Auscultation of the abdominal cavity. Methods for examining the abdomen: examination, palpation, percussion, auscultation

Zone of tympanic sound of the stomach it resembles a bull's horn in its figure, with a wider part of it facing upwards and located in the chest area, being limited from above by the lungs, on the left by the spleen, on the right by the left lobe of the liver - this area of tympanitis is called the crescentic space Traube; the other part, approximately equal to it in area, is located in the epigastric region.

Of course, the value area tympanitis of a normal stomach varies over an extremely wide range, being primarily dependent on the degree of filling of the stomach itself with gases and the state and position of the organs bordering on the stomach. For this reason, it cannot be of particular clinical significance.

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

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

In the same way, it is also necessary to note the abnormal position right upper border of gastric tympanitis with perigastric adhesions in the region of the pyloric part of the stomach. In this case, it is often noticed, as it were, that the right part of the tympanitis zone of the stomach rises upward to the costal arch, and then a clear tympanic sound is noticed between the right nipple line and the median on the right costal arch. extending upwards by 4-5 cm.

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

If the specified area is found during percussion additional tympanic tone on the lower ribs between the nipple and median lines, we notice that the lower percussion border of the liver seems to be pressed upward between these lines,

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

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

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

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

Examination of the patient

Examination of patients with diseases of the gastrointestinal tract ( gastrointestinal tract) allows you to identify emaciation, pallor, roughness and a decrease in skin turgor in malignant tumors of the stomach and intestines. But in most patients with stomach diseases, there are no visible manifestations. When examining the oral cavity in patients with acute and chronic diseases of the stomach and intestines, a white or brown coating on the tongue is detected. In diseases accompanied by atrophy of the mucous membrane of the stomach and intestines, the mucous membrane of the tongue becomes smooth, devoid of papillae ("varnished tongue"). These symptoms are nonspecific, but they reflect the pathology of the stomach and intestines.

Examination of the abdomen begins with the patient lying on his back. Determine the shape and size of the abdomen, the respiratory movements of the abdominal wall and the presence of peristalsis of the stomach and intestines. In healthy people, it is either somewhat retracted (in asthenics) or slightly protruded (in hypersthenics). Severe retraction occurs in patients with acute peritonitis. A significant symmetrical increase in the abdomen can be with bloating (flatulence) and accumulation of free fluid in the abdominal cavity (ascites). Obesity and ascites differ in some ways. With ascites, the skin on the abdomen is thin, shiny, without folds, the navel protrudes above the surface of the abdomen. With obesity, the skin on the abdomen is flabby, with folds, the navel is retracted. Asymmetric enlargement of the abdomen occurs with a sharp increase in the liver or spleen.

Respiratory movements of the abdominal wall are well defined when examining the abdomen. Their complete absence is pathological, which most often indicates diffuse peritonitis, but it can also be with appendicitis. Peristalsis of the stomach can be detected only with pyloric stenosis (cancerous or cicatricial), intestinal motility - with a narrowing of the intestine above the obstruction.

Palpation of the abdomen

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

Superficial (approximate and comparative) palpation reveals tension in the muscles of the abdominal wall, localization of pain and an increase in any of the abdominal organs.
Deep palpation is used to clarify the symptoms identified during superficial palpation and to detect a pathological process in one or a group of organs. When examining and palpating the abdomen, it is recommended to use schemes of the clinical topography of the abdomen.

The principle of the superficial palpation method

Palpation is carried out by slight pressure with fingers flat on the palpating hand located on the abdominal wall. The patient lies on his back on a bed with a low headboard. Arms extended along the body, all muscles should be relaxed. The doctor sits to the right of the patient, who must be warned to let him know about the occurrence and disappearance of pain. Start approximate palpation from the left inguinal region. Then the palpating hand is transferred 4-5 cm higher than the first time, and further into the epigastric and right iliac regions.

With comparative palpation, studies are carried out in symmetrical areas, starting from the left iliac region, in the following sequence: the iliac region on the left and right, the umbilical region on the left and right, the lateral abdomen on the left and right, the hypochondrium on the left and right, the epigastric region on the left and right of the white belly lines. Superficial palpation ends with a study of the white line of the abdomen (the presence of a hernia of the white line of the abdomen, divergence of the abdominal muscles).

In a healthy person, with superficial palpation of the abdomen, pain does not occur, the tension of the muscles of the abdominal wall is insignificant. Severe diffuse soreness and muscle tension over the entire surface of the abdomen indicates acute peritonitis, limited local soreness and muscle tension in this area - about an acute local process (cholecystitis - in the right hypochondrium, appendicitis - in the right iliac region, etc.). With peritonitis, a symptom of Shchetkin-Blumberg is revealed - increased pain in the abdomen with the rapid removal of the palpating hand from the abdominal wall after light pressure. When tapping on the abdominal wall with a finger, local soreness (Mendel's symptom) can be established. Accordingly, local protective tension of the abdominal wall (Glinchikov's symptom) is often found in the painful area.

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

Principles of deep sliding palpation

The fingers of the palpating hand, bent at the second phalangeal joint, are placed on the abdominal wall parallel to the organ being examined and, after gaining a superficial skin fold, which is necessary later for the sliding movement of the hand, carried out in the depths of the abdominal cavity along with the skin and not limited by skin tension, are immersed deeply during exhalation into the abdominal cavity. This must be done slowly without sudden movements for 2-3 breaths and exhalations, holding the reached position of the fingers after the previous exhalation. The fingers are immersed to the back wall so that their ends are located inward from the palpable organ. At the next moment, the doctor asks the patient to hold his breath while exhaling and conducts a sliding movement of the hand in a direction perpendicular to the longitudinal axis of the intestine or the edge of the stomach. When sliding, the fingers bypass the accessible surface of the organ. Determine the elasticity, mobility, soreness, the presence of seals and tuberosity on the surface of the organ.

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

Palpation of the sigmoid colon

The right hand is set parallel to the axis of the sigmoid colon in the left iliac region, a skin fold is collected in front of the finger, and then, during the exhalation of the patient, when the abdominal pressure relaxes, the fingers gradually sink into the abdominal cavity, reaching its back wall. After that, without relieving pressure, the doctor's hand slides along with the skin in a direction perpendicular to the axis of the intestine, and rolls the hand over the surface of the intestine while holding the breath. In a healthy person, the sigmoid colon is palpated in 90% of cases in the form of a smooth, dense, painless, and non-rumbling cylinder 3 cm thick. with a mesentery. With the accumulation of gases and liquid contents, rumbling is noted.

Palpation of the caecum

The hand is placed parallel to the axis of the caecum in the right iliac region and palpation is performed. The caecum is palpated in 79% of cases in the form of a cylinder, 4.5-5 cm thick, with a smooth surface; it is painless and non-displaceable. In pathology, the intestine is extremely mobile (congenital elongation of the mesentery), immobile (in the presence of adhesions), painful (with inflammation), dense, tuberous (with tumors).

Palpation of the transverse colon

Palpation is carried out with two hands, i.e., by the method of bilateral palpation. Both hands are set at the level of the umbilical line along the outer edge of the rectus abdominis muscles and palpation is performed. In healthy people, the transverse colon is palpated in 71% of cases in the form of a cylinder 5-6 cm thick, easily displaced. In pathology, the intestine is palpated dense, contracted, painful (with inflammation), bumpy and dense (with tumors), sharply rumbling, enlarged in diameter, soft, smooth (with narrowing below it).

Palpation of the stomach

Palpation of the stomach presents great difficulties, in healthy people it is possible to palpate a large curvature. Before palpating the greater curvature of the stomach, it is necessary to determine the lower border of the stomach by ausculto-percussion or by ausculto-affrication.

Ausculto-percussion is carried out as follows: a phonendoscope is placed above the epigastric region and at the same time a quiet percussion is performed with one finger in a direction radial from the stethophonendoscope or, conversely, to the stethoscope. The border of the stomach is located on listening to a loud sound.
Ausculto-affrication- percussion is replaced by a light intermittent sliding over the skin of the abdomen. Normally, the lower border of the stomach is determined 2-3 cm above the navel. After determining the lower border of the stomach by these methods, deep palpation is used: a hand with bent fingers is placed on the region of the lower border of the stomach along the white line of the abdomen and palpation is performed. A large curvature of the stomach is felt in the form of a "roll" located on the spine. In pathology, the descent of the lower border of the stomach, pain on palpation of the greater curvature (with inflammation, peptic ulcer), the presence of a dense formation (tumors of the stomach) are determined.

Palpation of the pylorus

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

Abdominal percussion

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

With it, you can determine the space of Traube (the area of tympanic sound on the left in the lower part of the chest, due to the air bubble of the fundus of the stomach). It is increased with a significant increase in the content of air in the stomach (aerophagia). Percussion allows you to determine the presence of free and encysted fluid in the abdominal cavity.

When the patient is on the back, a quiet percussion is performed from the navel towards the lateral parts of the abdomen. Above the liquid, the percussion tone becomes dull. When the patient is turned on his side, the free fluid moves to the lower side, and above the upper side, the dull sound changes to tympanic. Encapsulated fluid appears with peritonitis limited by adhesions. Above it, during percussion, a dull percussion tone is determined, which does not change localization when the position changes.

Auscultation of the gastrointestinal tract

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

With mechanical obstruction of the intestine, peristalsis increases, with paralytic obstruction it sharply weakens, with peritonitis it disappears. In the case of fibrinous peritonitis, during the respiratory movements of the patient, the rub of the peritoneum may be heard. Auscultation under the xiphoid process in combination with percussion (ausculto-percussion) and light short rubbing movements of the researcher's finger along the skin of the patient's abdomen along the radial lines to the stethoscope can roughly determine the lower border of the stomach.

Of the auscultatory phenomena that characterize sounds arising in the stomach, splashing noise should be noted. It is called in the supine position of the patient with the help of quick short blows with half-bent fingers of the right hand on the epigastric region. The appearance of splashing noise indicates the presence of gas and liquid in the stomach. This symptom becomes important if it is determined 6-8 hours after eating. Then, with a sufficient degree of probability, pyloroduodenal stenosis can be assumed.

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

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

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

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

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

During auscultation of the abdomen, one can also hear a specific noise resulting from turbulent blood flow in the renal or mesenteric arteries, as well as with an aneurysm of the abdominal aorta. Friction noise heard over the liver appears with perihepatitis in patients with hepatoma and in women with pelvic inflammatory disease, but in general this auscultatory phenomenon is not common. During auscultation of the abdomen, it is possible to exercise significant pressure on the anterior abdominal wall with a stethophonendoscope, which is a kind of palpation of the abdomen. This method is recommended for feigning patients who complain of severe abdominal pain, especially on palpation, while no other pathological symptoms are detected. The most active malingerers often do not realize that the doctor is doing much more than just listening to peristaltic noises. This technique is also recommended when examining children to detect the area of maximum pain. Children with abdominal pain on palpation are usually very tense, which makes it difficult to detect local tenderness. In such cases, distracting the attention of children with their actions, the surgeon can palpate the abdomen with a stethophonendoscope.

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Inspection, percussion, auscultation of the abdomen

Plan

1. Examination of the abdominal organs in the vertical position of the patient
1.1 Inspection of the abdomen
1.2 Abdominal percussion
1.3 Auscultation of the abdomen
2. Examination of the abdominal organs in the horizontal position of the patient
2.1 Inspection of the abdomen
2.2 Abdominal percussion
2.3 Auscultation of the abdomen

1. Examination of the abdominal organs in the vertical position of the patient

1.1 Inspection of the abdomen

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

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

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

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

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

two vertical lines, carried out along the outer edges of the rectus abdominis muscles, each of the departments is divided into three aboutblasty:

- epigastric: for two subcostal regions (right and left) And epigastric (subcutaneous)) located in the middle;

- mesogastric: on two lateral flank and on umbilical;

- hypogastric: on two located on the sides iliac region and suprapubic.

At the very beginning of the examination, it is determined belly shape.

In a healthy person, the shape of the abdomen largely depends on its constitution. With an asthenic physique, the abdomen is somewhat retracted in the upper section and slightly protruding in the lower. With a hypersthenic physique, the abdomen is evenly protruded anteriorly.

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

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

Uniform protrusion of the abdomen due to obesity, flatulence, ascites.

With obesity, the folding of the skin is preserved, the navel is always retracted.

The skin of the anterior abdominal wall with ascites is thinned, shiny, without folds, the navel is often protruding. Huge ascites cause a significant symmetrical increase in the entire abdomen in volume, small - only a protrusion of the lower part.

Bulging of the abdomen in its lower section may be associated with pregnancy, a large uterine fibroid, an ovarian cyst, or an enlarged bladder in violation of the outflow of urine.

Stenosis of the distal large intestine (sigmoid or rectum) is accompanied by flank flatulence, manifested by a clear smoothing of the lateral lines of the abdominal waist.

Asymmetric protrusion of the abdomen occurs with a significant increase in individual organs: the liver, spleen, tumors of the stomach, intestines, omentum, kidneys.

Physiological peristalsis can be seen only with a pronounced thinning of the anterior abdominal wall or divergence of the rectus abdominis muscles, pathological - if there is an obstacle to the passage of food through the stomach or intestines. Peristaltic waves in this case arise above the place of the obstacle, are easily caused by a slight shaking of the anterior abdominal wall.

Normally, the skin of the abdomen is smooth, pale- pink with a matte finish.

In multiparous and thin women, it is wrinkled with whitish jagged stripes. Reddish-cyanotic stripes on the lower lateral parts of the abdomen with a transition to the thighs are found in Itsenko-Cushing's disease. The nature and localization of postoperative scars make it possible to quite accurately establish the organ on which the operation was performed.

Under normal conditions, saphenous veins are visible in individuals with thin skin. The detected veins do not protrude above the surface of the skin.

With difficulty in blood circulation in the system of the portal or inferior vena cava, dilated veins on the anterior abdominal wall. Disturbance of outflow in the system portal vein with cirrhosis of the liver, thrombophlebitis of the portal vein, pressure on it of a tumor, enlarged lymph nodes, compression or thrombosis of the inferior vena cava is manifested by tortuosity of the saphenous veins of the abdomen protruding above the surface.

A significant expansion of the tortuous veins on the anterior abdominal wall in the navel is called " medusa head"(caput Medusae).

Examination of the abdomen in a vertical position ends with an examination beloy line, inguinal and femoral canals where hernias are found. The outer inguinal ring usually freely passes the index finger, the inner - only its tip.

Umbilical hernias and hernias of the white line of the abdomen are located above the navel. To detect hernias, it is necessary to palpate with the index finger the hernial rings, the expansion of which contributes to the formation of hernias.

In the upright position of the patient, a divergence of the rectus abdominis muscles can be recognized by palpation of the white line of the abdomen.

1.2 Abdominal percussion

Percussion of the abdomen in the vertical position of the patient used to detect normal or increased intestinal gas filling, as well as free fluid in the abdominal cavity (ascites) with the determination of its level.

Percussion is carried out from top to bottom along the midline from the xiphoid process to the pubis and on both sides along the flanks from the p eberna arch to the iliac bones. Finger plessimeter is installed horizontallyntally(Fig. 2.).

Finger mounted verticallypercussion is performed from the navel to the right and left flanks(Fig. 3.).

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

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

Rice. 2. Percussion of the abdomen in the vertical position of the patient

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

The violation of such a ratio of the severity of tympanic sound with its amplification in the departments with blunted tympanitis indicates metheorism.

In the presence of ascites(more than 1 liter) along all three lines we get a horizontal level between the tympanic and the underlying dull sound (on the border between the loops of the small intestine that have floated upwards and the fluid that has shifted downwards). The difference in sounds is most clearly captured when using direct percussion according to V.P. Obraztsov.

1.3 Auscultation of the abdomen

Auscultation of the abdomen in the standing position of the patient is carried out to determine the friction noise of the peritoneum in the right and left hypochondria with perihepatitis and perisplenitis.

When a liquid is swallowed by a healthy person, listening to the epigastric region below the xiphoid process or above it allows you to hear two noises: the first - immediately after swallowing, the second after 6-9 seconds. The delay or absence of a second murmur associated with the passage of fluid through the cardia indicates an obstruction in the lower third of the esophagus or in the cardia of the stomach.

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

During the study, the patient should lie on his back, on a semi-rigid bed with a low headboard with a completely bare abdomen, legs extended and arms along the body. The doctor should sit on the right side of the patient in a chair, the level of which is close to the level of the bed, turning sideways to her.

2.1 Inspection of the abdomen

abdomen topography percussion auscultation

At examination pay attention to the changes that occurred at the time of changing the position of the patient's body. In a horizontal position, visible hernias usually disappear.

In the presence of free fluid in the abdominal cavity, flattening of the abdomen occurs, which expands laterally (the fluid spreads along the posterior surface of the abdominal cavity) and takes on the shape of a "frog".

Asymmetric bulges are more clearly manifested due to an increase in the liver, spleen, the formation of cysts or tumors, and the presence of flatulence.

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

Bloating in the epigastric region, combined with visible peristalsis, indicates an obstruction to gastric emptying (pyloric stenosis).

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

The complete absence of abdominal movement during deep breathing may be a sign of widespread peritonitis in patients with abdominal breathing. Local restriction of respiratory movements of the anterior abdominal wall occurs with severe pain syndrome, focal peritonitis.

2.2 Abdominal percussion

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

With ascites, the localization of a dull sound obtained by percussion in the vertical position of the patient changes. Its horizontal level disappears, now a dull sound is determined above the lateral parts of the abdomen, and in the middle, above the floating intestine, we get a tympanic sound.

When the patient's body is turned on its side, the dull sound zone in the flank located below increases due to the additional fluid from the other flank. Tympanitis is revealed in the opposite flank (Fig. 3.). Turning the patient to the other side completely changes the percussion picture - a tympanic sound appears in place of the former dull sound and vice versa.

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

With the help of percussion, local pain in the epigastric region can be determined during an exacerbation of gastric or duodenal ulcer (Mendel's symptom). They strike abruptly with the middle finger of the right hand on the upper parts of the rectus abdominis muscles. Due to the increased sensitivity of the parietal peritoneum in the projection of the diseased organ, the blow is painful.

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

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

2.3 Auscultation of the abdomen

To listen to intestinal motility, a stethoscope is installed at the site of the projection of the sigmoid, caecum and small intestine (Fig. 5.).

The point of auscultation of the sigmoid colon is between the outer and middle thirds of the line connecting the navel and the anterior superior iliac spine on the left.

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

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

The point of auscultation of the small intestine is 2 cm from the navel along the line between the left costal arch and the navel.

In a healthy person, peristaltic sounds (rumbling) are heard, alternating with periods of lack of peristalsis.

The frequency of peristaltic noises over the large intestine is about 4-6 per minute, over the small intestine - 6-8 per minute.

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

The absence of peristalsis is a sign of intestinal paresis, peritonitis.

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