What is liver palpation? The liver is not palpable what does it mean The liver is at the edge of the costal arch what does it mean

The structures of this body carry out:

• Bile production.
• Neutralization of toxic and foreign substances that have entered the body.
• Metabolism of nutrients (represented by vitamins, fats, proteins and carbohydrates).
• The accumulation of glycogen, which is the main form of glucose storage in the human body. Deposited in the cytoplasm of hepatic cells, glycogen is an energy reserve, which, if necessary, can quickly resume an acute lack of glucose.

Given the great importance of this organ for the human body, it is necessary to promptly identify and treat pathological processes that can bring discord into its work. It is known that at the earliest stages of damage to liver cells, clinical manifestations of the disease may be completely absent.

Pain sensations, as a rule, appear along with an increase in the organ and the stretching of the capsule provoked by it. In particular, the duration of the incubation period for hepatitis of viral etiology can be at least six months.

Clinical symptoms at this stage are still absent, but pathological changes in the structures of the liver are already occurring.

The first task of the doctor is a thorough collection of information, including the analysis of complaints and an assessment of the general condition of the patient. The next stage of diagnosis is a physical examination of the patient, which includes the mandatory percussion and palpation of the liver.

These diagnostic techniques, which do not take much time and do not require any preliminary preparation of the patient, help to establish the true size of the affected organ, which is extremely important for timely diagnosis and the appointment of the correct treatment tactics.

Given the high prevalence of diseases leading to liver damage, the problem of their timely diagnosis continues to be relevant today. The most significant contribution to the development of methods for palpation and percussion examination of the liver was made by the therapists Obraztsov, Kurlov and Strazhesko.

The percussion method, which allows you to establish the location, condition and various kinds of disturbances in the functioning of internal organs, consists in tapping the abdominal cavity or chest. The diverse nature of the sounds that arise in this case is due to the different density of the internal organs.

The preliminary diagnosis depends on the doctor's ability to correctly analyze the information obtained during percussion.

There are two types of percussion:

• Direct, consisting in the implementation of tapping on the surface of the chest or abdominal wall.
• Mediocre, performed with the help of a plessimeter, the role of which can be played by a special plate (metal or bone) or the fingers of the doctor himself. By constantly changing the amplitude of percussion manipulations, an experienced specialist is able to determine the functional abilities of internal organs lying at a depth of up to seven centimeters. The results of a percussion examination may be affected by factors such as: the thickness of the anterior abdominal wall, the accumulation of gases or free fluid in the abdominal cavity.

With percussion of the liver, it is clinically important to determine the absolute dullness of those parts of it that are not covered by lung tissues. Determining the boundaries of the organ under study, the doctor is guided by a change in the nature of percussion sounds, the range of which can vary from clear (pulmonary) to dull.

To determine the upper and lower border of the liver, the specialist uses three vertical lines as a visual guide:

• anterior axillary;
• peristernal;
• mid-clavicular.

In a person who has a normosthenic physique and does not have external signs of damage to internal organs, an area of ​​​​absolute dullness can be detected using the anterior axillary line: it will be localized on the right side, approximately at the level of the tenth rib.

The next landmark - the mid-clavicular line - will indicate that the border of the liver continues along the lower edge of the right costal arch. Having reached the next line (right peristernal), it will go down a couple of centimeters below the mark just mentioned.

At the point of intersection with the anterior median line, the border of the organ does not reach the end of the xiphoid process by several centimeters. At the point of intersection with the parasternal line, the border of the liver, having moved to the left half of the body, reaches the level of the left costal arch.

Localization of the lower border of the liver may be different depending on the type of human physique. In asthenics (people with asthenic physique), the lower position of this organ is considered normal. In patients with a hypersthenic physique (hypersthenics), the parameters of the location of the liver are shifted by one to two centimeters above the landmarks just described.

When analyzing the results of percussion, it is necessary to take into account the age of the patient, since in small patients there is a downward shift of all boundaries.

So, in an adult patient, the liver accounts for no more than 3% of the total body weight, while in a newborn baby this figure is at least 6%. Thus, the younger the child, the greater the place in his abdominal cavity is occupied by the organ of interest to us.

The video shows the technique of percussion of the liver according to Kurlov:

The essence of the Kurlov method, designed to determine the size of the liver, is as follows: the boundaries and dimensions of this organ are revealed using percussion - a diagnostic manipulation that boils down to tapping this organ and analyzing the resulting sound phenomena.

Due to the high density of the liver and the lack of air in its tissues, dull sounds occur during percussion; when tapping a part of the organ blocked by lung tissues, the percussion sound is significantly shortened.

Kurlov's technique, which is the most informative way to determine the boundaries of the liver, is based on the identification of several points that make it possible to indicate its true size:

• First point, indicating the upper limit of hepatic dullness, should be at the lower edge of the fifth rib.
• Second the point corresponding to the lower border of hepatic dullness is localized either at the level or one centimeter above the costal arch (relative to the mid-clavicular line).
• Third the point must correspond to the level of the first point (relative to the anterior midline).
• Fourth the point marking the lower border of the liver is usually located at the turn of the upper and middle third of the segment between the navel and the xiphoid segment.
• Fifth the point denoting the lower edge of the wedge-shaped tapering organ should be located at the level of the seventh-eighth rib.

Having outlined the boundaries of the location of the above points, they begin to determine the three sizes of the organ under study (this technique is usually used in relation to adult patients and children over seven years old):

• The distance between the first and second points is the first dimension. Its normal value in adults ranges from nine to eleven, in children of preschool age - six to seven centimeters.
• The second size, determined by the difference in the nature of percussion sounds, gives the distance between the third and fourth points. In adults, it is eight to nine, in preschoolers - five to six centimeters.
• Third - oblique - the size is measured diagonally connecting the fourth and fifth points. In adult patients, it is normally seven to eight, in children - no more than five centimeters.

In the conditions of modern clinics, the results obtained during palpation and percussion of the liver can be clarified with the help of high-tech equipment used for ultrasound, magnetic resonance and computed tomography.

All these procedures provide comprehensive information about the boundaries, size, volume of the organ under study and about possible violations in its work.

Measurement of the right and left lobes of the liver is carried out separately, focusing on three main indicators: oblique vertical size, height and thickness.

• Anteroposterior size(thickness) of the left lobe of the organ in a healthy adult should not exceed eight centimeters, the right - twelve.
• Craniocaudal size(height) of the right lobe can vary between 8.5-12.5 cm, the left - 10 cm.
• Skew vertical dimension value for the right lobe of the organ, it is normally fifteen centimeters, for the left - no more than thirteen.

The number of obligatory measured parameters includes the length of the studied organ in the transverse plane. Its value for the right lobe is from fourteen to nineteen centimeters, for the left - from eleven to fifteen.

The parameters of the liver in a child differ significantly from those in an adult. The size of both its lobes (together with the diameter of the portal vein) constantly change as his body grows.

For example, the length of the right lobe of the liver in a one-year-old child is six, the left lobe - three and a half centimeters, the diameter of the portal vein can be from three to five centimeters. By the age of fifteen (it is at this age that the growth of the gland is completed), these parameters are respectively: twelve, five and from seven to twelve centimeters.

In Russian medical institutions, palpation of hepatic structures in adult patients and children is most often performed according to the classical Obraztsov-Strazhesko method. Referred to as bimanual palpation, this technique is based on feeling the lower edge of the liver while taking a deep breath.

Before conducting this study, the doctor must properly prepare the patient (especially a small child), convincing him to completely relax, relieving tension from the abdominal muscles. Given the high soreness of the affected organ, this is not at all easy to do.

Palpation of the liver can be performed in both the vertical and horizontal position of the patient, however, taking a supine position, he will feel more comfortable. This statement is especially true for young children.

• Before palpation of the liver, the specialist should position himself on the right side of the patient, facing him.
• The patient is asked to lie on his back (on a couch with a slightly raised headboard). His forearms and hands should lie on his chest; legs can be straightened or bent.
• The left hand of the specialist performing palpation should fix the lower part of the right half of the patient's chest. By holding the costal arch and thereby limiting its excursion at the moment of inhalation, the doctor provokes a greater downward displacement of the organ under study. The palpating (right) hand is laid flat at the level of the navel on the right half of the anterior abdominal wall, slightly to the side of the outer edge of the rectus muscle. The middle finger of the right hand should be slightly bent.

Examining the patient's liver, the doctor uses deep palpation techniques applied to the abdominal organs.

For palpation, the patient most often takes a supine position, much less often it is carried out in a vertical position of the body.

Some specialists seat their patients or lay them on their left side before performing palpation. Let's consider several methods of palpation in more detail.

• Palpation of the liver, carried out in the position of the patient lying down, is performed synchronously with the patient's breathing (a detailed description of the patient's posture and the position of the doctor's hands is given in the previous section of our article). At the phase of exhalation performed by him, the doctor plunges the palpating hand into the patient's abdominal cavity, holding it perpendicular to the anterior wall of the abdomen and parallel to the edge of the liver.

A characteristic feature of palpation of the liver, carried out in the supine position, is the ultimate relaxation of the abdominal muscles, slight pressing of the patient's shoulders to the chest and laying his forearms and hands on the chest. This position of the hands helps to significantly reduce upper costal breathing, increasing diaphragmatic breathing.

Thanks to the correct preparation of the patient, the doctor manages to achieve the maximum displacement of the examined gland down during a deep breath and its exit from the hypochondrium, making the organ more accessible to the study.

During the inhalation phase, the palpating hand moves forward and upward, forming a skin fold called an "artificial pocket". At the moment of very careful and gradual immersion of the fingers deep into the abdominal cavity, the doctor asks the patient to take slow breaths and exhalations of medium depth.

With each exhalation, the researcher's fingers steadily move down and slightly forward - under the examined gland. At the moment of inhalation, the doctor's fingers, which resist the rising wall of the abdomen, remain immersed in the region of the right hypochondrium.

After two or three respiratory cycles, contact is reached with the edge of the organ under study, thanks to which the specialist can obtain information about the outlines, boundaries, dimensions and quality of its surface.

• The edge of a healthy, painless gland, which has a smooth surface and a soft elastic consistency, should be located at the level of the costal arch.
• Omission of the liver entails a shift and its upper border, determined during percussion. This phenomenon usually accompanies an increase in the gland that occurs in patients suffering from acute and chronic hepatitis, obstruction of the bile ducts, cirrhosis, cysts and tumor lesions of the liver.
• Congestive liver has a soft texture and a sharp or rounded edge.
• Patients with cirrhosis or chronic hepatitis are the owners of a gland with a denser, pointed, painful and uneven edge.
• The presence of a tumor provokes the formation of a scalloped edge.
• In patients with a rapidly developing hepatoma (primary malignant tumor of the organ under study) or the presence of metastases, palpation reveals the presence of an enlarged dense liver with large nodes on the surface.
• The presence of decompensated cirrhosis is evidenced by the small size of a significantly compacted organ with a bumpy surface. Palpation is extremely painful.
• The granular surface of the affected organ is observed with the development of an abscess and in patients suffering from syphilis or atrophic cirrhosis.
• If the rapid decrease in the liver continues for some time, the doctor may assume the development of severe hepatitis or massive necrosis.

The above palpation technique is used several times, gradually increasing the depth of immersion of the fingers inside the hypochondrium. If possible, it is desirable to explore the edge of the organ of interest to us throughout its entire length.

If, despite all efforts, it is not possible to find the edge of the gland, it is necessary to change the position of the fingers of the palpating hand, moving them slightly up or down. In this way, the liver can be palpated in almost 90% of perfectly healthy people.

After completing the palpation procedure, the patient should be held in a supine position for a while, and then carefully and slowly help him to rise. Elderly patients who have undergone this procedure are advised to take a sitting position for a while: this will prevent the occurrence of dizziness and other negative consequences.

• Palpation of the liver is also possible in a patient who has taken a sitting position. For maximum relaxation of the abdominal muscles, he should lean forward slightly, resting his hands on the edge of a hard chair or couch.

Standing on the right side of the patient, the doctor with his left hand should hold him by the shoulder, tilting the body of the patient as necessary, contributing to muscle relaxation. Having established the right hand at the outer edge of the rectus muscle, the doctor, over three respiratory cycles, gradually, without changing their position, immerses the fingers into the depths of the right hypochondrium.

Having reached the back wall, the specialist asks the patient to inhale slowly and deeply. At this moment, the lower surface of the organ under study will lie on the palm of the doctor, giving him the opportunity to carefully feel his surface. By slightly bending the fingers and making sliding movements with them, the specialist can assess the degree of elasticity of the organ, the sensitivity and nature of its edge and lower surface.

Palpation, carried out in a sitting position (in contrast to the classical method described above, which makes it possible to touch the liver with only the very tips of the fingers), allows the doctor to feel the gland of interest to us with the entire surface of the terminal phalanges, endowed with maximum sensitivity for a person.

• In patients with severe ascites (a pathological condition accompanied by the accumulation of free fluid in the abdominal cavity), it is not always possible to palpate the liver using the methods described above. In such cases, specialists use the technique of jerky (or "balloting") palpation.

Squeezing together three fingers of the right hand (second, third and fourth), the doctor puts them on the abdominal wall - above the location of the liver - and makes a series of short jerky movements directed inside the abdominal cavity. The depth of immersion of the fingers in this case should be from three to five centimeters.

Starting the study from the lower third of the abdomen, the doctor gradually, adhering to special topographic lines, moves towards the liver.

At the moment of impact on it, the researcher's fingers feel the presence of a dense body, easily immersed in ascitic fluid and soon returning to its previous position (this phenomenon was called the "floating ice" symptom).

Jerky palpation can also be applied to patients who do not have ascites, but have an enlarged liver and a very weak abdominal wall, in order to locate the edge of the affected organ.

Tightly squeezing two or three fingers on the right hand, the doctor begins to perform light jerky or sliding movements down from the end of the xiphoid process and from the edge of the costal arch. In a collision with the liver, the fingers will feel resistance, but at the end of the liver, the fingers, without meeting resistance, will simply fall deep into the abdominal cavity.

The video shows the method of palpation of the liver according to Obraztsov-Strazhesko:

The displacement of the upper border of the liver upward can be triggered by:

• a tumor;
• high standing diaphragm;
• echinococcal cyst;
• subphrenic abscess.

Moving the upper border of the organ down can occur due to:

• pneumothorax - accumulation of gases or air in the pleural cavity;
• emphysema of the lungs - a chronic disease leading to pathological expansion of the distal branches of the bronchi;
• visceroptosis (synonymous name - splanchnoptosis) - prolapse of the abdominal organs.

The shift of the lower border of the liver upwards may be the result of:

• acute dystrophy;
• tissue atrophy;
• cirrhosis of the liver, which has reached the final stage;
• ascites (abdominal dropsy);
• increased flatulence.

The lower border of the liver may shift down in patients suffering from:

• heart failure;
• hepatitis;
• liver cancer;
• liver damage due to stagnation of blood as a result of increased pressure in the right atrium (this pathology is called the "stagnant" liver).

The culprits of a significant increase in the liver can be:

• chronic infectious diseases;
• right ventricular heart failure;
• different types of anemia;
• her chronic illnesses;
• cirrhosis;
• lymphogranulomatosis;
• malignant neoplasms;
• leukemia;
• violations of the outflow of bile;
• hepatitis.

Palpation of the liver

Superficial palpation in liver diseases can reveal a zone of pain in the right hypochondrium and epigastric region. Especially severe local pain, even with a light touch to the anterior abdominal wall in the area of ​​the projection of the gallbladder, is observed in acute cholecystitis and biliary colic. In chronic cholecystitis, only mild or moderate pain is usually determined at the so-called point of the gallbladder: it corresponds to the projection of its bottom onto the anterior abdominal wall and is normally localized in most cases directly under the right costal arch along the outer edge of the right rectus abdominis muscle.

Palpation of the liver is carried out according to the Obraztsov-Strazhesko method. The principle of the method is that with a deep breath, the lower edge of the liver descends towards the palpating fingers and then, bumping into them and sliding off them, becomes palpable. It is known that the liver, due to its close proximity to the diaphragm, has the highest respiratory mobility among the abdominal organs. Consequently, during palpation of the liver, an active role belongs to its own respiratory mobility, and not to palpating fingers, as during palpation of the intestine.

Palpation of the liver and gallbladder is performed with the patient standing or lying on his back (however, in some cases, palpation of the liver is facilitated when the patient is positioned on the left side; in this case, the liver, under the influence of gravity, comes out of the hypochondrium and then it is easier to probe its lower front edge). Palpation of the liver and gallbladder is carried out according to the general rules of palpation, and most of all they pay attention to the anteroinferior edge of the liver, by the properties of which (contours, shape, soreness, consistency) the physical state of the liver itself, its position and shape are judged. In many cases (especially when the organ is lowered or enlarged), in addition to the edge of the liver, which can often be traced by palpation from the left hypochondrium to the right, it is also possible to palpate the upper anterior surface of the liver.

The examiner sits on the right next to the bed on a chair or on a stool facing the subject, puts the palm and four fingers of the left hand on the right lumbar region, and with the thumb of the left hand presses the costal arch from the side and front, which contributes to the approach of the liver to the palpating right hand and, making it difficult to expand the chest during inspiration, it helps to increase the excursions of the right dome of the diaphragm. The palm of the right hand is placed flat, with fingers slightly bent, on the patient's stomach directly under the costal arch along the mid-clavicular line and slightly pressed with fingertips on the abdominal wall. After such an installation of the hands, the subject is offered to take a deep breath; the liver, descending, first approaches the fingers, then bypasses them and slips out from under the fingers, that is, it is palpable. The hand of the researcher remains motionless all the time, the technique is repeated several times.

The position of the edge of the liver can be different depending on various circumstances, therefore, in order to know where to place the fingers of the right hand, it is useful to first determine the position of the lower edge of the liver by percussion.

According to V.P. Obraztsov, a normal liver is palpable in 88% of cases. Palpation sensations obtained from the lower edge of the liver, allow you to determine its physical properties (soft, dense, uneven, sharp, rounded, sensitive, etc.). The edge of the unchanged liver, palpable at the end of a deep breath 1-2 cm below the costal arch, is soft, sharp, easily folded and insensitive.

The lower edge of the normal liver is usually palpable along the right mid-clavicular line; to the right of it, the liver cannot be palpated, since it is hidden by the hypochondrium, and on the left, palpation is often difficult due to the severity of the abdominal muscles. With an increase and compaction of the liver, it can be felt along all lines. Patients with bloating should be examined on an empty stomach to facilitate palpation. With the accumulation of fluid in the abdominal cavity (ascites), it is not always possible to palpate the liver in the horizontal position of the patient. In these cases, the indicated technique is used, but palpation is performed in an upright position or in the position of the patient on the left side. With the accumulation of a very large amount of fluid, it is first released using paracentesis. If there is a large accumulation of fluid in the abdominal cavity, the liver is also palpated with jerky ballot palpation. To do this, the right hand with slightly bent II IV fingers is placed at the bottom of the right half of the abdomen, perpendicular to the supposed lower edge of the liver. With closed fingers of the right hand, jerky blows are applied to the abdominal wall and moved in the direction from the bottom up until the dense body of the liver is felt, which, when the fingers are struck, first goes into the depths of the abdominal cavity, and then hits them and becomes palpable (a symptom of a floating ice floe).

Soreness is characteristic of inflammatory liver damage with the transition of the inflammatory process to the liver capsule or to stretch it (for example, with stagnation of blood in the liver due to heart failure).

The liver of a healthy person, if it is accessible to palpation, has a soft texture, with hepatitis, hepatosis, cardiac decompensation, it is more dense. The liver is especially dense with its cirrhosis (at the same time, its edge is sharp, and the surface is even or finely tuberous), tumor lesions of multiple cancer metastases (in these cases, sometimes the surface of the liver is rough-hilly, corresponding to superficially located metastases, and the lower edge is uneven), with amyloidosis. Sometimes it is possible to palpate a relatively small tumor or echinococcal cyst.

The protrusion of the lower edge of the enlarged liver is determined in relation to the costal arch along the right anterior axillary, right near the sternal and left parasternal lines. Palpation data clarify the idea of ​​the size of the liver, obtained by percussion.

The gallbladder is normally not palpable, as it is soft and practically does not protrude from under the edge of the liver. But with an increase in the gallbladder (dropsy, filling with stones, cancer, etc.), it becomes accessible to palpation. Palpation of the bladder is carried out in the same position of the patient as palpation of the liver. The edge of the liver is found and directly below it, at the outer edge of the right rectus muscle, the gallbladder is palpated according to the rules of probing the liver itself. It can be most easily detected by moving the fingers transversely to the axis of the gallbladder. The gallbladder is palpated in the form of a pear-shaped body of various sizes, density and soreness, depending on the nature of the pathological process in itself or in the organs surrounding it (for example, an enlarged soft-elastic bladder when the common bile duct is blocked by a tumor - a sign of Courvoisier - Terrier; dense - tuberous bladder with neoplasms in its wall, with overflowing with stones, with inflammation of the wall, etc.). The enlarged bubble is mobile during breathing and makes pendulum movements. The mobility of the gallbladder is lost with inflammation of the peritoneum covering it, pericholecystitis. With cholecystitis and cholelithiasis, sharp pain and reflex tension of the muscles of the anterior abdominal wall in the right hypochondrium make palpation difficult.

This technique of palpation of the liver and gallbladder is the simplest, most convenient and gives the best results. The difficulty of palpation and, at the same time, the consciousness that only it allows obtaining valuable data for diagnosis, forced us to look for the best method of palpation. Various techniques have been proposed, mainly reduced to a variety of positions of the examiner's hands or a change in the position of the examiner in relation to the patient. However, these methods do not have any advantages in the study of the liver and gallbladder. The point is not in the variety of techniques, but in the experience of the researcher and his systematic implementation of the study plan for the abdominal cavity as a whole.

Percussion of the liver

The percussion method allows you to determine the boundaries, size and configuration of the liver. Percussion determine the upper and lower boundaries of the liver. There are upper limits of two types of hepatic dullness: relative dullness, which gives an idea of ​​the true upper limit of the liver, and absolute dullness, i.e. the upper border of the area of ​​the anterior surface of the liver, which is directly adjacent to the chest and is not covered by the lungs. In practice, they limit themselves to determining only the boundaries of the absolute dullness of the liver, since the position of the upper limit of the relative dullness of the liver is not constant and depends on the size and shape of the chest, the 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, the enlargement of the liver occurs predominantly downward, as judged by the position of its lower edge.

Percussion of the liver is carried out in compliance with the general rules of topographic percussion. Quiet percussion is used to determine the upper limit of absolute dullness of the liver. Percussion from top to bottom along vertical lines, as in determining the lower boundaries of the right lung. Borders are found by the contrast between a clear pulmonary sound and a dull one from the liver. The found border is marked with dots on the skin along the upper edge of the plessimeter finger along each vertical line. Normally, the upper limit of the absolute dullness of the liver is located along the right parasternal line at the upper edge of the VI rib, along the right mid-clavicular line on the VI rib and along the right anterior axillary line on the VII rib, i.e., the upper limit of the absolute dullness of the liver corresponds to the position of the lower edge right lung. In the same way, it is possible to establish the position of the upper border of the liver and behind, however, they are usually limited to determining only along the indicated three lines.

Determining the lower limit of the absolute dullness of the liver presents some difficulty due to the proximity of hollow organs (stomach, intestines), which give high tympanitis during percussion, hiding the hepatic sound. With this in mind, 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 dullness of the liver according to Obraztsov Strazhesko begins in the region of the right half of the abdomen along the right anterior axillary line in the horizontal position of the patient. The finger-plessimeter is placed parallel to the intended position of the lower edge of the liver and at such a distance from it that a tympanic sound is heard when the blow is applied (for example, at the level of the navel or below). Gradually moving the plessimeter finger up, they reach the border of the transition of tympanic sound to absolutely dull. In this place, along each vertical line (right mid-clavicular line, right parasternal line, anterior midline), and with a significant increase in the liver and along the left parasternal line, a mark is made on the skin but the lower edge of the plessimeter finger

When determining the left border of the absolute dullness of the liver, the finger-plessimeter is set perpendicular to the edge of the left costal arch at the level of VIII IX ribs and percussed to the right directly under the edge of the costal arch to the point of transition of tympanic sound (in the region of Traube's space) into a dull one.

Normally, the lower limit of the absolute dullness of the liver in the horizontal position of a patient with a normosthenic form of the chest passes in the right anterior axillary line on the X rib, along the mid-clavicular 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 arches, along the anterior median line, 3-6 cm from the lower edge of the xiphoid process (on the border of the upper third of the distance from the base of the xiphoid process to the navel), does not go to the posterior median line on the left. The position of the lower edge of the liver and in the norm can be different depending on the shape of the chest, the human constitution, but this is mainly reflected only at the level of its position along the anterior midline. So, with a hypersthenic chest, the lower edge of the liver is located slightly above the indicated level, and with an asthenic chest, it is lower, approximately halfway from the base of the xiphoid process to the navel. The displacement of the lower edge of the liver down by 1 - 1.5 cm is noted in the vertical position of the patient. With an increase in the liver, the border of 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 costal arch).

The obtained data of percussion of the liver allow to determine the height and dimensions of hepatic dullness. To do this, vertical lines measure the distance between the two corresponding points of the upper and lower limits of the absolute dullness of the liver. This normal height along the right anterior axillary line is 10 - 12 cm. on the right mid-clavicular line 9-11 cm, and on the right parasternal line 8-11 cm. It is difficult to determine the percussion zone of dullness of the liver behind (it merges with the zone of dull sound formed by a thick layer of muscles of the lower back, kidneys and pancreas), but sometimes it is possible in the form of a strip 4-6 cm wide. This avoids the erroneous conclusion that the liver is enlarged in cases where it is lowered and comes out from under the right costal arch, and also slightly rotated around its axis anteriorly, then the band of dull sound behind becomes narrower.

Percussion of the liver according to Kurlov. During percussion of the liver according to Kurlov, the following three sizes are determined: the first size along the right mid-clavicular line from the upper to the lower border of the absolute dullness of the liver (normally 9-11 cm), the second size along the anterior midline from the upper border of the liver to the bottom (normally 7 9 cm), the third size along the edge of the costal arch (normally 6-8 cm).

Determination of the percussion borders of the liver and its size is of diagnostic value. However, the displacement of the upper border (up or down) is more often associated with extrahepatic changes (high or low standing of the diaphragm, the presence of a subdiaphragmatic abscess, pneumothorax, exudative pleurisy). Only with echinococcosis and liver cancer, its upper border can shift upwards. The displacement of the lower border of the liver upward indicates a decrease in its size, but can also be observed with flatulence and ascites, pushing the liver upward. The downward displacement of the lower border of the liver is observed, as a rule, with an increase in the organ as a result of various pathological processes (hepatitis, cirrhosis, cancer, echinococcus, blood stasis in heart failure, etc.), but sometimes due to the low standing of the diaphragm. Systematic monitoring of the percussion borders of the liver and changes in the height of hepatic dullness makes it possible to judge the increase or decrease in this organ during the course of the disease.

The gallbladder is usually not detected percussion, but with a significant increase it can be determined using very quiet percussion.

Percussion is used not only to determine the size of the liver and gallbladder (topographic percussion), but also to assess their condition: percussion (careful) on the surface of the enlarged liver or over the area of ​​the gallbladder causes pain during inflammatory processes (hepatitis, cholecystitis, pericholecystitis and etc.). Tapping (succusio) on the right costal arch also causes pain in diseases of the liver and biliary tract, especially in cholelithiasis (Ortner's symptom).

Palpation of the spleen

Palpation of the spleen is carried out in the position of the patient lying on his back or on his right side. In the first case, the patient lies on a bed with a low headboard, his arms are extended along the body, his legs are also extended. In the second case, the patient is laid on the right side, his head is slightly tilted forward to the chest, the left arm, bent at the elbow joint, lies freely on the front surface of the chest, the right leg is extended, the left is bent at the knee and hip joints. In this position, maximum relaxation of the abdominals is achieved and the spleen is moved closer anteriorly. All this facilitates its determination by palpation, even with a slight increase. The doctor sits to the right of the patient facing him. The doctor places his left hand on the left half of the patient's chest between the 7th and 10th ribs along the axillary lines and squeezes it somewhat, limiting its movement during breathing. The doctor places the right hand with slightly bent fingers on the anterolateral surface of the patient's abdominal wall at the edge of the costal arch, at the junction of the end of the X rib with it, or, if the examination and preliminary percussion data suggest an enlarged spleen, at the supposed location of its anteroinferior edge. Then, as the patient exhales with his right hand, the doctor slightly presses the abdominal wall, forming a pocket; then the doctor asks the patient to take a deep breath. At the moment of inhalation, if the spleen is accessible to palpation and it is carried out correctly, the spleen, moving downward by the descending diaphragm, approaches the fingers of the doctor’s right hand with its anteroinferior edge, rests against them and, with its further movement, slips under them. This technique is repeated several times, trying to explore the entire edge of the spleen accessible to palpation. At the same time, attention is paid to the size, soreness, density (consistency), shape, mobility of the spleen, and the presence of cuts on the front edge is determined. Characteristic for the spleen, one or more cuts on the front edge are determined with a large increase in it. They allow you to distinguish the spleen from other enlarged abdominal organs, such as the left kidney. With a significant increase in the spleen, it is also possible to examine its anterior surface, emerging from under the edge of the costal arch.

Normally, the spleen is not palpable. It becomes accessible to palpation only with a significant omission (rarely with an extreme degree of enteroptosis), most often with an increase. Enlargement of the spleen is observed in some acute and chronic infectious diseases (typhoid and relapsing fever, Botkin's disease, sepsis, malaria, etc.), liver cirrhosis, thrombosis or compression of the splenic vein, as well as in many diseases of the hematopoietic system (hemolytic anemia, thrombocytopenic purpura, acute and chronic leukemias). A significant increase in the spleen is called splenomegaly (from the Greek. Splen - spleen, megas - large). The greatest increase in the spleen is observed in the final stage of chronic myeloid leukemia, in which it often occupies the entire left half of the abdomen, and goes into the small pelvis with its lower pole.

In acute infectious diseases, the density of the spleen is low; especially soft, doughy consistency of the spleen in sepsis. In chronic infectious diseases, cirrhosis of the liver and leukemia, the spleen becomes dense; it is very dense in amyloidosis.

In most diseases, palpation of the spleen is painless. It becomes painful with splenic infarction, perisplenitis, and also in case of a rapid increase due to stretching of the capsule, for example, when venous blood stagnates in it during thrombosis of the splenic vein. The surface of the spleen is usually smooth, the roughness of its edge and surface is determined with perisplenitis and old heart attacks (there are retractions), the tuberosity of its surface is observed with syphilitic gums, echinococcal and other cysts and extremely rare tumors of the spleen.

The mobility of the spleen is usually quite significant; it is limited to the perispleen. The sharply enlarged spleen remains motionless during breathing, but it usually still manages to be displaced by hand during palpation. Often, with leukemia, not only the spleen increases, but also the liver (due to metaplasia), which is also examined by palpation.

Percussion of the spleen

In the study of the system of hematopoietic organs, percussion is of limited importance: it is used only for an approximate determination of the size of the spleen. Due to the fact that the spleen is surrounded by hollow organs (stomach, intestines), containing air and giving a loud tympanic sound during percussion, it is impossible to accurately determine its size and boundaries by this method.

Percussion is carried out in the position of the patient standing or lying on the right side. You need to percuss very quietly from a clear sound to a dull one; It is best to use the Obraztsov method. To determine the diameter of splenic dullness, percussion is carried out along a line located 4 cm lateral to the left costoarticular line (this line connects the sternoclavicular joint with the free end of the XI rib). Normally, splenic dullness is determined between the IX and XI ribs: its size is 4 6 cm. The length of the spleen comes medially to the costoarticular line; the percussion size of the dullness of the length of the spleen is 6-8 cm

Percussion of the liver is a diagnostic method, followed by palpation during the initial examination of the patient on suspicion of a pathology of the hepatic organ. The essence of the diagnostic method lies in the fact that various organs of the human body have a certain density, due to which, when tapping, one can determine the approximate state of the internal organ.

Percussion of the liver - a diagnostic method during the initial examination of the patient

There are two types of percussion: mediocre and direct. The direct view is that tapping is carried out in the epigastric region or on the chest in order to check the general condition of the patient's organs. The mediocre view is that you need to knock on the plessimeter and try to find out the state of the organ as accurately as possible.

With the correct application of the technique, one can quite accurately find out about the state of internal organs at a depth of up to 7 cm. Gases, the presence of free fluid, as well as the individual thickness of the abdominal wall can also affect the result of the study.

Percussion of the liver by the Kurlov method is recognized as one of the most effective and convenient methods, especially if you need to know the exact boundaries and dimensions of the liver. First you need to designate the boundaries of the liver with conditional points, in the area of ​​\u200b\u200bwhich percussion will be performed. This will be the upper border, which is located along the perithoracic line near the sixth rib on the right. Percussion is performed from above along this line down, where, when the percussion sound changes, the first point is noted. The lower limit is determined along the same line down and percussion starts upward from the right iliac region. When the sound is dulled, the second point is located (at the norm, at the edge of the costal arch). The third mark is the intersection of the perpendicular from the first mark and the anterior midline (upper border of the second topographic line). The fourth mark (the region of the lower border of the liver) is percussion from the navel upwards until the percussion sound is dulled. The third topographic line is the left costal arch. Percussion starts up the line of the ribs to a dull sound, where the fifth point is noted. Normally, the dimensions of the right lobe of the liver should correspond to 9 cm (deviation from measurements +/- 1 cm is possible). The left lobe of the liver or the first topographic dimension should correspond to 8 cm (deviation from measurements +/- 1 cm is possible). The second topographic size of the left lobe of the liver should correspond to 7 cm (deviation from measurements +/- 1 cm is possible). If the liver changes its size due to a pathological process, then this will immediately become noticeable by measurements. The borders of the liver normally correspond to the indicated measurements.

The most reliable palpation of the liver and spleen is by the Obraztsov-Strazhesko method. The essence of the diagnostic method lies in the fact that during a deep breath, the lower part of the organ becomes well felt with palpable fingers. After all, it is a well-known fact that during breathing it is the liver that has the best mobility among all the other viscera located in the epigastric region.

For a successful diagnosis, it is necessary for the patient to take a supine position on his back or stand still. In some cases, it is required that the patient lies on his left side, because it happens that it is in this position that probing turns out to be the most informative. In 90% of cases, a healthy liver should be normally palpable. The examiner of the organ should sit opposite the patient and place 4 fingers of the left hand on the lower back on the right side.

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ACTIVE METHOD

For a successful diagnosis, it is necessary for the patient to take a supine position or stand still.

Next, with your thumb, you need to press on the lateral part of the costal arch, thanks to which you can bring the organ closer to the hand that palpates it. The right hand rests palm down flat with fingers slightly bent on the patient's abdomen under the arch of the ribs, where the mid-clavicular line is located, and then press with the fingertips on the abdomen. Then, at the doctor's command, the patient takes a deep breath, while the liver begins to rise to the fingers, and then slips, which helps to assess the condition of the organ.

Normally, the lower part of the organ is easily palpable on the right side of the mid-clavicular line. It is impossible to feel the right side of the liver, as it is hidden by the ribs, and the left side is difficult to feel in case of abdominal muscle tone. If the organ is abnormally enlarged and compacted, then it can be felt from all sides. If the patient suffers from bloating, then palpation is performed in the morning on an empty stomach. If the patient has ascites (accumulation of fluid in the epigastric region), then in the supine position, palpation will be difficult.

Pain during palpation of the organ indicates an inflammatory process. In a healthy patient, the liver is soft, partially palpable and does not cause pain. If the patient has a history of hepatitis, then the organ acquires a denser consistency. In the presence of cirrhosis, it acquires a clear density with a sharp edge and a bumpy surface. If the patient has stage 4 oncology, then the surface of the organ becomes too bumpy in accordance with metastases. Sometimes it is even possible to feel small seals in the case of oncology.

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It should be clarified that the palpation method is a safe procedure that can be mastered at home. There are a large number of demonstrative videos on the Internet where you can choose your favorite sample for teaching techniques and start learning from people who agree.

To correctly palpate the patient's spleen, he must be laid on his back or on his right side. If on the back, then the patient lies on a flat bed, he should relax and keep his arms along the body. In the second case, the patient on the right side presses his head down to himself, and the left arm is bent at an angle of about 90 degrees, the right arm is extended, and the knees of the left leg are bent. The second option is more optimal, since it is in this position that the spleen is better palpated, the stomach relaxes, and it is closer to the surface of the body, respectively, so it is easier to find and feel it.

The doctor sits opposite the patient and places his left hand on the left side of the chest between the 7th and 10th ribs and squeezes it slightly to limit the patient's inspiratory force. The right hand should be placed on the anterior surface of the abdominal cavity from the side and slightly bend the fingers where the costal arch is located. Then the doctor asks the patient to try to take a deep breath. Thanks to inspiration, the examined spleen comes closer to the doctor's fingers and slips slightly between them. A deep breath is taken several times to assess the condition of the spleen.

During probing, it is assessed: what shape the inside has, whether the consistency is normal, mobility, whether there is an increase and what density it has. If the spleen is too enlarged, then clippings are palpated. The clippings also help distinguish the spleen from other possibly diseased and enlarged abdominal organs (eg, the left kidney). Also, if the spleen is too enlarged, its anterior surface can be palpated, which extends beyond the edge of the rib arc.

If the spleen is affected by infectious diseases, then it is not too dense and soft. When affected by sepsis, the spleen resembles dough in consistency. The spleen acquires a special density in the presence of a destructive process in the liver (cirrhosis). Painful spleen occurs only in the presence of heart attacks and perisplenitis.

Percussion of the spleen is not a very important diagnostic criterion, since it is needed solely to determine its approximate size. Due to the fact that the stomach and intestines are located around the spleen, and they contain air, due to which a loud sound is created during percussion and dimensions are determined only approximately, accurate measurements are impossible. The normal length of the spleen ranges from 4-6 cm.

Percussion and palpation are not new diagnostic methods, but they are primary, and with a well-studied technique, they are quite accurate. Also, these diagnostic methods cannot harm the patient and are quite safe.

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Have you recently experienced symptoms such as nausea, heartburn, or excessive belching?

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Yes, allegory appears from time to time

Do you have pain in the right side under the ribs of a aching character after physical activity?

Yes, always

Yes, periodically

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• What is liver palpation?
• Percussion of the liver
• A small conclusion

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Superficial palpation of the liver in the epigastric region, as well as on the right side under the ribs, helps to determine the process of development of liver diseases in the human body. Also, with diseases such as cholecystitis and biliary colic, even a minimal touch in the anterior abdominal wall will cause significant pain. For chronic cholecystitis, a characteristic symptom is mild pain in the region of the gallbladder point.

What is liver palpation?

To conduct liver palpation, specialists work according to the Obraztsov-Strazhesko method. This method is based on the principle of the doctor's ability to feel the lower edge of the liver, in the process of deep inspiration, when slipping from palpating fingers. It is a well-known fact that the liver is the most mobile organ of the abdominal cavity in the process of respiratory activity, due to its proximity to the diaphragm. Therefore, when palpating the liver, unlike the intestines, the result depends on the respiratory mobility of the organ itself, and not on the palpating fingers.

Palpation of the liver due to the anatomical features of the human body is carried out in a standing position, or in a prone position. In this case, it is necessary to adhere to the general rules for palpation. In this case, the most attentive should be taken to the state of the anterior edge of the liver, to its consistency, shape, severity of contours and painful sensations. According to these indicators, it is possible to determine the physical condition of the organ, its shape and correct position. An increase in the liver or its omission can be said with certainty in the case when, during palpation, the upper anterior part of the organ is clearly palpated.

Depending on the physiological characteristics of the human body, the location of the edge of the liver is different. Therefore, to determine the location, for palpation, percussion should be performed in order to determine the location of the lower edge of the organ.

As V.P. Samples, in 88 cases out of 100 human liver is in a normal state. The physical properties of the organ are determined by palpation sensations when examining its lower edge. For a person with a liver in its normal state, when the organ has not undergone any changes, the edge is usually located at a level of 120 mm below the costal arch. The edge of the liver is sharp, soft, easily subject to minor movements that will not cause pain in a healthy person.

Often, unhindered palpation in the region of the right mid-clavicular line is an indicator of an increase or compaction of the organ. In a normal state, it will not be possible to palpate it in this place, since the abdominal muscles and the hypochondrium, respectively, will interfere. If swelling occurs, it is advisable to conduct a study on an empty stomach.

Ascites (when fluid accumulates in the abdominal cavity) can be concluded by the impossibility of palpation of the liver in the supine state. For the study in this case, the patient is asked to stand upright. The rest of the palpation process is the same. If the amount of accumulated fluid is too large, the doctor may prescribe its removal using paracentesis. Here jerky balloting palpation can be applied. With this method of research, the liver, with jerky blows, moves away into the abdominal cavity, and then returns to the fingers and can be felt without hindrance.

Pain during palpation of the liver can occur if there is an inflammatory process in the organ or if it is stretched, which can occur, for example, with congestion in the liver due to heart failure.

A normal liver is soft to the touch. A denser structure of the organ is observed in diseases such as hepatitis, hepatosis, and cardiac decompensation. The maximum density of the organ is noticeable in cirrhosis, metastases in oncological diseases, in the case of amyloidosis. Periodically, an echinococcal cyst or a tumor of small size lends itself to palpation.

The realization of the fact that thanks to the palpation of the liver using various methods, it is possible to obtain the most important information for the timely diagnosis of the disease, makes specialists constantly in search of the best method of palpation. At the moment, the search is reduced to a variety of positions of the hands of the palpating specialist or to a change in the position of the patient's body. However, the advantages of such methods are rather doubtful. The leading role in this case is played by the experience of the doctor conducting palpation of the liver and the timeliness of the studies.

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Percussion of the liver

Using this research method, the size, size and configuration of the liver is determined. Using percussion, the upper and lower boundaries of the organ are determined.

Types of the upper limit of hepatic dullness:

1. Relative: the doctor gets an idea of ​​the real upper border of the organ.
2. Absolute dullness: the area of ​​the upper border of the surface of the organ, which is not covered by the lungs, is located closely with the chest.

However, in practice, there is practically no need to determine the upper limit of hepatic dullness, since this value fluctuates and directly depends on the shape of the chest in a person and what size it is. In addition, in the exceptional majority of cases, the liver increases along the lower border, therefore, such an increase is diagnosed by the location of the lower edge of the organ.

It is often difficult to determine the lower limit of the absolute dullness of the liver due to the proximity of the hollow organs - the stomach and intestines, which during percussion give a high level of tympanitis, due to which the hepatic sound is hidden. Therefore, the most accurate study is percussion with one finger using the Obraztsov-Strazhesko method.

Depending on the structure of the human body and its anatomical features, the level of position of the anterior edge of the liver may vary relative to the position along the midline in front:

• with a hypersthenic type of chest, the lower edge of the liver is located above the considered level;
• with an asthenic type of chest, the lower edge of the liver is located much lower, exactly in the middle of the distance from the navel to the base of the xiphoid process.

It should be noted that when the position of the patient's body changes to a vertical one, a natural displacement of the organ occurs by 10-15 mm downwards.

Palpation is one of the initial research methods in order to determine the edges and density of the abdominal organs and superficial changes. Palpation determines the intensity of pain, the location of organs and possible pathological formations.

Through superficial diagnostics, the degree of density and elasticity of the liver, gallbladder, pancreas, and even the stomach is established. On palpation, the doctor determines the painful areas, determines the severity of the injury and its localization.

Palpation is of several types. Distinguish deep and superficial research. Involve fingers, palmar surface, one or two hands.

• sliding (study of the surface of the organ, boundaries, volume of formations);
• jerky (allows you to identify excess fluid in ascites);
• penetrating (due to the indentation of the fingertips, pain points and the intensity of sensations are determined).

Palpation is carried out with clean, warm hands. The first movements are used in the form of minor touches with observation of the patient's reaction. If the patient can withstand superficial pressure, a deeper palpation is performed.

The initial inspection is carried out in a certain sequence. First, the skin, fiber are felt, then pressure is applied. This will allow the patient to relax before a deeper impact.

In the process of research, the patient needs to be warned about all the sensations that appear. When palpation of the abdominal wall in children, the doctor draws attention to the change in the child's facial expressions.

Of no small importance is the turgor of the subcutaneous tissue, its density is determined by deeper finger grips. Usually, an enlarged liver is recognized by normal pressure. With various violations, the edges of the organ come out from under the costal arch, which the specialist can easily calculate with his fingers.

Methodology rules

When conducting palpation, it is important to know how it goes:

1. During the examination, the patient is placed on his back.
2. He should lower his arms along the torso. An important condition is the surface on which the patient lies. Usually a hard couch is used, and a low roller is placed at the head.
3. Before palpation, the brushes must be warmed up.
4. The patient before the study should not eat, it is advisable to empty the intestines.
5. The patient breathes through the mouth, the movements are even and deep without interruption.
6. The abdomen is completely relaxed.
7. On inspiration, the doctor's hand rushes up, and on exhalation it smoothly follows the movements of the abdominal wall.

Superficial palpation of the abdomen

Feeling begins with slight sliding movements. This allows you to determine the resistance of the muscles of the abdominal wall, the level of reaction to exposure and soreness. With the help of fingers, a specialist detects diastasis or divergence of muscle fibers. Examine the umbilical ring.

In complicated conditions, the doctor immediately determines the behavior of the abdominal muscles. The spill of pus inside or ascites is characterized by an uneven lowering and raising of the abdominal wall.

Superficial diagnosis is carried out with the right hand or both hands along symmetrical lines. The palm closes, and the specialist's fingers straighten. Movements are carried out smoothly, without visual penetration and pressure on the abdominal cavity. All actions are sliding and stroking. The brush gradually moves from one part of the abdomen to another.

During superficial palpation, the patient should not talk. Pain is briefly discussed. The doctor should pay attention to the facial expressions of the patient in order to determine the reaction to probing.

The technique of carrying out includes successive movements in paired areas of the abdomen (iliac, lateral and hypochondrium regions). Then the doctor proceeds to unpaired places (epigastrium, navel and above the pubis). Areas with increased soreness are determined at the last stage.

• not tense abdominal wall;
• muscles are supple, there is no pain;
• the abdominal press responds with fuzzy resistance to pressing;
• fingers do not fall into the umbilical ring and abdominal muscles.

With pathologies of organs, the reaction of muscle tissues is somewhat reduced or absent altogether. From resistance of a stomach there is a dull, but tolerable pain syndrome. In some cases, there is mild or increased discomfort without pain.

A sharp spasm in the abdomen, emanating from the gallbladder or intestines, is not excluded. This condition is determined by the sudden onset of colic.

Deep palpation of the abdomen

A more in-depth examination reveals irritation of the peritoneum. Thanks to finger pressure, symptoms are determined:

• appendicitis;
• pancreatitis;
• enlargement of the spleen and many other pathologies.

With a hernial protrusion involved with loops of the small intestine, a rumbling sound and fluid transfusion are detected. In the process of deep palpation, the doctor can independently correct the hernia, if there is no infringement.

Deep palpation of other organs

Each organ requires an individual approach:

• Stomach

Successive movements affect the pyloric region and the curvature of the stomach. In the normal state, other departments are not palpable. An exception is carcinomatosis, in which the abdominal wall is in a tense protruding state. You should also know:

1. The skin fold shifts in front of the fingers, when exhaling, the hand sinks deep inward to the spine.
2. Sliding movements are made. Normally, the greater curvature is limited in mobility, has no pain, and makes a rumbling sound when pressed.
3. The pyloric region is palpable when the hand is positioned on the right rectus abdominis.
4. The fingers are placed 3 cm up from the umbilical ring. They move the skin fold and feel the area in the direction from the left side to the top, then to the right side and down.

• Pancreas

The organ is located behind the stomach in the region of the posterior wall of the abdomen. The head lies on the right side of the spine, the tail is observed on the left. In the diameter of the iron, under normal conditions, it does not exceed 2 cm. The right palm is placed in a longitudinal position on the stomach, the skin fold moves, and on exhalation, the organ is felt behind the curvature. The head of the pancreas is defined as a smooth, painless roller.

In most cases, the body in the normal state is not detected by superficial palpation. The pancreas is located deep in the abdominal cavity, so it is often palpated in pathological conditions. Compaction and increase associated with the tumor process

• Liver

The organ during palpation is characterized by slight mobility, as well as:

1. Initially, movements determine the lower border of the organ, which is located in the transverse region and occupies the entire right hypochondrium.
2. After placing the fingers on the surface, the doctor performs slight tapping. This type of movement allows you to determine the boundaries of the transition.
3. When tapping the liver, a dull and deaf sound is heard.
4. The study of the liver is carried out with the palm placed on the right hypochondrium. The fingertips are located at the lower edge of the organ. The thumb is not involved in palpation. During the procedure, the specialist monitors the patient's breathing.

Normally, the liver does not appear due to the costal arch, the exception is the prolapse of the organ, if there are no other pathologies. In other cases, the detection of the edge on palpation indicates a change in the liver due to hepatitis, cirrhosis, or cancer.

• gallbladder

The organ is located in the lower part on the surface of the liver. Its consistency is soft, it is inaccessible to palpation in the normal state. A slightly enlarged gallbladder is poorly palpable, which happens with cholelithiasis. Usually, pain is not felt on palpation. In what cases is a certain disease detected by palpation:

1. With dropsy of the organ and a violation of the outflow of bile, a bulge at the bottom of the costal arch is determined with the help of palpation. The walls are tense, the organ itself is mobile during breathing.
2. A strong increase and soreness can indicate purulent-serous processes inside the organ. If the doctor suspects the risk of gallstone rupture, palpation is carried out with extreme caution.

Examination of the abdomen by percussion and auscultation

Palpation, percussion and auscultation at the initial stage of the examination can indicate to the doctor possible deviations. It is impossible to make an accurate diagnosis using these methods, but they are necessary for further tactics:

• Percussion, one of the methods of medical diagnosis, which uses tapping with hands. The doctor makes rhythmic movements and evaluates the nature of the sounds produced. The vastness of the sound, its frequency and timing of decay are directly related to the physical properties of the medium from which it comes. The organs of the abdominal cavity differ in density, therefore, when tapped, they make a different sound.
• Another method for determining the work of organs is auscultation. It helps to determine the tone, rhythm and noise coming from the organs. Auscultation can be performed directly, when the doctor applies the ear to the body. But in most cases, a stethoscope is used. Auscultation creates silence and warmth in the room. The chest of the patient is exposed so that the sound of clothing does not interfere.

You can also watch a video that clearly shows the process of palpation of the liver, kidneys, and spleen.

This organ. Palpation of the liver is performed according to all the rules of deep sliding palpation according to Obraztsov. The doctor is located on the right side of the patient lying on his back with his arms extended along the body. A necessary condition is the maximum relaxation of the muscles of the abdominal wall of the patient during his deep breathing. It is recommended for greater liver excursion to use the pressure of the palm of the doctor's left hand, located on the anterior chest wall at the bottom right. The palpating right hand lies flat on the anterior abdominal wall below the edge of the liver, which is determined by percussion, while the fingertips are located along the supposed lower edge, sink inward synchronously with the patient's breathing and, with the next deep breath, meet with the descending edge of the liver, from under which they slip.

On palpation of the liver, its lower edge is first of all assessed - shape, density, presence of irregularities, sensitivity. These properties can be extended to the entire mass of the liver. The edge of a normal liver on palpation is soft, smooth, thin, painless.

The displacement of the lower edge of the liver may be associated with the prolapse of the organ without its increase: in this case, the upper limit of hepatic dullness will also be lowered. Of greater importance, of course, is the statement of an enlarged liver (hepatomegaly), which is most often observed in congestive heart failure, in acute and chronic hepatitis, and cirrhosis of the liver. Usually the edge of the congestive liver is more rounded and painful on palpation, the edge of the cirrhotic organ is more dense, uneven. Pressure on the enlarged congestive liver causes swelling of the right jugular vein - a simple but very important sign of detecting blood stasis in a large circle (reflux symptom, or hepatojugular reflux).

It should be noted that with large ascites, ordinary percussion and palpation of the liver are difficult, therefore, the method of balloting palpation (a symptom of "floating ice") is used, with which you can get an idea of ​​​​the features of the edge of the liver and its surface.

The dynamics of changes in the size of the liver is very important. A rapid increase is usually observed in liver cancer, a rapid decrease in liver cirrhosis and acute fulminant hepatitis, as well as with successful treatment of congestive heart failure.

Hepatomegaly (enlargement of the liver) is an essential sign of liver damage (hepatitis, cirrhosis of the liver, as well as primary cancer or cirrhosis - liver cancer). Other causes of hepatomegaly are congestive heart failure, metastases of various tumors, polycystosis, lymphomas (primarily lymphogranulomatosis).

Causes of hepatomegaly

Venous congestion in the liver:

1. Congestive heart failure.
2. Constrictive pericarditis.
3. Tricuspid valve insufficiency.
4. Obstruction of the hepatic veins (Budd-Chiari syndrome).

Infection:

1. Viral hepatitis (A, B, C, D, E) and cirrhosis of the liver (B, C, D).
2. Leptospirosis.
3. Liver abscess:
   1. amebic;
   2. pyogenic.
4. Other infections (tuberculosis, brucellosis schistosomiasis, syphilis, echinococcosis, actinomycosis, etc.).

Hepatomegaly not associated with infection:

1. Hepatitis and cirrhosis of the liver of non-viral etiology:
   • alcohol;
   • medications:
   • toxins;
   • autoimmune disorders;
   • nonspecific reactive hepatitis.
2. Infiltrative processes:
   • fatty liver, lipoidosis (Gaucher disease);
   • amyloidosis;
   • hemochromatosis;
   • Wilson-Konovalov disease;
   • a1-antitrypsin deficiency;
   • glycogenosis;
   • granulomatosis (sarcoidosis).

Bile duct obstruction:

1. Stones.
2. Strictures of the common bile duct.
3. Tumors of the pancreas, ampulla of Vater's nipple, bile duct pancreatitis.
4. Compression of the ducts by enlarged lymph nodes.
5. Sclerosing cholangitis (primary, secondary).

1. Hepatocellular carcinoma, cholangiocarcinoma.
2. Metastases of tumors in the liver.
3. Leukemias, lymphomas.

Cysts (polycystic).

In addition to these reasons, an increase in the liver is observed with fatty degeneration (often of alcoholic or diabetic origin), amyloidosis (especially secondary), liver alveococcosis, with large cysts and abscesses located close to the anterior surface of the organ.

Since an enlargement of the spleen (splenomegaly) is often noted simultaneously with hepatomegaly, it is advisable to use the term "hepatolienal syndrome".

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Causes of hepatolienal syndrome

The gallbladder becomes accessible for palpation when it is significantly enlarged: with empyema (purulent inflammation), dropsy, chronic cholecystitis, cancer. In these cases, it can be palpated in the form of a sac-like body of a dense or elastic consistency in the area between the lower edge of the liver and the edge of the right rectus abdominis muscle. Courvoisier's symptom is distinguished - a bladder stretched by bile with normal elastic walls (with blockage of the common bile duct by a tumor of the pancreatic head). It is very rarely possible, with the help of palpation, to get a feeling of vibration, which is transmitted to the adjacent fingers of the left hand, which are apart, when tapping on one of them.

A free self-diagnosis checklist will help determine if your liver is damaged. The liver can be damaged by drugs, mushrooms, or alcohol. You can also have hepatitis and not know it yet. You will answer 21 intelligible simple questions, after which it will become clear whether you need to see a doctor.

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Specialist in modeling acute and chronic poisoning, author and co-author of models of the most dangerous of the most common poisonings, created over ten years on the basis of clinical data (more than 400 cases) of the toxicological department of the 1st City Clinical Hospital, the Center for Extrarenal Methods of Cleansing the Body (Kazan) and information - advisory toxicological center of the Ministry of Health of the Russian Federation (Moscow).

Also the expert of the section is a gastroenterologist Purgina Daniela Sergeevna.

Daniela Sergeevna works at the Pasteur Research Institute of Epidemiology and Microbiology Medical Center. Engaged in the diagnosis and treatment of patients with a wide range of diseases of the gastrointestinal tract.

Education: 2014-2016 - Military Medical Academy. S. M. Kirov, residency in the specialty "Gastroenterology"; 2008-2014 - Military Medical Academy. S. M. Kirov, specialty "Medicine".