The sequence and methods of clinical evaluation of lung auscultation data. Palpation of the sigmoid colon Deep palpation of the intestine

The caecum is located in the right iliac region and has a somewhat oblique direction: from right to top to bottom to the left.

In women, the lower border of the caecum coincides with the upper border of the iliac region (interosseous line), in men it is located somewhat lower. However, often the caecum is much higher than usual. The caecum is located on the border of the middle and outer thirds of the right umbilical-spine line (linea umbilico-iliaca dextra - a conditional line connecting the upper spine of the right iliac bone with the navel). The right hand is placed flat on the stomach so that the back surface of the fingers is facing the navel, the line of the middle finger coincides with the right umbilical line, and the line of the tips of the II-V fingers crosses the umbilical line approximately in its middle. Touching the skin of the abdomen with the fingertips, the examiner moves the brush towards the navel. In this case, a skin fold is formed in front of the nail surface of the fingers. At the same time, the patient is asked to inhale with the stomach. After this, the patient is asked to exhale and the fingers of the right hand are immersed deep into the abdominal cavity until the fingertips touch the posterior abdominal wall. At the end of exhalation, the fingertips slide along the posterior abdominal wall in the direction of the iliac spine and, in doing so, roll over the caecum. At the moment of rolling, the diameter, consistency, surface, mobility, soreness of the intestine and the phenomenon of rumbling are determined (Fig. 69).

Fig.69. Palpation of the caecum (top view).

In a healthy person, the caecum is palpated as a painless cylinder of soft-elastic consistency, 3-4 cm wide, has moderate mobility and usually rumbles under the hand.

Palpation of the terminal ileum. The terminal ileum is located in the right iliac region (oblique direction from bottom to right up) and flows from the inside at an acute angle into the caecum (45°). The right (palpating) hand is placed flat on the stomach so that the line of the fingertips coincides with the projection of the intestine. Touching the skin of the abdomen with the fingertips, the examiner moves the brush towards the navel. In this case, a skin fold is formed in front of the nail surface of the fingers. After this, the patient is asked to exhale and, taking advantage of the relaxation of the anterior abdominal wall, immerse the fingers of the right hand vertically deep into the abdominal cavity until the fingertips come into contact with the posterior abdominal wall. At the end of exhalation, the fingertips slide along the posterior abdominal wall in an oblique direction from top left to bottom right. At the moment of rolling, the diameter, consistency, surface, mobility, soreness of the intestine and the phenomenon of rumbling should be determined.

The terminal part of the ileum can be palpated for 10-12 cm. If the intestine is contracted or filled with dense contents, there is a feeling of rolling through a smooth, dense cylinder, as thick as a little finger. If the intestinal wall is relaxed and the contents are liquid, then a thin-walled tube is felt, the palpation of which causes a loud rumbling.

Palpation of the transverse colon.

Before palpation of the transverse colon, it is necessary to find the greater curvature of the stomach. For this purpose, the following methods are used.

Method of percussion palpation. Using the ulnar edge of the straightened left hand, placed transversely to the axis of the body, the doctor presses the anterior abdominal wall at the point of attachment of the rectus abdominis muscles to the chest wall. The right (palpating) hand is placed flat on the stomach (the direction of the hand is longitudinal to the axis of the body, the fingers are closed and facing the epigastric region, the fingertips are at the level of the lower border of the liver, the middle finger is on the midline). Investigating by jerky, quick bending of the II-IV fingers of the right hand, without tearing them off the anterior surface of the abdominal wall, produces jerky blows. If there is a significant amount of liquid in the stomach, splashing noise is obtained. By shifting the palpating hand down by 2-3 cm and making similar movements, the study is continued until the splash noise has disappeared, this level represents the border of the greater curvature of the stomach.

Ausculto-percussion method. The examiner with his left hand places a stethoscope (phonendoscope) on the anterior abdominal wall under the edge of the left costal arch on the rectus abdominis muscle, with the tip of the index finger of the right hand inflicts jerky, but not strong blows on the inner edge of the left rectus abdominis muscle, gradually descending from top to bottom. Listening with a stethoscope (phonendoscope) percussion sounds above the stomach, mark the boundary of the transition of a loud tympanic sound into a deaf one. The zone of change in percussion sound will correspond to the border of the greater curvature of the stomach.

Ausculto-affrication method. This method differs from the previous one only in that instead of fingertip strokes, dashed jerky transverse slides are made on the skin over the left rectus abdominis muscle. The place where the sound changes from a loud rustle to a quiet one is the level of the greater curvature of the stomach.

Palpation technique of the transverse colon. Palpation of the intestine is carried out with one (right) or two hands (Fig. 70).

The palpating hand is given the position necessary for palpation of the intestine, it is placed on the stomach along the axis of the body at the outer edge of the rectus muscle (muscles) of the abdomen. In this case, not a single finger of the palpating hand should lie on the rectus abdominis muscles. The fingers are located 2 cm below the level of the previously found greater curvature of the stomach along the expected projection of the intestine. During the inhalation of the patient, the arm (arms) is moved up so that a skin fold forms in front of the nail surface of the fingers. After this, the patient is asked to exhale and, taking advantage of the relaxation of the anterior abdominal wall, immerse the fingers of the hand (brushes) deep into the abdominal cavity until the fingertips come into contact with the posterior abdominal wall. At the end of exhalation, the fingertips slide down the posterior abdominal wall, while there should be a sensation of rolling over the roll of the transverse colon.

Peculiarities:

ü On palpation of the sigmoid, caecum, ascending and descending colon, the skin moves towards the navel;

ü On palpation of the transverse colon and the greater curvature of the stomach, the skin moves upward from the navel.

ü On palpation of the sigmoid, caecum, ascending and descending colon, slide (palpate) away from the navel.

ü On palpation of the transverse colon and the greater curvature of the stomach, they slide (palpate) down.

ü The second variant of palpation of the sigmoid and descending colon is possible - the movement of the hand and sliding away from oneself, from right to left and, as it were, from bottom to top.

ü You can palpate the sigmoid colon not with four fingers, but with the ulnar side of only one little finger. But in this case, all four moments of palpation are sequentially performed.

ü When the muscles of the anterior abdominal wall are tense, preventing palpation of the caecum, the thumb and the thenar region of the left hand are pressed in the navel, which achieves some relaxation of the muscles (V.P. Obraztsov).

ü Before palpation of the transverse colon, the lower border of the stomach should be determined (see below), since the transverse colon is usually located 2 to 3 cm below the stomach.

ü If at the first attempt it was not possible to clearly palpate the intestine, then the hand is moved to the left or right, higher or lower.

ü For a more accurate determination of the properties of the palpated organ, it is necessary to repeat palpation 2-3 times.

5.7.4. Palpation of the small intestine

Of all the parts of the small intestine, only the terminal segment of the ileum.

Execution technique.

ü Half-bent fingers of the right hand are placed deep in the right iliac cavity at the junction of the ileum with the large intestine.

ü During inhalation, the skin is shifted to the navel.

ü During exhalation, the right hand is immersed deep into the abdomen.

ü At the end of exhalation, they slide along the intestine outwards (from the navel), perpendicular to the axis of the intestine.

All other parts of the small intestine are palpated in the mesogastrium, mainly around the umbilicus. However, due to the absence of any dense bone formations here, it is impossible to press and clearly palpate individual segments of the small intestine. The state of the small intestine can be judged by indirect signs - the presence of pain and tumor-like formations on palpation in this area. Pain on palpation on the left and above the navel at the level of the XII thoracic and I lumbar vertebrae (Porges symptom) testifies to the defeat of the small intestine.

5.7.5. Examination of intra-abdominal lymph nodes

With deep palpation of the abdomen, the mesenteric and para-aortic lymph nodes are examined.

1) mesenteric lymph nodes determined in the umbilical zone in the position of the patient on the back with deep abdominal breathing, similar to the study of the intestines.

2) Para-aortic lymph nodes palpate to the right and left of the abdominal aorta along the midline of the abdomen in the epigastric and mesogastric regions with deep breathing of the patient in the position on the back. Move the hand from top to bottom from the epigastric to the umbilical region.

The same group of lymph nodes is also palpated in the position on the left side in the areas of the left and right hypochondria and flanks.

An example of a conclusion for a norm:

On palpation of the large intestine in the left iliac region, the sigmoid colon is palpable in the form of a cylinder, up to 2 cm thick, its displacement up to 3 cm down and up. In the region of the left flank, the descending colon is determined, up to 2.5 cm thick, with displacement up to 2 cm to the right and left. At the level of the navel, to the right and left of it, in the region of mesogastrium, the transverse colon is determined in the form of a cylindrical cord, up to 2 cm thick, its displacement up to 3 cm. In the region of the right flank, the ascending colon is palpable, 2.5 cm thick, displacement its 2-3 cm. In the right iliac region, the caecum is palpated, displacement is within 1.5-2 cm. All sections of the large intestine have a smooth surface, elastic consistency, are painless and without rumbling.

To the left of the lower third of the ascending large intestine, the final segment of the ileum is palpated in the form of an elastic, rounded, smooth cord up to 1.5 cm thick, painless. On palpation in the region of the remaining parts of the small intestine (around the navel), pain, rumbling, and tumor-like formations are not determined. Mesenteric and para-aortic lymph nodes are not palpable.

Conclusion: a variant of the norm.

An example of a conclusion for pathology:

With deep palpation of the abdomen in the left iliac region, a sigmoid colon 5 cm thick is palpated, inactive, painful, with a bumpy surface, almost woody density, without rumbling.

In the region of the left flank, the descending colon is palpated in the form of a swollen cylinder, up to 3 cm wide, with a smooth surface, slightly painful, of medium density, without rumbling, displaced by 1.5–2 cm.

In the mesogastrium, 2 cm above the navel, the transverse colon is palpable in the form of a rounded cylinder, with a smooth surface, medium density, painless and without rumbling, with a mobility of 1.5–2 cm. The ascending colon could not be palpated.

In the right iliac region, the caecum is palpated in the form of a short rounded cylinder, up to 3 cm thick, with a smooth surface, medium density, painless, without rumbling.

On palpation of the small intestine, seals, tumors, rumbling, pain are not determined. Mesenteric and para-aortic lymph nodes are not palpable.

Conclusion: symptoms of a malignant tumor of the sigmoid colon.

5.7.6. Palpation of the stomach

Perform both in the vertical and horizontal position of the patient. The small curvature of the stomach, as a rule, cannot be felt even in the vertical position of the patient due to its high and deep location. However, in its zone (in the epigastric region, under the xiphoid process), the patient can detect tumor-like formations and pain.

Research technique.

1. Find lower border of the stomach(large curvature). The simplest method for determining the position of the greater curvature of the stomach is ausculto-affrication method:

The membrane of the phonendoscope is placed in the epigastrium just to the left of the anterior midline. With the second finger of the right hand, “strokes” are applied in the radial direction along the anterior surface of the abdomen. At the same time, loud scraping sounds are heard over the stomach, which stop at certain points (outside the projection zone of the stomach).

ü Mark these points and connect them together. The result is an arcuate line corresponding to the greater curvature of the stomach.

(carried out according to the Obraztsov-Strazhesko method)

1. Palpation of the sigmoid colon:

a) set four slightly bent fingers of the right hand on the anterior abdominal wall at the border of the middle and outer third of the line connecting the navel with the anterior superior iliac spine, parallel to the length of the sigmoid colon;

b) during the patient's inhalation, move the fingers of the right hand towards the navel to create a skin fold;

c) while exhaling the patient, gently immerse your fingers in the abdominal region;

d) having reached the posterior abdominal wall, slide along it perpendicular to the length of the sigmoid colon in the direction from the navel to the anterior superior iliac spine (palpable fingers roll through the sigmoid colon).

2. Palpation of the caecum:

a) set four half-bent fingers of the right hand folded together parallel to the length of the intestine;

b) during the patient's inhalation, move the fingers towards the navel to create a skin fold;

c) while exhaling the patient, gradually immerse your fingers in the abdominal region, reach the posterior abdominal wall;

d) slide along it perpendicular to the intestine, towards the right anterior iliac spine.

Determine the thickness, consistency, nature of the surface, soreness, peristalsis, mobility and rumbling of the caecum.

3. Palpation of the ascending and descending parts of the colon (first palpate the ascending part, then the descending part):

a) put the palm of the left hand under the right half of the lower back, and then under the left;

b) the left hand should be pressed to the corresponding half of the lumbar region and directed towards the palpating right hand (bimanual palpation).

c) place the fingers of the right hand half-bent at the joints and closed together in the region of the right and left flanks, along the edge of the rectus abdominis muscle, parallel to the intestine, at the place of its transition to the cecum (or sigmoid) intestine;

d) during the patient's inhalation, with a superficial movement of the fingers of the right hand towards the navel, create a skin fold;

e) while exhaling, immerse your fingers in the abdominal cavity to the posterior abdominal wall until there is a feeling of contact with the left hand;

f) with a sliding movement of the fingers of the right hand perpendicular to the axis of the intestine, roll them through the ascending (descending) segment.

The ascending and descending segments of the colon with the help of bimanual palpation can be felt in thin people with a thin, flaccid abdominal wall. This possibility increases with inflammatory changes in one or another segment and with the development of partial or complete obstruction of the underlying sections of the large intestine.

4. Palpation of the transverse colon:

a) place the bent fingers of both hands on the sides of the white line, parallel to the desired intestine, that is, horizontally, 2-3 cm below the greater curvature of the stomach;

b) moving the fingers while the patient inhales, move the skin up;

c) during exhalation, gradually immerse your fingers into the abdominal cavity until it touches its back wall and slide along it from top to bottom. When sliding, the fingers of one or both hands roll over the transverse colon.

If palpation is impossible, move the fingers down to the hypogastric region.

Normally, the intestine has the shape of a cylinder of moderate density, easily moves up and down, painless, does not growl.

The process of palpation of the stomach and intestines is important in terms of diagnostic studies of the human body. Monitoring of the digestive organs is carried out as follows: at the first stage, a qualified specialist carefully probes the sigmoid colon - this is the most common landmark and the most accessible organ for palpation. Next, the doctor proceeds to study the state of the caecum and transverse colon. The ascending and descending sections of the suction organ are quite problematic to probe.

In practice, in the process of palpation, the fingers must be carefully immersed on the surface of the body area and gently pressed onto the organ under study (in the direction of the posterior abdominal wall). With the help of sliding movements, you can clearly determine the contours, density, the presence of various neoplasms and abnormalities. When touching (feeling) the sigmoid colon, one gets the impression that there is a smooth, dense and movable cylinder in the human body. The size of such a "geometric figure" does not exceed the thickness of the human thumb. The formation parameters are directly related to the state of the walls, which are densely filled with gases and decay products (fecal / fecal masses).

During the course of the inflammatory process of the infiltrating walls, a significant thickening of the membrane occurs. Ulcerative manifestations form a bumpy and uneven surface of the suction organ. Acute inflammation of the sigmoid colon is accompanied by the formation of a dense consistency of painful manifestations. Due to dense overflow with gases and liquid contents, motility retardation occurs. The spasm is palpable in the form of a cord and a cord. The patient experiences systematic rumbling + false urge to defecate (false diarrhea).

In a normal state, the caecum is easily palpable. A specialist can detect a moderately active cylinder up to 3 cm in movement. Its mobility in pathological disorders is significantly increased. The internal consistency is significantly compacted with coprostasis and chronic inflammation. The volume and shape of the cecum directly correlates with the contents. In a normal functional state, the intestines do not rumble.

The patient should remember that the presence of pain during palpation in the region of the caecum indicates the development of the pathological process. The digestive organ requires systematic and complex treatment.

In practice, after examining the caecum (+ appendix), it is possible to examine the less accessible parts of the large intestine. Palpation is carried out from the ascending to the transverse colon and descending intestines. The transverse-colic part of the suction organ is qualitatively palpated only in the case of chronic inflammation. Tone, consistency, volume, shape depend on the tone and degree of muscle tension. For example, an inflammatory process of the ulcerative type forms serious prerequisites for the transformation of the transverse colon. At the same time, the musculature of the organ thickens significantly, its configuration changes.

To date, chronic colitis and percolitis are quite common. With these ailments, the wall of the suction organ begins to contract painfully. Due to the bumpy surface, palpation is accompanied by sharp pain sensations. For example, with pericolitis, respiratory and active mobility are lost.

Palpation of the abdomen allows you to feel the tumor of the intestine, which is often confused with the pathology of various organs. Oncology of the caecum and transverse colon is distinguished by already known mobility. Pain is activated during the act of breathing (tumors below the navel are immobile). Feeling the abdomen with enterocolitis is accompanied by rumbling in the navel. The disease has specific signs and symptoms: painful diarrhea (mushy, slimy stools, abdominal pain, hardened colon). Palpation of the abdomen is carried out in combination with a digital examination of the rectum (sigmoidoscopy + radiography). These actions make it possible to predict the formation of rectal cancer and the formation of various syphilitic structures. It will also be possible to clearly determine the presence of inflammatory processes, cracks, fistulas, hemorrhoids and all kinds of tumors. The specialist can get a clear vision of the tone of the sphincter, the level of filling of the ampulla of the colon. In some cases, it is rational to palpate neighboring organs (the bottom of the bladder, the prostate gland, the uterus with appendages). This will reveal an ovarian cyst, a tumor of the genital organs, the degree of constipation, etc.

The mechanism of the procedure

Palpation is the last stage of a full and objective examination of the abdomen. The patient will need to cough vigorously before the procedure. In practice, a person with developed peritonitis manages to do this only superficially (holding the abdomen with his hands). It is allowed to make a small impact on the couch, on which the patient is located in the supine position. The vibration impulse will provoke the manifestation of pain in the digestive tract. Thus, it is quite easy to establish the diagnosis of peritonitis without touching the hand. To detect symptoms of peritoneal irritation, it is allowed to gently shake the patient, after grasping the crests of the ileum (or jumping on one leg).

The palpation procedure begins with the patient being asked to clearly indicate the area where the first pains formed (the primary localization of the disease). The specialist needs to carefully monitor the actions of the patient himself. This is how you can identify the causes of irritation of the peritoneum. Diffuse pain of the visceral type in the abdomen is easily determined with the help of circular movements of the palm. Hands should be warm.

The procedure begins as far as possible from the main focus of pain. This helps to avoid unplanned pain at the very beginning of the study. Children, and sometimes adult patients, sometimes do not allow a quality examination due to pain.

First of all, the doctor must perform a gentle and accurate palpation (superficial). An experienced specialist moves gently, methodically and consistently. Fingers make the minimum number of movements. It is strictly forbidden to palpate the abdomen randomly! The pressure on the surface of the body should not be high. Otherwise, there will be a protective tension of the muscles of the abdominal cavity. Touching the sore spot should be carried out until the patient says that he really hurts.

A qualified specialist can always determine the degree of tension in the muscles of the anterior wall of the abdomen. The physician must distinguish between voluntary and involuntary muscle tension. To clearly determine this factor during palpation, a person takes a deep breath and exhale. If muscle activity persists, then this indicates the development of peritonitis.

It is rational to make a deeper palpation if peritonitis was not detected during a superficial examination. This allows you to detect various tumor formations, hepatosplenomegaly, aortic aneurysm. It is very important for the physician to remember the optimal dimensions for normal structures so as not to confuse them with malignant ones. Pain during palpation of the abdomen and intestines has two types:

1. immediate local pain - the patient experiences a sharp pain at the site of the study;
2. indirect (reflected soreness) - pain sensations are formed in a different place when palpated. For example, in the course of acute appendicitis, pain accumulates at the McBurney point in the left side of the iliac fossa. This symptom is called "Rovsing" and is a reliable sign of peritoneal irritation.

It is easy to carry out comparative palpation of the patient with tense abdominal muscles. For this, the patient, who is in a supine position, is asked to gently lift their head off a pillow.

The classic symptom of irritation of the parietal peritoneum is not difficult to identify. To do this, at the time of the study, the doctor must sharply remove his hand from the surface of the body and observe the patient's reaction. In most cases, patients experience a significant increase in pain. This classic survey technique is rather crude, some scholars refer to it as a barbaric method of study.

With the development of various pathologies in the digestive organs (for example, acute appendicitis), hyperesthesia of the skin in the abdomen is observed. It is for this reason that if a patient is pinched or lightly pricked, then a painful reaction of the body will instantly occur. This is a fairly common clinical symptom, but its establishment is not enough for a firm diagnosis of acute appendicitis and other diseases of the abdominal organs.

An integral part of the palpation study is gentle tapping on the lumbar region (+ sides of the abdomen) to determine the degree of pain in these areas. Quite often, pyelonephritis and urolithiasis correlate with sharp pains in the abdomen (rib-vertebral region).

In doubtful clinical situations, examination alone is not enough. An accurate assessment of the dynamics of the disease is established by repeated palpation of the abdomen by the same doctor.

Varieties of pain syndromes

Causes of pain in women

To date, medicine identifies two types of fundamental causes that affect pain during palpation. Organic factors include:

• inflammatory processes in the genitourinary system (cyst, endometritis, fibroids);
• use of the spiral as a contraceptive;
• the formation of various pathological formations;
• the presence of inflammation in the gallbladder (including appendicitis, pyelonephritis);
• severe pain during pregnancy (placental abruption, miscarriage).

The functional reasons are as follows:

• systematic failures in cycles during menstruation;
• allocation of uterine bleeding;
• ovulation + uterus bending.

Inflammatory processes are the main reason for the occurrence of pain during palpation of the stomach and intestines. The disease begins with classic acute manifestations and is supplemented by various signs of intoxication of the body, namely:

1. Endometritis is accompanied by aching pain in the abdomen. You can establish their manifestation with a slight palpation. The patient experiences heaviness in the area of ​​​​the appendages + compaction of the uterus;
2. Endometriosis is a pathological disorder that affects the uterus and appendages. Severe pain is observed on palpation of the middle of the abdomen;
3. Ovarian apoplexy correlates with ovulation. In this case, part of the blood enters the abdominal cavity due to strong physical exertion;
4. Uterine myoma. The pain syndrome is localized in the lower abdomen (squeezing of adjacent organs);
5. Appendicitis requires prompt medical intervention. Pain on palpation in the region of the appendix;
6. Cholecystitis is an inflammatory process of the gallbladder. Pain gives clearly to the lumbar and back;
7. Cystitis is a lesion of the bladder. Pain is observed both during palpation and during urination.

Causes of pain in men

Pain on palpation in men is preceded by a number of factors. It can be both inflammation of the appendages, and prostatitis, cystitis, various formations. Doctors identify some signs of pain in which it is necessary to hospitalize a person. If the pain is concentrated in the area of ​​​​the formation of the appendix, then this indicates the course of appendicitis. Inguinal hernia and its pinching are also dangerous. In this case, the organ simply protrudes outward and has a hard cover. The patient experiences severe pain. Abdominal pain is also the result of poor-quality food. Thus, a peptic ulcer is formed. The main causes of pain in men are: diverticulitis, genitourinary disease, cystitis, pyelonephritis and excessive hypothermia.

In some cases, sharp pains are localized not only on the right side, but also on the left. Quite often, the main reason lies in the spread of intestinal infection. At the same time, the main symptoms of appendicitis are observed, which have a paroxysmal manifestation. The pain syndrome often intensifies during the meal.

Getting Started palpation of the caecum, it must be remembered that in normal cases it is located in the right iliac fossa, and the direction of its axis is somewhat indirect - namely to the right and from above - down and to the left. Therefore, remembering the obligatory rule for probing the abdominal organs - to palpate in a direction perpendicular to the axis of the organ - it is necessary to palpate indirectly to the left and from top to right and downwards along the right umbilical spine line or parallel to it.

Usually when probing it is most convenient to use 4 slightly bent fingers, which we gradually try to immerse in the abdominal cavity to the inside from the location of the caecum. Taking advantage of the relaxation of the abdominal press during exhalation, and having reached the contact of the ends of the palpating fingers with the back wall of the abdominal cavity, without relieving pressure, we slide along it, while our fingers roll over the caecum and bypass it for approximately 3/4 of its circumference .

Gausman advises on probing coeci apply oblique palpation with 3 fingers, but I do not see any particular advantages in this technique and always use the typical palpation with 4 fingers, proposed for the first time by Obraztsovym. In most cases, at the first movement along the posterior surface of the iliac cavity, we manage to feel the intestine. However, if there is some tension in the abdominals, it may be useful to move the resistance of the abdominals to another area in the neighborhood in order to reduce the resistance at the site of the examination of the caecum.

To this end, on the advice Obraztsova, it is useful with the free left hand, namely with the tenar and the outer edge of the thumb, to press near the navel and not to loosen the pressure during the entire examination. In other cases, when the caecum is high, when it lies, therefore, in the right flank, it is useful to place the left hand flat under the right lumbar region in order to create a more dense wall against which the cecum is pressed during probing. In other words, you need to apply bimanual palpation.

If at the first moving the movement of our fingers If we do not palpate the intestines, then this usually depends on the fact that its walls are in a relaxed state and, therefore, in order to probe, you need to wait for their physiological contraction. According to Gausman's statistics, the normal caecum is palpable in 79%, therefore, quite often, although less often than S. R.

I must say I'm blind intestine for the first time I felt Glenard in 10% in the form of an oval body the size of a chicken egg (boudin coecal) and considered its palpability to be a pathological phenomenon, depending on the tension of its walls due to the narrowing of the large intestine above the cecum. Only Obraztsov showed that the perfectly normal caecum was also palpable. Probing the caecum, we usually find not only the caecum, but at the same time we palpate some part of the ascending colon over a distance of 10-12 cm, i.e., what is commonly called typhlon in the clinic.

According to Sample, longitudinal axis of the caecum is separated from the spina osis ilei anterior superior by an average of 5 cm, while the lower border of the caecum on average lies slightly above the interosseous line in men, and in women at its level. But Obraztsov had already drawn attention to the fact that the position of coeci is individually different and fluctuates within fairly wide limits.

At present time after work Wandel, Faltin "a and Ekehorn" a, Wilms "a, Klose and others, we know that the position of the coeci, its thickness and length, and the methods of its attachment are individually so different that it is difficult to find two identical cases in this regard. Normally we palpate the caecum (typhlon) in the form of a smooth, two fingers wide, slightly rumbling, painless on palpation and moderately movable cylinder with a small pear-shaped blind extension downwards (actually the caecum), which has moderately elastic walls.