boundaries, size and configuration.
When percussing the liver, the usual topographical landmarks are used - ribs and conditional vertical lines of the chest. First, the upper and then the lower boundaries of the liver are determined. From above, there are two boundaries of hepatic dullness - relative and absolute.
Relative liver dullness- this is the boundary between a clear pulmonary sound and dullness due to the deep-lying dome of the diaphragm. This border is close to the true one; it often coincides with the border determined using ultrasound and computed tomography. However, this border is not always easy to find by percussion due to the depth of its location, especially in obese patients and hypersthenics. Therefore, in practice they are often limited to defining only absolute hepatic dullness, that is, the upper border of the liver, not covered by the edge of the lung, which corresponds to the lower borders of the lung. In our opinion, when assessing the size of the liver, it is necessary to constantly focus on absolute hepatic dullness with a certain correction and caution. There are many examples in the clinic when the lower edge of the lung is “in place”, and the dome of the diaphragm is significantly raised upward. This is observed with relaxation of the diaphragm, subphrenic abscess, liver echinococcosis, and liver cancer. In these cases, the error in determining liver size can be significant.
Relative hepatic dullness is determined, first of all, along the right midclavicular line, then along the middle axillary and scapular lines. Mediocre loud percussion is used. The force of the blow depends on the physical development of the person: the larger he is, the stronger the blow on the plessimeter finger should be, up to strong palpation percussion. This achieves penetration of the percussion wave to a depth of 7-9 cm.
Percussion begins from the intercostal space along the mid-key
chin line with sequential movement of the finger downwards by 1-1.5 cm, you just need to take into account some difference in sound over the ribs and intercostal spaces, as well as the fact that the transition from a clear pulmonary sound to a dull one will be gradual. First noticeable
dullness against the background of a clear pulmonary sound will correspond to the border of relative hepatic dullness. For accuracy, it is better to repeat percussion 2-3 times. Along the axillary line, percussion begins from the IV-V rib, along the scapular line - from the middle of the scapula.
Upper limit of relative hepatic dullness along the midclavicular line with quiet breathing, a healthy person is at level of the V rib, it is marked along the upper edge of the pessimeter finger. Upper limit The middle axillary line is located at the level of the VII rib, along the scapular line - on the IX rib.
To determine the upper limit absolute liver dullness Quiet percussion is used on the principle of determining the lower edge of the lung. The border of the upper absolute hepatic dullness along the midclavicular line is located on the VI rib(lower edge of the VI or upper edge of the VII rib), along the middle axillary line - on the VIII rib, along the scapular line - on the X rib. The difference between relative and absolute hepatic dullness lies within 1-2 ribs.
Percussion of the lower limit of absolute hepatic dullness from the front and side presents certain difficulties due to the close proximity of the hollow organs, giving a high tympanitis that conceals the dull sound. When percussing from behind, difficulties are caused by the fusion of hepatic dullness with the dull sound of the thick lumbar muscles and the right kidney. It is impossible to distinguish them.
Tympanitis of the abdominal cavity with percussion of the liver from the front and side can be significant (by 2-3 cm) "decrease" the true size of the liver, especially if swollen loops of intestines rise between the costal arch and the liver, which also contributes to pushing the liver back. Therefore, the results of liver percussion should be assessed with some caution.
To determine the lower border of the liver along the anterior and lateral surfaces, only quiet or the quietest percussion. You can use the direct percussion method, applying light blows with the flesh of the terminal phalanx of the middle finger directly to the abdominal wall (F.G. Yanovsky’s method).
When percussing in the usual way, the finger-pessimeter is positioned horizontally parallel the expected edge of the liver. The study usually starts from the level of the navel and is carried out along vertical topographic lines: along the right midclavicular;
Along the right parasternal;
On the anterior axillary right;
On the middle axillary;
Along the anterior median;
By left parasternal.
Moving the finger upward during percussion should be no more than 1-1.5 cm until the tympanic sound becomes completely dull. Along each line, a mark is made along the outer edge of the pessimeter finger, that is, from the bottom. By connecting the dots, you can get an idea of the position of the lower edge of the liver and its configuration.
In a healthy normosthenics, the lower edge of the liver is located:
along the right midclavicular line - at the edge of the costal arch;
Along the right parasternal line - on 2 cm below the edge costal arch;
Along the anterior axillary line on the right - on the IX rib;
along the midaxillary line on the right - on the X rib;
along the anterior midline- 3-6 cm below the edge of the xiphoid process,
along the left parasternal line- at the edge of the costal arch (VII-
VIII rib).
In asthenics, the lower edge of the liver along the midline is located in the middle of the distance from the base of the xiphoid process to the navel, in hypersthenics with a wide chest - at the level of the upper third of this distance, and sometimes at the apex of the xiphoid process. With a large gas bubble of the stomach, a swollen intestine, as well as with a marginal position of the liver (the liver is turned backward along the frontal axis), the lower edge of the liver is sometimes impossible to find.
The most widely used method in clinical practice is the method for assessing liver size according to M.G. Kurlov(Fig. 430). Using conventional moderate percussion, three sizes of the liver are determined:
the first size is midclavicular; percussion is carried out along the midclavicular line from above to relative and absolute hepatic dullness and below; it reflects the size (thickness) of the right lobe of the liver;
the second size is the middle size; the upper point is not determined by percussion due to the fusion of cardiac and hepatic dullness,
Rice. 430. Percussion determination of the boundaries and sizes of the liver according to M.G. Kurlov.
A. The figure reflects the position of the finger during percussion, the place where percussion begins and ends. Mid-clavicular size:
- the beginning of percussion from the intercostal space on the right;
- the upper limit of relative hepatic dullness is on the 5th rib, the absolute limit is on the 6th rib;
-
- the lower border of the liver is located at the edge of the costal arch. Average size:
- the base of the xiphoid process (the level of the dome of the diaphragm) is taken as the upper level of the liver;
- the beginning of percussion from below the level of the navel;
- the lower border of the liver is located just above the middle of the distance from the xiphoid process to the navel (depending on the type of constitution).
Oblique size:
- the upper point is the base of the xiphoid process;
Percussion begins from the left midclavicular line, percussion is carried out along the costal arch;
The lower limit of dullness is at the intersection of the left parasternal line and the costal arch.
B. A-B - midclavicular size, relative hepatic dullness is equal to 12 cm, from absolute hepatic dullness (A 1 -B) is equal to 10 cm. This size reflects the thickness of the right lobe. V-G - the average size is - 9 cm, reflects the thickness of the left lobe. V-D - oblique size is equal to 8 cm, reflects the length of the left lobe.
Formula for liver size according to M.G. Kurlov: for men = 12(10), 9, 8 for women - 1-2 cm less than for men.
it is found by drawing a perpendicular from the point of relative hepatic dullness to its intersection with the midline; this most often corresponds to the base of the xiphoid process (diaphragm level); the lowest point of the second size is determined by percussion from the level of the navel to the hepatic dullness. The second size reflects the thickness of the liver in its middle part - that is, the thickness of the left lobe;
third size - percussion begins with determining the lower border of the liver at the edge of the left costal arch, a finger-pessimeter is installed perpendicular to the costal arch at the level of the midclavicular line and percussed upward along the costal arch until hepatic dullness appears; the measurement is made from the found point to the base of the xiphoid process; this size reflects the length of the left lobe of the liver.
For a normosthenic person with average height, the size of the liver according to M.G. Kurlov are approximately equal to:
First - 12 cm when measured from relative liver dullness; 10 cm when measured from absolute hepatic dullness;
Second - 9 cm;
The third is 8 cm.
In women, the liver size is 1-2 cm smaller than in men. For high and low stature, an adjustment is made by 2 cm for every 10 cm deviation from average height.
There is an option Determination of liver size according to M.G. Kurlov, with it only the upper point of size I is determined by percussion. The lowest points of all three sizes are established by palpation.
Such a modification in some cases can give more accurate results, especially with bloating.
Results of a study of liver size according to M.G. Kurlov can be written as a formula:
Percussion indicators of liver size can differ significantly from normal due to true liver pathology, leading to enlargement or reduction of the organ. However, in some cases, with a normal liver condition, percussion data may be overestimated or underestimated (false deviation). This happens with pathology of neighboring organs, producing a dull sound that merges with the hepatic one, or a tympanic sound, “absorbing” the hepatic dullness.
True increase all three liver sizes are more often associated with diffuse liver damage for hepatitis, hepatocellular liver cancer, echinococcosis, amyloidosis, fatty degeneration, sudden disruption of bile outflow, cirrhosis, abscess formation, as well as heart failure. It should be emphasized that liver enlargement is always accompanied by displacement mainly its lower border, upper almost always remains at the same level.
False increase in the size of hepatic dullness observed when compaction occurs in the lower lobe of the right lung, fluid accumulation in the right pleural cavity, with encysted diaphragmatic pleurisy, subphrenic abscess, relaxation of the diaphragm, as well as with a significant enlargement of the gallbladder, an abdominal tumor located in the right hypochondrium.
True reduction in liver size occurs with acute liver atrophy and the atrophic version of liver cirrhosis.
False reduction of liver dullness It is noted when the liver is covered by swollen lungs (emphysema), swollen intestines and stomach, with pneumoperitoneum, with the accumulation of air over the liver due to perforation of a stomach and duodenal ulcer, as well as with the marginal position (“throwing back”) of the liver.
Disappearance of liver dullness may be for the following reasons:
Pneumoperitoneum;
Pneumoperitonitis with perforation of the abdominal wall, perforation of the stomach and intestines;
Extreme degree of yellow liver atrophy (“wandering liver”);
Pronounced rotation of the liver around the frontal axis - marginally up or down. Their upward shift may be due to high intra-abdominal pressure during pregnancy, obesity, ascites, very large abdominal cysts, as well as with a decrease in the volume of the right lung (shrinkage, resection) and relaxation of the right dome of the diaphragm.
Simultaneous downward displacement of the upper and lower boundaries is possible with severe pulmonary emphysema, visceroptosis, and right-sided tension pneumothorax.
Percussion of the gallbladder (Fig. 431)
Percussion of the gallbladder with its normal size it is not very informative. This is due to the fact that it protrudes below the edge of the liver by no more than 0.5-1.2 cm. Only with enlargement of the gallbladder can one obtain a zone of dull (dull) sound above the place of its projection onto the abdominal wall: the intersection of the edge of the costal arch with outer edge of the right rectus abdominis muscle.
For percussion, the finger-pessimeter is placed horizontally on the abdominal wall at the level of the navel so that the middle of the second phalanx was at the outer edge of the rectus muscle. Using soft or gentle percussion, the finger is slowly moved upward towards the costal arch. The coincidence of the level of dullness with the border of the lower edge of the liver indicates the normal size of the gallbladder.
If, before percussion of the gallbladder, the lower edge of the liver was already determined along topographic lines, and he turned out to be smooth, then there is no point in percussing the gallbladder. If the edge of the liver is deformed with bulging down the midclavicular line or slightly to the right or left, then there is reason to assume an enlarged gallbladder.
Palpation of the liver and gallbladder
The palpation method is decisive when examining the liver and gall bladder; it allows you to obtain the most complete
new information about the physical condition of these organs:
localization;
size;
form;
Rice. 431. Percussion of the gallbladder.
The pessimeter finger is installed horizontally at the level of the navel, the middle of the phalanx should be at the outer edge of the rectus muscle. The bubble is localized at the intersection of the edge of the costal arch and the outer edge of the rectus muscle.
the nature of the surface;
the nature of the edge of the liver;
sensitivity;
displacement.
Each time after palpation of the liver and gall bladder, the doctor must characterize them according to the diagram presented above.
The difficulties of palpation of the liver and gallbladder lie in the fact that most of these organs lie deep in the hypochondrium and Only small areas of them are accessible to palpation:
Anterior surface of the left lobe of the liver;
The anterior inferior edge of the liver from the right midclavicular to the left parasternal line;
Partially bottom surface right lobe of the liver;
The bottom of the gallbladder.
However, often due to the significant thickness of the anterior abdominal wall and the tension of its muscles, the anterior surface of the left lobe of the liver and its lower edge cannot be palpated and the doctor has to judge the condition of the liver, focusing only on palpation of its lower edge at the costal arch along the midclavicular line. Only with a weak abdominal wall, low nutrition, prolapse and enlargement of the liver and gall bladder, the information can be quite complete.
Palpation of the liver and gall bladder is carried out according to the principles of deep palpation of the abdominal organs(Fig. 432). The patient is usually in a horizontal position; less often, the study is performed in a vertical position, lying on the left side and sitting.
Pay attention to the position of the doctor's hands. Left hand covers and compresses the costal arch, limiting its movement during inspiration, which contributes to a greater downward displacement of the liver. The fingers of the right hand are placed parallel to the edge of the liver, the hand lies on the stomach, obliquely, the palm is located above the navel.
Rice. 432. Bimanual palpation of the liver
The peculiarity of palpating the liver in a lying position is that the abdominal muscles should be as relaxed as possible, The shoulders are slightly pressed to the chest, the forearms and hands are laid on the chest. The meaning of this hand position is to significantly limit upper costal breathing and increase diaphragmatic breathing. This achieves a maximum downward displacement of the liver with a deep breath, its exit from the hypochondrium and b O greater accessibility to research.
Additional in palpation of the liver is the participation of the doctor’s left hand. The left hand is placed on the right lumbar region from the level of the last two ribs perpendicular to the spine and immerses himself in it as much as possible, which leads to a significant forward displacement of the posterior abdominal wall. The thumb of the same hand is placed on the edge of the costal arch in front. In this way, conditions are created for a significant reduction in the posterolateral section of the lower part of the chest, which prevents its expansion during deep inspiration and promotes greater displacement of the liver down from the hypochondrium.
The palm of the doctor’s right hand is placed flat on the stomach in the right hypochondrium with four fingers extended and the middle finger slightly bent so that the ends of the fingers are in line parallel to the estimated or already known by percussion lower edge of the liver. The fingertips should be placed 1-2 cm below the edge of the liver (costal arch) along the midclavicular line and make a small skin fold, moving the skin down.
After installing the hands, the patient is asked to inhale and exhale average depths, during each exhalation fingers gradually and carefully (not roughly) plunge into the depths of the right hypochondrium (down and forward under the liver). We must pay attention to during inhalation, the fingers remained immersed, providing resistance to the rising abdominal wall. Usually 2-3 cycles are enough.
The depth of immersion of the fingers will depend on the resistance of the patient’s abdominal wall and his sensations, If moderate pain occurs, the study is stopped. It is necessary to make the first immersion of the fingers shallow (about 2 cm), given that the edge of the liver lies superficially just behind the abdominal wall.
After the fingers enter the abdominal cavity, the subject is asked to take a calm but deep breath from your belly. In this case, the liver descends and the anterior-inferior edge of the liver
falls into an artificial pocket (duplication of the abdominal wall), formed when the abdominal wall is pressed with the doctor’s fingers. At the height of inhalation, when the fingers are not deeply immersed, the edge of the liver slips out of the pocket and goes around the fingers. During a deep dive, the doctor moves his fingertips upward to the costal arch, sliding along the lower surface of the liver, and then along its edge.
The palpation technique is repeated several times, the degree of immersion of the fingers into the depth of the hypochondrium gradually increases. In the future, a similar study is carried out with the doctor’s palpating hand shifted to the right and left of the midclavicular line. If possible, it is necessary to examine the edge of the liver along the entire length from the right to the left costal arch.
If palpation fails, the edge of the liver is not caught, you need to change the position of the fingers, moving them slightly down or up.
Using the described method, the liver can be palpated in most healthy people (up to 88% in young people). It cannot be palpated for the following reasons:
Powerful development of the abdominal wall muscles;
Resistance of the test subject to palpation;
Obesity;
Turning the liver back around the frontal axis (edge position - the lower edge of the liver moves up, and the upper edge moves back and down);
An accumulation of swollen loops of intestine between the abdominal wall and the anterior surface of the liver, pushing the liver back. Most often, the edge of a normal liver is determined by palpation
at the edge of the costal arch along the midclavicular line, and at the height of inspiration it falls 1-2 cm below the edge of the ribs. Along other vertical lines, especially along the right parasternal and anterior median, the liver is often not palpable due to tense rectus muscles. Along the right anterior axillary line, a normal liver is also not palpable, but due to the depth of its location under the costal arch.
If the abdominal wall does not offer strong resistance and there is no obesity, bloating, and the liver is not palpable (this is usually combined with a significant decrease in hepatic dullness), the method of palpating the liver in an upright position or with the patient being examined on the left side can be used. The principle of palpation is the same. Palpation is performed while standing
with a slight tilt of the patient forward, which helps to relax the abdominal muscles and lower the liver by 1-2 cm.
Palpation of the liver and gallbladder with the patient sitting(Fig. 433). This method is not described in textbooks, however, it has a number of advantages. It is convenient, simple, and often more informative than classic palpation with the patient lying down.
The subject sits on a hard couch or chair, leaning forward slightly and resting his hands on its edge. This achieves relaxation of the abdominal muscles. The inclination can change, breathing movements are performed with the stomach.
The doctor, positioned in front and to the right of the patient, holds his shoulder with his left hand, changing the tilt of the torso until the abdominal muscles relax as much as possible. Right hand The doctor is placed at the outer edge of the right rectus muscle perpendicular to the abdominal wall, but with the palm facing up. With each exhalation (2-3 respiratory cycle) fingers, without changing position, plunge deep into the hypochondrium right up to the back wall. After this, the patient is asked to take a slow deep breath. At this moment, the liver lowers and lies with its lower surface on the palm, creating ideal conditions for palpation.
The doctor makes a sliding movement by slightly bending his fingers
to the costal arch (liver edge), while getting an idea of the elasticity of the liver, the nature of the lower surface and edge of the liver, and their sensitivity. By successively moving the hand laterally and medially, you can get an idea of most of the lower surface of the liver and its edge. Sometimes, during palpation at the edge of the rectus muscle, the gallbladder or local tenderness can be palpated. This is especially successful in people with a weak abdominal wall and an enlarged gallbladder. With the classical method of palpation this is less likely to happen.
It should be noted that with the classical method of palpation of the liver, the doctor’s fingers touch the organ only
Rice. 433. Palpation of the liver and gallbladder with the patient in a sitting position.
preungual areas of the terminal phalanges and mainly the most protruding, accessible parts of the liver. When palpating in a sitting position, the liver and gall bladder are felt over the entire surface of the terminal phalanges, which have the greatest sensitivity, and the area of study is much larger. This technique often makes it possible to differentiate the cause of pain in the right hypochondrium - whether it is caused by pathology of the liver or gallbladder, or both, or a disease of the duodenum.
When palpated, the liver of a healthy person is elastic, its surface is smooth, even, the edge of the liver is sharp, or somewhat rounded, painless, sometimes during examination it can turn slightly under.
When palpating the lower edge of the liver, in rare cases it is possible to identify two notches: one is localized on the right at the edge of the rectus muscle and corresponds to the location of the gallbladder, the other at the anterior midline of the body.
In addition to the described techniques for palpating the liver in the presence of ascites, you can use the so-called “balloting” or jerky palpation (Fig. 434). To do this, the doctor places the clenched II, III and IV fingers of the right hand on the abdominal wall above the interested area and makes short, jerky movements deep into the abdominal cavity to a depth of 3-5 cm. The examination begins from the lower third of the abdomen, going up to the liver; it is better to adhere to topographic lines.
When touching the liver, the fingers perceive a dense body, which easily moves down, and then floats up like a piece of ice in the water and hits the fingers.
A similar technique with some features can also be used in the absence of ascites in order to determine the edge of the liver, especially in people with a weak abdominal wall and with an enlarged liver. To do this, use two or three fingers of your right hand the doctor makes sliding movements with slight jolts(it is possible without them) from the xiphoid process, from the edge of the costal arch down. Where there is a liver, the fingers perceive resistance; where it ends, the resistance disappears and the fingers easily fall into the depths of the abdominal cavity. You can modify the technique somewhat - go from the navel level up. The first resistance to the fingers will be due to the edge of the liver.
Rice. 434. Jerky palpation of the liver in the presence of ascites (A.F. Tomilov, 1990).
A- initial position of the hand; B- push and blow of the fingers on the liver (arrows show spreading fluid from the space between the abdominal wall and the liver); IN- after the blow, the liver goes deep into the abdomen, fluid again fills the space between the abdominal wall and the liver; G- the liver floats up - the second blow, felt by the fingers.
When percussing and palpating the liver, difficulties sometimes arise due to its rotation around the frontal (transverse) axis forward or backward (Fig. 435). When turning back, the edge of the liver goes into the hypochondrium; upon percussion, the anterior dimensions of the liver decrease and it is not palpable. When turning forward, the anterior edge of the liver drops below the costal arch while maintaining the upper limit of the relative hepatic dullness at the same level. Percussion increases the anterior dimensions of the liver and creates false impression of its increase.
Rice. 435. Scheme of liver rotation around the frontal axis:
A- turn back, B- turn forward (marginal position of the liver).
To differentiate between true and false enlargement or reduction in the size of the liver, after determining its anterior dimensions, it is necessary to determine the amount of hepatic dullness along the vertical topographic lines at the back, where normally the dullness band is 4-6 cm. When the liver is rotated forward, the band will be narrowed or may disappear, if turning back - increases. To more accurately determine the size, liver ultrasound and scanning are used.
An examination of the liver must necessarily include percussion to determine the boundaries and size of the liver, then palpation. This sequence is important to take into account because the liver may descend; sometimes its lower edge may be at the level of the navel, which, in the absence of percussion, creates a false impression of an enlarged organ. N.D. especially drew attention to this. Strazhesko (Fig. 436).
The technique of palpation of the gallbladder does not differ from the technique of a similar study of the liver, however, more informative, in our opinion, is palpation in a sitting position of the patient (Fig. 433). The area for palpation of the gallbladder is 2-3 cm below the place of its projection or slightly to the right at the level of the midclavicular line. In a healthy person, the gallbladder is not palpable, since its density is less than the density of the abdominal wall, the examination is painless.
Rice. 436. Variants of the position of the liver in the abdominal cavity:
1 - normal position; 2 - moderate liver prolapse; 3 - significant omission.
Please note that it is mostly the right one that goes down outer section liver.
Exists special technique palpation examination of the gallbladder (Fig. 437). It is that left palm The doctor places it on the costal arch of the patient so that the first phalanx of the thumb is above the area of the gallbladder, and the rest lie on the surface of the chest wall. At the height of inhalation, thumb
palpates the area where the gallbladder is located, making a sliding movement in different directions and gradually plunging 2-3 cm into the hypochondrium.
Signs of pathology revealed by palpation of the liver:
An increase or decrease in the size of the liver, which is assessed by the level of the lower edge of the liver;
Changes in the nature of the lower edge and anterior surface of the liver;
Presence of pain on palpation;
Presence of liver pulsation.
The doctor judges an increase or decrease in the size of the liver primarily based on the results of percussion, as discussed in detail above. However, this can also be done based on the results of palpation, according to the level of the lower edge. As is known, the upper level of the liver has significant positional stability, and when the size of the organ changes, only its lower border shifts.
Liver enlargement May be uniform And uneven.
Uniform enlargement of the liver occurs with liver edema (blood stagnation, inflammation, impaired bile outflow), with storage diseases (fatty hepatosis, hemochromatosis, obstruction
Rice. 437. Palpation of the gallbladder with the left hand.
copper metabolism, amyloidosis), with diffuse development connective tissue, diffuse growth of the tumor and foci of hematopoiesis. The greatest enlargement of the liver, when its lower edge reaches the navel and even the ilium, is characteristic of congestive liver, hepatocellular carcinoma, hypertrophic cirrhosis of the liver, amyloidosis.
Uneven enlargement of the liver caused by growth in one of the lobes of the tumor, the formation of syphitic gumma, the growth of alveolar or unilocular echinococcus of the liver.
Reduction in liver size occurs with acute liver atrophy, atrophic cirrhosis of the liver, and sometimes with syphilis.
We again draw attention to the fact that an increase or decrease in the size of the liver may be false due to the rotation of the liver around the frontal axis forward or backward.
Liver edge should be investigated with special care all over. It must be characterized by the following qualities:
Localization;
Edge directionality;
Density (consistency);
The nature of the edge surface;
Ripple;
Soreness.
Localization of the lower edge of the liver usually assessed along 4 vertical lines: right midclavicular, right parasternal, median and left parasternal. He might be omitted with enlargement of the liver, with prolapse of the liver, with its rotation along the frontal axis forward. The edge of the liver may be once-
return to the right along the sagittal axis, while right lobe the liver will be lowered, and the left one will be raised. Thus, the edge of the liver goes obliquely upward from right to left.
The edge of the liver may not be palpable, which is facilitated by a decrease in the size of the liver, turning the liver back (marginal position), covering the liver with gas or swollen intestines.
Liver margin density can be increased or decreased. Moderate edge compaction observed with developing right ventricular failure, with hepatitis, fatty hepatosis, syphilis. Significant density occurs with liver cirrhosis, cancer, leukemia, echinococcosis, but especially with amyloidosis (woody density).
Soft, doughy liver observed in acute liver atrophy.
By shape in pathological conditions, the edge of the liver may be sharp, thickened, rounded and wavy.
Sharp edge becomes with cirrhosis of the liver, this is always combined with an increase in its density. Rounded it happens when venous stagnation(right ventricular failure), fatty degeneration, amyloidosis. Wavy shape the edge acquires with cirrhosis and liver cancer. Thickened the edge becomes due to venous stagnation, with inflammatory damage to the liver, or with difficulty in the outflow of bile.
Anterior and inferior surface of the liver in pathological conditions it can be even, smooth, but it can also be lumpy. Rovnaya the surface is noted in hepatitis, storage diseases, leukemia, hepatocellular carcinoma. Lumpy the liver has a surface in case of cirrhosis, metastatic cancer, echinococcosis, syphilis (gumma). At hydatid cyst, located on the anterior surface of the liver, a round, painless, elastic formation can be detected.
Ripple the entire edge of the liver, its entire surface, is observed with tricuspid heart valve insufficiency. Liver pulsation only along the midline is a transmission pulsation from the abdominal aorta.
Liver soreness upon palpation due to mechanical irritation of the overstretched liver capsule, what happens with congestive liver, hepatitis, abscess, cholangitis, rapid tumor growth, echinococcus, syphilis. Pain on palpation occurs when irritation of the inflamed peritoneum covering the lower
surface of the liver, that is, with perihepatitis. With amyloidosis, cirrhosis, storage diseases, leukemia, and liver cancer, there is often no pain on palpation.
Pathological condition of the gallbladder palpation may manifest:
Enlargement of the bubble;
Pain in the area where the gallbladder is located. Gallbladder enlargement happens due to an increase in its content:
An increase in the amount of bile;
Presence of stones;
Accumulation of inflammatory fluid of a serous or purulent nature;
Hydrocele of the gallbladder; as well as bladder tumor growth. An increase in the volume of the gallbladder occurs due to a violation of the outflow of bile due to poor patency of the bile ducts in areas of the vesical or common bile duct(stone, compression, scars, tumor). The volume of the gallbladder increases with its atony, as well as with its dropsy. Dropsy develops against the background of prolonged blockage by a stone or compression of the cystic duct, cystic bile is absorbed, and the bladder is filled with transudate.
An enlarged gallbladder is palpably perceived as an elastic, round or pear-shaped formation, often easily displaced to the sides. Only with a tumor does it acquire an irregular shape, tuberosity and dense consistency.
Soreness upon palpation of the gallbladder, it is observed when it is overstretched, inflammation of its wall, including inflammation of the peritoneum covering it (pericholecystitis). Pain is often noted in the presence of stones or gallbladder cancer.
There are several palpation techniques that provoke pain, used to diagnose gallbladder pathology. 1. Penetrating palpation to identify Ker's symptom
(Fig. 438) and Obraztsov-Murphy sign (Fig. 439).
The doctor's hand is placed on the stomach so that the terminal phalanges of the II and III fingers are above the point of the gallbladder - the intersection of the costal arch and the outer edge of the right rectus muscle. Next, the patient is asked to take a deep breath. At the height of inhalation, the fingers plunge into the depths of the hypochondrium. The appearance of pain indicates
Rice. 438. Position of the hand when examining Ker's sign.
Rice. 439. Hand position when studying the Obraztsov-Murphy symptom.
indicates pathology of the gallbladder - positive Ker's symptom, absence of pain - Ker's symptom (-).
The doctor's hand is placed flat along the rectus abdominis muscles so that the terminal phalanx of the thumb was at the point of the gallbladder. Next, against the background of the patient’s calm breathing, the finger is carefully plunged into the hypochondrium by 3-5 cm. Then the patient is asked to take a calm, deep breath, during which the doctor’s thumb should remain in the hypochondrium, putting pressure on the abdominal wall. During inhalation, the gallbladder “bumps” into the finger. With its pathology, pain occurs, the Obraztsov-Murphy symptom is positive, the absence of pain is a symptom (-).
2. Tapping the ulnar part of the palm along the costal arch left then right- identification of the Grekov-Ortner symptom (Fig. 440). In case of gallbladder pathology, tapping on the right side causes pain.
3. Pressure with the index finger in the supraclavicular areas left, then
Rice. 440. Identification of the Grekov-Ortner symptom.
right between the legs of the sternocleidomastoid muscles - identification of Mussy's symptom (phrenicus symptom, rice. 441). With gallbladder pathology, pressure on the right side causes pain.
Detection upon palpation of enlarged, with smooth, tense walls, painful, the gallbladder displaced during inspiration and palpation is defined as positive Courvoisier-Terrier sign.
Rice. 441. Identification of Mussi's symptom.
Auscultation of the liver and gallbladder
Auscultation of the liver is not very informative. Its purpose is to identify peritoneal friction noise that occurs during the development of perihepatitis and pericholecystitis (Fig. 442). Listening is carried out with sequential movement of the phonendoscope over the anterior surface of the liver ( upper half epigastrium) and at the edge of the costal arch along the midclavicular line on the right. During auscultation the patient makes calm deep breaths and exhalations with the stomach, which contributes to greater displacement of the liver, gall bladder and friction of the peritoneum.
In healthy people, there is a friction sound of the peritoneum over the liver and gallbladder is absent, the ear often only detects the sounds of peristalsis of gas-containing organs.
With perihepatitis, pericholecystitis, a peritoneal friction noise is heard, reminiscent of a pleural friction noise, its intensity can be different.
Rice. 442. Listening to peritoneal friction noise during perihepatitis and pericholecystitis.
