Feeling of the stomach. Conducting palpation of the intestine. Sharp sharp pains in the abdomen on the right

Palpation is last step full-fledged objective examination belly. Before starting it, the patient should be asked to cough vigorously. As a rule, patients with developing peritonitis can cough only superficially, holding their hands on the stomach. It is possible, as it were, to accidentally kick (not very strongly) the bed or gurney on which the patient lies, which leads to a sharp increase in abdominal pain as a result of the transmission of a vibrational impulse. Thus, it is possible to easily diagnose peritonitis without even touching the patient's abdomen with a hand. In addition, malingerers often come across these tricks, who complain of pain in the abdomen upon direct palpation, but may cough vigorously and do not react in any way to a blow to the bed or gurney. In addition, to detect symptoms of peritoneal irritation, you can try to shake the patient by grasping the combs. ilium, or ask him (her) to jump on one leg.

Palpation of the abdomen begins with asking the patient to indicate the area where the pain first arose and where it is localized at the time of examination. It is necessary to carefully look at how the patient does this. If he accurately indicates the place of greatest pain with one or two fingers, then this testifies in favor of local irritation of the peritoneum. In the presence of diffuse pain in the abdomen, the patient usually either places the palm over the area that disturbs him, or makes circular movements with his palm around the entire abdomen. This allows the doctor to suspect irritation of the visceral peritoneum (so-called visceral pain).

Palpation of the abdomen must be performed with warm hands, with the whole palm, and not just with the fingertips. It is necessary to start palpation of the abdomen at the maximum distance from the area of ​​greatest pain, so as not to cause pain at the very beginning of the study. Many patients, especially children, are anxious and do not allow thorough palpation of the abdomen if this causes severe pain.

First of all, it is necessary to perform gentle (superficial) palpation, gradually moving the hands to the area of ​​greatest pain. The doctor's hands should move gently, consistently and methodically. Fingers should make as little movement as possible. You can not palpate the abdomen randomly, "jumping" from one area to another, because abdominal pain and tenderness may spread to more than one area of ​​the abdomen. The pressure of the hands on the patient's abdominal wall must be slowly increased until soreness appears or a protective tension of the muscles of the anterior abdominal wall occurs. With adequate examination of patients with acute abdominal pain, it is not necessary to cause severe pain on palpation. The pressure on the anterior abdominal wall should be increased only until the patient says that he is in pain, or the doctor feels an increase in the tone of the muscles of the anterior abdominal wall.

During palpation, it should be established whether there is tension in the muscles of the anterior abdominal wall, and if so, whether the entire anterior abdominal wall or some part of it is tense. In addition, the physician must determine whether this protective tension of the muscles of the anterior abdominal wall is arbitrary or involuntary. Voluntary muscle contraction decreases on inspiration, therefore, during palpation of the abdomen, the doctor should ask the patient to do deep breath and then exhale. If at the same time the tension of the muscles of the anterior abdominal wall is preserved, then it is regarded as involuntary, which is a sign of peritonitis. If the patient is ticklish or deliberately contracts the muscles of the anterior abdominal wall, then you can ask him to bend his legs at the hip and knee joints, which to some extent leads to relaxation of the rectus abdominis muscles and facilitates palpation. In case of tension of not the entire anterior abdominal wall, it is necessary to establish areas of muscle contraction. Palpation of the abdomen must be performed with both hands, which makes it possible to detect even slight differences. muscle tone in different departments abdominal wall (above, below, right and left). Patients consciously cannot contract the muscles of the anterior abdominal wall only on one side, therefore, one-sided protective tension of the abdominal wall is a sign of an inflammatory process in the abdomen.

Deeper palpation in order to detect tumor-like formations in the abdomen and to identify more deeply localized pain should be performed at the very end of the study and only in those patients who have no signs of peritonitis on superficial palpation. During deep palpation of the abdomen, hepatosplenomegaly, an aneurysm of the abdominal aorta, or tumor-like masses in the abdomen can be detected. The doctor should always be aware of the formations that exist in the norm, which, upon palpation of the abdomen, can be mistaken for pathological neoplasms (Fig. 18).

Pain that occurs during palpation of the abdomen can be of two types: direct, local pain, when the patient feels pain at the site of palpation, and indirect, or reflected, pain, when pain occurs in some other place. For example, in patients with acute appendicitis, pain may appear at McBurney's point on palpation of the abdomen in the left iliac fossa. This symptom is called Rovsing's symptom and is a characteristic sign of peritoneal irritation. Comparative palpation of the abdomen with a relaxed and tense anterior abdominal wall can be performed by asking the patient to raise his head from the pillow: while the muscles of the anterior abdominal wall are reduced. If the source of pain is located in the thickness of the anterior abdominal wall or in the parietal peritoneum, then with tension of the muscles of the anterior abdominal wall, the pain usually increases. If the source of pain is located in the retroperitoneal space or in abdominal cavity, but in pathological process Since neither the parietal peritoneum of the anterior abdominal wall nor the abdominal wall itself is involved, then with the tension of the muscles of the anterior abdominal wall, the intensity of pain usually does not change.

A classic symptom of irritation of the parietal peritoneum is a significant increase in pain with deep palpation of the abdomen at the moment when the doctor abruptly removes his hand from the patient's abdominal wall. As already noted, this classic, time-tested symptom is still gross. Some authors consider it even barbaric, often leading to overdiagnosis of peritonitis, especially in children. Currently, to detect local irritation of the peritoneum and the inflammatory process in the abdominal cavity, more cautious techniques are more often used, which are described earlier.

For some pathological conditions, most often it occurs in patients with acute appendicitis, hyperesthesia of the skin of the abdominal wall is noted. If the skin is pinched or pricked with a pin, then a pronounced painful reaction occurs. Hyperesthesia of the skin of the anterior abdominal wall is an important clinical symptom, but it alone is not enough to make a diagnosis of acute appendicitis or any other disease of the abdominal organs. Pain in this case may resemble those of skin diseases.

Part of the objective examination of the abdomen is tapping on lumbar region or sides of the abdomen to identify soreness in these areas. Often, pyelonephritis or urolithiasis is manifested by pain in the abdomen. However, in such patients, upon detailed examination, the maximum pain is detected in the region of the costovertebral angles.

In unclear clinical situations, an examination by only one doctor is sometimes not enough. However, to assess the dynamics of the disease, it is very important that the repeated palpation of the abdomen is performed by the same doctor using the same techniques.

Other symptoms of abdominal pain

Psoas symptom (symptom of the lumbar muscle). The patient lying on his back, the doctor asks to raise the straightened leg, at the same time creating resistance with his hand (Fig. 20). In this case, with an inflammatory process that captures a large psoas or developing in its immediate vicinity (for example, in patients with acute appendicitis), as well as if the pathological process primarily affects the lumbosacral spine (for example, in patients with intervertebral hernia), pain occurs.

Obturator muscle symptom. For the patient lying on his back, the leg is bent at the hip and knee joints at an angle of 90° and then rotated inwards. With an inflammatory process in the region of the internal obturator muscle (m. obturatorius interims) (in particular, with pelvic abscesses, acute appendicitis, acute salpingitis), pain appears.

SYMPTOM Murphy. In the area below the right costal corner, the doctor exerts moderate pressure on the hypochondrium with the palm of his hand. The patient is asked to take a deep breath. Murphy's symptom is positive in the case when pain occurs when the liver and gallbladder are displaced downward. In this case, the patient even holds his breath in the middle of inhalation. This symptom is considered classic in patients with acute cholecystitis, but can also occur with hepatitis, massive liver lesions, and pleurisy.

Symptom Kehr (Kehr) is the occurrence of pain in the upper parts of the shoulder on both sides with palpation of the abdomen in the upper quadrants. Classically, this symptom appears on the left side in patients with splenic injury. The pathophysiology of Kera's symptom and the characteristic reflection of pain are associated with the peculiarities of the innervation of the diaphragm, which is carried out by Civ. This symptom can also occur on the right side. The development of the Kehr symptom is caused by irritation of the diaphragm, for whatever reason it may occur. This symptom can also be seen in the Trendelenburg position.

L.Nyhus, J.Vitello, R.Conden

"Palpation of the abdomen for pain" and other articles from the section

175 918

« Acute abdomen"- a threatening condition in which significant damage to the abdominal organs occurs and requires immediate surgical care. This condition can be in many diseases, but the signs characteristic of an "acute abdomen" will be common. it the following symptoms:
Intolerable sudden onset pain in the abdomen, causing groaning
Increased pain with the slightest movement and coughing
Can't find a position to relieve suffering
Signs of intestinal obstruction: no stool, bloating
Protective tension of the abdominal muscles
heavy general state with tachycardia, cold sweat, collapsed weakness, pallor, falling blood pressure.

"Acute abdomen" may occur as a single symptom for the first time without a previous disease. This, for example, is a rupture of the spleen with an abdominal injury or acute appendicitis, which will immediately require surgical care.
But very often acute abdomen» arises as a complication already an existing disease. For example, perforation of a long-standing stomach ulcer or rupture of an ovarian cyst, renal colic with urolithiasis, which is not eliminated by taking antispasmodics.
Therefore, timely adequate treatment chronic diseases is the prevention of their exacerbation and severe consequences.

Diseases that can give a picture of "acute abdomen"
Acute intestinal obstruction
Acute appendicitis
Acute pancreatitis
Hepatic and renal colic
Perforated ulcer of the stomach or duodenum
Peritonitis
Aneurysm rupture abdominal aorta
Thrombosis, embolism and spasm of mesenteric (mesenteric) vessels
ovarian cyst torsion, ovarian rupture
Aborted ectopic pregnancy with rupture fallopian tube
Tumors
Heart attack or rupture of the spleen
Liver rupture
Strangulated hernia, etc.
In any of these conditions, you can not hesitate to call an ambulance for a minute.
We present short description the main symptoms of these diseases.

Acute intestinal obstruction
Causes leading to intestinal obstruction: intestinal spasm or paresis (disappearance of peristalsis), swelling, strangulated hernia, adhesions, fecal stones, thrombosis and embolism of the mesenteric vessels, foreign bodies, peritonitis, helminthic and hair balls, overeating after hunger. And on adhesive disease accounts for up to 70% of all cases of obstruction.
Cramping unbearable pain all over the abdomen occurs suddenly, and its intensity increases, the patient groans from pain.
It is during this first period that it is urgent to call an ambulance. Before her arrival, you can give the sick antispasmodic (no-shpu, baralgin, papaverine), laxatives are categorically contraindicated.
Then (without rendering medical care) against the background of a slight decrease in pain, repeated vomiting occurs, first with the remains of food with bile, subsequently acquires a fecal character, severe dryness in the mouth, thirsty.
There is no stool and gases do not go away, the stomach is swollen and asymmetrical, intestinal peristalsis can sometimes be seen by eye.
With some types of obstruction from the rectum, mucus with blood may be released.
The patient is very restless, tossing about in bed.
Pallor of the skin, tachycardia, decreased pressure, shock are characteristic.
Before the development of peritonitis, the abdomen is soft, painful in the area where the obstruction to feces is located.

Acute appendicitis
This disease is more common than all other acute conditions of the abdomen, but its danger cannot be underestimated.
Characterized by a sudden onset with pain in the epigastric or umbilical region. Gradually, the pain intensifies and passes to the right lower part belly. Often gives to the rectum, lying on the left side and increases during walking (especially when right leg appears at the back).
There is an increase in temperature up to 37.2-38 ° C, nausea or vomiting, tachycardia, dry mouth.
When probing the right lower abdomen, the pain intensifies, especially during the removal of hands ( positive symptom Shchetkin-Blumberg), the muscles in this area are tense.
In old age, signs of appendicitis can be smoothed out, because. sensitivity decreases with age nerve endings, and the process is slow.

Acute pancreatitis
In acute pancreatitis, massive destruction of pancreatic tissue occurs. This is extremely dangerous disease which requires immediate medical attention. If this help is not provided to the sick person, he may die after a few hours or days from the onset of the disease.
The pain first occurs in the right or left upper abdomen or under the "spoon", then becomes girdle. May spread throughout the abdomen.
The pain is severe, unbearable, as in myocardial infarction or perforated ulcer.
Often the onset of pain is preceded by the use of a large amount of strong alcoholic beverages or fatty foods.
Repeated vomiting is typical, which does not bring relief and bloating.
The general condition is severe, inhibited, the skin is cold and wet, the pressure is reduced, tachycardia, shock is possible in severe pancreatitis.
The stool becomes light or gray, its amount increases significantly.
The tongue is dry and inflamed, the inflammation may cover the whole mouth.
The skin is pale, icteric or cyanotic. May appear small hemorrhages around the navel and on the buttocks.

biliary or hepatic colic (Acute cholecystitis)
Occurs usually in the evening or at night in patients with cholelithiasis or a tumor, when a stone or tumor blocks the outflow of bile from the gallbladder, i.e. there is an infringement of the stone in the bile ducts.
Characterized by sharp, sharp, cramping pain in the right hypochondrium or right side, gives to the back, under right shoulder blade, in the shoulder or neck.
The temperature can rise to 37.5-38.5 ° C and be accompanied by chills, nausea, vomiting, a feeling of bitterness in the mouth, tachycardia. Occasionally - jaundice and itching of the skin.
Patients often groan and rush about to find a position in which the pain would decrease, but they cannot find it.
The occurrence of an attack is preceded by the use of fatty or fried foods, alcohol, cold drinks, as well as overeating, physical activity, shaking driving, stress.
When probing, there is tension in the muscles of that part of the abdominal wall where the projection of the gallbladder is located. Shchetkin-Blumberg's symptom is positive (maximum pain during taking hands off the stomach).
An attack of biliary colic can be a single one, when the removal of the gallbladder is immediately required, or it can last up to 5-6 hours and pass after the use of antispasmodics.

nephrolithiasis (renal colic)
This condition develops when stones (and sometimes a tumor) block the outflow of urine from the kidneys.
The pain is unilateral in the side or lower back, unbearable, cutting, cramping with irradiation to the lower abdomen, thigh and inguinal region.
Often joins bloating, nausea and vomiting, constipation, urination becomes more frequent. There may be an increase in temperature.
The skin is pale, cold, moist.
Behavior during such an attack of colic is restless, impossible to find comfortable position, so the patient rushes about in bed.

Perforation of a stomach or duodenal ulcer
Occurs against the background of an existing peptic ulcer or may be its first sign. The duodenum is more often affected (85%).
The maximum perforation occurs in autumn or spring.
Before the perforation of the ulcer, there are often precursors - increased pain, chills, subfebrile temperature, nausea.
sudden strongest dagger pain in the region of the stomach or in the right hypochondrium, which then spreads to the right lower abdomen, and later throughout the abdomen.
Pain radiates to right shoulder, collarbone or right shoulder blade.
There may be vomiting with an admixture of blood.
Skin pale or ash gray, moist, cold sweat.
The abdomen does not participate in breathing, it is very tense.
The patient occupies a forced immobile position lying on the right side with legs bent and brought to the stomach.
After the first attack, the dagger pain may subside for 3-6 hours, the condition improves, but then everything returns again, because. peritonitis occurs; vomiting appears, sometimes with blood, the temperature rises, the pulse quickens, the pressure drops. Waiting for a period of improvement after the first symptoms of perforation is a direct threat to life.

Peritonitis (inflammation of the peritoneum)
Peritonitis, as a rule, is the result of a complication of other diseases of the abdominal organs (appendicitis, acute cholecystitis, ruptured abdominal aortic aneurysm, perforated ulcer stomach, acute pancreatitis). The main signs of peritonitis underlie the concept of "acute abdomen".
The strongest unbearable pain in the abdomen, which increases with movement, coughing and even breathing with tension in the muscles of the anterior abdominal wall.
The pain first occurs at the location of the organ where the disaster occurred, and then spreads to the entire abdomen.
At various diseases pain can radiate to different places:
- In diseases of the liver and gallbladder - in the right shoulder.
- In case of damage to the spleen - in left shoulder.
- In diseases of the pancreas - in the back.
- In diseases of the kidneys and urinary tract- in the lower abdomen.
Heat.
Severe bloating, signs of intestinal obstruction.
Vomiting, blood in stool,
Severe general condition: pallor, cold sweat, tachycardia, there may be shock.

Dissecting aneurysm of the abdominal aorta with its rupture
tear of the inner layer of the aorta with blood flowing between the layers of the walls of the aorta and subsequent dissection.
Sudden tearing, stretching or burning pain in the umbilical region.
The pain is very intense from the very beginning and continues continuously, spreading along the course of the dissection, often radiating to the lower back.
Slight tension in the muscles of the anterior abdominal wall, but there are no symptoms of peritoneal irritation.
More often develops in the morning.
Mostly men after 55 years of age with a hereditary predisposition are ill.
Develops against the background of severe atherosclerosis, hypertension, rheumatism or syphilis. The risk also increases during pregnancy.
If during dissection all 3 layers of the aortic wall break through, then internal bleeding occurs with rapid blood loss, which is later joined by symptoms of peritoneal irritation, i.e. "acute abdomen"
Great tension in the muscles of the abdominal wall, with inability to move or touch the abdomen.
Dizziness, pallor, cold sweat, pressure drop with collapse, tachycardia, loss of consciousness.
There may be vomiting.

Thrombosis, embolism, spasm of mesenteric (mesenteric) vessels
The mesenteric vessels supply the intestines with blood.
These three states have similar clinical picture, because and spasm, and thrombosis, and embolism of the mesenteric vessels lead to circulatory disorders in the intestinal wall, oxygen starvation and development of gastrointestinal infarction.
With spasm of the mesenteric vessels, the pain is periodic, acute, intermittent, spreads throughout the abdomen and lasts about 3-4 minutes.
Taking antispasmodics (papaverine, no-shpa, nitroglycerin) with spasm of the mesenteric vessels eliminates pain.
Blockage (thrombosis) blood clot mesenteric vessels or their embolism, there are signs of peritonitis and intestinal obstruction:
Pain with thrombosis of the mesenteric vessels is constant, strong, cutting, begins suddenly and is accompanied by severe swelling belly.
The localization of pain depends on the location of the vascular lesion: in the navel, in the right or left iliac region or spread throughout the abdomen.
The pain is aggravated by the slightest movement, so the patients lie motionless on their backs, bending their knees.
Nausea and indomitable vomiting are observed from the very beginning of the disease.
Retention of stool and bloating.
Sometimes it can be frequent at the beginning liquid stool mixed with blood.
The condition is severe, characterized by pallor, cold sweat, dry tongue, tachycardia, sometimes shock.
There is tension in the muscles of the abdominal wall.
Thrombosis of the mesenteric vessels is most common in patients with atrial fibrillation, atherosclerosis and suffered a heart attack myocardium.

Rupture of an ovarian cyst
The provoking factor is physical activity, trauma, sexual intercourse.
It manifests itself as a sudden pain in the lower abdomen, first the pain is local on the right or left, then it becomes diffuse.

Torsion of an ovarian cyst
The pain is associated with ovarian ischemia and is manifested suddenly by acute pain in the lower abdomen on the right or left. There is an increase in pain during probing and there are symptoms of irritation of the peritoneum.
Often a woman knows that she has a cyst.

Spontaneous (spontaneous) abortion
Pain in the abdomen is acute, severe, cramping, sudden. Occurs in the suprapubic region.
Accompanied by uterine bleeding.
It often occurs after physical effort, heavy lifting, trauma, sexual intercourse.

Rupture of the fallopian (uterine) tubes in ectopic pregnancy
Ectopic pregnancy accompanied by moderate pain and delayed menstruation, there may be minor bloody issues from the vagina. If a complication occurs in the form of a rupture of the tube, the pain suddenly intensifies, becomes diffuse, the bleeding becomes severe, leading to fainting. The lower abdomen is very painful when palpated, symptoms of peritoneal irritation appear.
This condition is often associated with physical activity, heavy lifting, sexual intercourse.

Tumor diseases of the abdominal organs
Pain malignant tumors very rarely is the first sign of the disease, and its appearance speaks of a far-reaching process.
Almost always pain is preceded by " precancerous disease”, for example, long-term and improperly treated chronic atrophic gastritis or peptic ulcer, intestinal polyps. Therefore, the pain in tumors at first has the character of the disease against which they develop, but later the nature of the pain, its dependence on food and other symptoms familiar to the patient change.
It is necessary to be attentive to the appearance of new symptoms or the change in the nature of old and familiar signs. It is at this stage that the treatment nice results. But "acute abdomen" with tumors is a sign that speaks of a far-reaching process. Don't wait for threatening symptoms.
Always to be considered heredity through parents, brothers and sisters.
Signs of neoplasms at the onset of the disease are nonspecific and may resemble other diseases. This is bloating, nausea, heartburn, discomfort in the stomach, loss of appetite, constipation, diarrhea, etc.
However, regardless of which organ is affected, there are a number of signs that
allow to suspect the presence of a tumor in the abdominal cavity:
Anemia of unknown nature
Unexplained weight loss and loss of appetite,
Abdominal pain that occurs at night
If the disease began after 50 years;
Fever of unknown origin
Causeless general failure weakness, depression, apathy
Persistent constipation that does not apply drug treatment,
The appearance of blood and mucus in the stool,
Pale earthy skin tone
Sudden onset of jaundice
The tumor may be palpable.

Spleen infarction
The reason for the development of this pathology is thrombosis or embolism of the spleen vessels, which occur with certain heart defects, increased pressure in the vena cava, bacterial endocarditis, rheumatism, coronary artery disease, leukemia.
If the infarction is small-focal, it may be asymptomatic or with minor pain in the left hypochondrium.
If the infarction affects a large area, there is a strong, sudden pain in the left hypochondrium (sometimes extending to the entire abdomen), which is aggravated by breathing, movement and coughing. The pain radiates under the left shoulder blade and in the lower back.
At extensive heart attack collapse may develop.
There is an increase in temperature, tachycardia, a drop in pressure, vomiting, and intestinal paresis are possible.
Muscle tension in the left hypochondrium is insignificant, palpation of the abdomen is painful.
More often, self-healing occurs.

Spleen rupture
Spleen rupture can occur in two situations: 1. Spontaneously, if the spleen is pathologically changed as a result of leukemia, mononucleosis, liver cirrhosis, etc., it is enlarged and its capsule is thinned. In this case, a break can occur even without apparent reason or with the slightest injury to the abdomen. Therefore, with an enlarged spleen, great physical exertion is contraindicated and contact types sports. 2. Rupture of a healthy spleen occurs during strong blows or injuries. The presence of an injury to the trunk or a blow to the left side immediately before the disease is very important in the diagnosis.
The moment of rupture is most often manifested by fainting, and lasts several hours. Later, pain appears in the left hypochondrium, sometimes it covers the entire abdomen, sometimes it radiates to the left shoulder. The pain is sharp, but not as severe as with peritonitis.
Then there may be signs of irritation of the peritoneum with slight tension in the abdominal muscles. Shchetkin-Blumberg's symptom is not always positive.
During rupture of the spleen, blood in in large numbers enters the abdominal cavity, causing all the signs of internal bleeding: a sensation of flashes of light before the eyes, cold, moist and pale skin, dizziness, cold sweat, weakness, rapid thready pulse, decreased pressure, lethargy, confusion. Shock does not always develop.
Patients take a position on the left side with legs bent to the stomach.
On palpation, pain is present, but muscle tension is weak.
A ruptured spleen always requires surgery.

Liver rupture
The reason is abdominal trauma.
Often occurs simultaneously with rupture of the spleen.
Signs of internal bleeding are mild, because. the liver does not bleed as much as the spleen, but the general condition is always worse when the liver ruptures, because. almost always accompanied by shock.
The pain is expressed more in the right hypochondrium.
When the liver ruptures, jaundice sometimes develops, because blood clots can clog the bile duct.
The prognosis for a ruptured liver is always worse than for a ruptured spleen.

Strangulated hernia
A hernia is a protrusion of organs located in the abdominal cavity with a parietal sheet of the peritoneum into the spaces between the muscles or under the skin through natural anatomical openings or acquired after trauma and surgery.
Most often there are inguinal, umbilical, postoperative hernias.
The cause of hernia is an increase intra-abdominal pressure, which increases during severe physical activity, with constipation, difficult childbirth, prolonged strong cough.
A hernia can develop even after a single increase in intra-abdominal pressure, for example, when lifting heavy objects.
A hernia can be in a person for a long time and not disturb. But sometimes the hernial contents come out through the hernial opening and are not reduced. The result is abuse.
Infringement of the intestine is especially dangerous, because. plus, to the violation of blood circulation in it, intestinal obstruction with severe intoxication is added.
When a hernia is infringed, regardless of its location, the symptoms will be the same:
Acute onset pain physical stress and does not decrease after its termination.
Severe pallor of the skin, tachycardia, drop in blood pressure, anxiety.
If you cough with your hand on the hernia, you can feel that the cough impulse is not transmitted to it.
There may be vomiting, sometimes with a fecal odor, bloating.
With infringement of the intestine, signs of intestinal obstruction develop.
In case of prolonged infringement, suppuration of the hernia occurs with high temperature, intoxication, severe swelling and redness in the area of ​​the hernial protrusion.
Subsequently, peritonitis may develop.
At the location of the hernia, a dense rounded formation is determined.
Don't try to fix the hernia yourself! You can do it wrong and cause further complications. Urgent call ambulance, and before her arrival, you need to lie on your back, put a container of ice on the area of ​​\u200b\u200bthe hernial protrusion and drink an antispasmodic (baralgin or no-shpu).

The general condition of patients with irritable bowel syndrome is usually good and does not correspond to numerous complaints. The nature of complaints is changeable, there is a connection between the deterioration of well-being and psycho-emotional factors.

The main complaints are abdominal pain, stool disorders and flatulence. Irritable bowel syndrome typically has no symptoms at night.

The symptoms of irritable bowel syndrome are extremely varied. The most characteristic symptoms are the following:

Abdominal pain - observed in 50-96% of patients, they are localized around the navel or in the lower abdomen, have different intensity(from slight aching to very pronounced intestinal colic). As a rule, pain decreases or disappears after defecation or gas discharge. Pain in irritable bowel syndrome is caused by nervous regulation motor function colon and hypersensitivity stretch receptors in the intestinal wall.

A characteristic feature is the occurrence of pain in the morning or daytime hours(when the patient is active) and subsides during sleep, rest.

Violation of the stool - observed in 55% of patients and is expressed in the appearance of diarrhea or constipation. Diarrhea often comes on suddenly after eating, sometimes in the morning. The absence of polyfecal matter is characteristic (the amount of feces is less than 200 g per day, often it resembles “sheep”). The stool often contains mucus. Intestinal mucus is composed of glycoproteins, potassium and bicarbonates and is produced by goblet cells. Increased mucus secretion in irritable bowel syndrome is due to mechanical irritation of the large intestine due to a slowdown in the transit of intestinal contents. Many patients feel incomplete emptying intestines after defecation. Often the urge to defecate occurs immediately after eating, which is associated with the stimulating effect of gastrin and cholecystokinin on the motor-evacuation function of the intestine. This is especially pronounced after eating fatty and high-calorie foods. It is possible to alternate diarrhea and constipation: in the morning the feces are dense or in the form of lumps with mucus, several times a half-formed stool during the day.

Flatulence is one of characteristic features irritable bowel syndrome, usually worse in the evening. As a rule, bloating increases before a bowel movement and decreases after it. Quite often, flatulence has a local character. The combination of local flatulence with pain leads to the development characteristic syndromes. BUT. V. Frolkis (1991) identifies three main syndromes.

The splenic flexure syndrome is the most common. Due to anatomical features(high location under the diaphragm, sharp corner) in the splenic flexure in patients with irritable bowel syndrome and motor dysfunction are created favorable conditions for congestion stool and gas and development of a syndrome of a splenic bend. Its main manifestations are as follows:

• feeling of fullness, pressure, fullness in the left upper section abdomen
• pain in the left side chest, often in the region of the heart, less often in the region of the left shoulder;
• palpitations, a feeling of lack of air, sometimes these phenomena are accompanied by a feeling of fear;
• the appearance or intensification of these manifestations after eating, especially plentiful, stool retention, exciting situations and a decrease after passing gases and defecation;
• bloating and severe tympanitis in the region of the left hypochondrium;
• accumulation of gas in the area of ​​​​the splenic flexure of the colon (detected by x-ray examination).

Hepatic bend syndrome - manifested by a feeling of fullness, pressure, pain in the left hypochondrium, radiating to the epigastrium, to the right shoulder, the right half of the chest. These symptoms mimic the pathology of the biliary tract.

Cecum syndrome - occurs frequently and simulates the clinic of appendicitis. Patients complain of pain in the right iliac region, radiating to the region of the right abdomen; the intensity of pain may gradually increase, however, as a rule, it does not reach such severity as in acute appendicitis. Patients are also concerned about the feeling of fullness, heaviness in the right iliac region. On palpation of the abdomen, pain in the region of the caecum is determined. A. V. Frolkis (1991) indicates that abdominal massage in the region of the caecum and palpation towards the colon ascendens contribute to the movement of chyme and gas from the caecum to ascending division large intestine and bring significant relief to patients. Palpation of the area of ​​the ascending colon towards the caecum can cause a significant increase in pain (usually with insufficiency of the ileocecal sphincter).

Non-ulcer dyspepsia syndrome - observed in 30-40% of patients with irritable bowel syndrome. Patients complain of a feeling of heaviness and overflow in the epigastrium, nausea, belching with air. These symptoms are due to impaired motor function. gastrointestinal tract.

Severe neurotic manifestations are quite common in patients with irritable bowel syndrome. Patients complain of headaches (reminiscent of a migraine), a feeling of a lump when swallowing, dissatisfaction with inhalation (a feeling of lack of air), and sometimes they are worried about frequent painful urination.

Spastically reduced areas of the large intestine (usually the sigmoid colon) - are detected by palpation in many patients (the term "spastic colitis" was often used to refer to this condition).

Abdominal pain on palpation. AV Frolkis (1991) describes three situations that may occur during palpation of the abdomen in patients with irritable bowel syndrome.

1. the situation is palpatory soreness of the abdomen of a neurotic type. It is characterized by diffuse palpation sensitivity of the entire abdomen, both during palpation along the intestine and outside it. During palpation, inappropriate behavior of the patient is possible, even slight palpation of the abdomen causes pain, sometimes patients scream, they have tears in their eyes (especially in women). In some patients, there is marked sensitivity to palpation of the abdominal aorta.
2. situation - pain on palpation of the entire colon.
3. situation - palpation determines the sensitivity of individual segments of the intestine, mainly descending sections.

When diagnosing diseases of the gastrointestinal tract, palpation of the intestine is performed. This method allows you to put provisional diagnosis and determine the presence of pathology. When palpating, the localization of symptoms and the degree of pain are detected, the doctor determines the temperature and the presence or absence of seals, checks the general condition of the internal organs, appearance belly.

When are they assigned?

It is prescribed in the presence of complaints in the patient in the abdomen. Acute or persistent attacks of pain, delayed or upset stool, gas formation, suspicion of a cyst or tumor, and other pathologies are indications for a primary external examination of the peritoneum. Palpation - main method in the detection of pathological changes in the abdominal cavity and abdominal organs. After an external examination, the doctor prescribes additional tests based on preliminary findings.

Types of palpation

It is divided into 2 types: approximate and deep. First, the doctor conducts an approximate examination, and then proceeds to deep palpation. This pattern of inspection is concretely defined and unchangeable. The doctor moves from one examined organ to another in the required sequence. If the patient has severe abdominal pain, the doctor is very careful when applying pressure. It is carried out on an empty stomach, after emptying the intestines.

Approximate palpation

With its help, the doctor determines the body temperature, the state of the peritoneum - asleep or inflated. Soreness and the location of tense organs, muscle tone, and the level of sensitivity are felt. The procedure is performed with the patient lying down, limbs extended along the body. The patient's breathing is deep and even. The doctor on the right puts his hands on the patient's abdomen and lets him get used to his hand. Superficial palpation is performed with both hands.

AT normal condition the surface of the abdominal cavity does not hurt, soft, healthy mobility of organs is felt. With pathologies in the place where the disease is localized, the muscles are tense, involuntary resistance to pressure is felt. With a bulging or protruding anterior wall of the abdomen, the doctor determines the cause of this condition using approximate palpation.

Upon completion of the initial palpation, the doctor proceeds to a deep examination. Using this method, pathologies of internal organs, muscle tissues and anterior inner wall belly. In the presence of pathologies, neoplasms, tumors, hematomas and swellings are probed. Such a detailed examination allows you to assess the state of the location of the organs, their displacement. Feeling the hollow organs, the doctor pays special attention to the nature of the sounds - their absence means that the organ is healthy.

When discovered painful swelling or a cyst, its size, location, shape, density, level of pain and other characteristics are determined by palpation. Particular attention is paid to sounds - rumbling, noise, splashing. The technique of the method is complex, probing is carried out, starting from left to right, from bottom to top. The wall of the abdominal cavity with a thick fat layer, swelling or with developed muscle tissue represents an obstacle to a full inspection.

Technique

Palpation is carried out when the patient lies on his back, arms and legs are extended along the body, breathing is deep and even. The doctor sits to the right of the patient, his hands are dry and warm, the room is warm and quiet. Right wrist puts on left side iliac abdominal region of the patient, making light pressure with straight 4 fingers. This method assesses the tone and degree of muscle tension. The brush moves to the right, and then up to the epistragia, also first to the left, and then to right side abdomen through the intestines.

The technique of deep palpation is carried out according to the Strazhesko-Obraztsov method. With its help, the condition of the internal organs and the peritoneum is examined. This palpation is also called sliding and methodical, because the state of the organ is felt at the moment when the researcher's hand slips off it. There are strictly prescribed rules in which order the abdominal organs are examined.

Sigmoid colon

During probing, the surface condition, mobility, intestinal diameter and other characteristics are determined. If the organ is healthy, the intestine feels like a dense smooth cylinder, there are no pain symptoms when pressed, it easily slips under the fingers. If rumbling is heard, this is a sign of gas formation and fluid accumulation, which usually happens with inflammatory processes. Probing causes pain. At malignant formations or constipation, the bowel feels hard, immobile, and enlarged.

Examination of the caecum

In the groin area, where the navel and ilium connect, the hands form skin fold and with a sliding movement from the navel to the upper part of the ilium, the caecum is felt. In 80% of cases, the procedure is successful. A healthy gut feels like a smooth, pear-shaped cylinder. Pain and a strong rumbling when pressed indicate inflammation. The mobility of this intestine should normally not exceed 3 cm. If the range is greater, there is a risk of volvulus and obstruction.

Quite often, before referring the patient to a hardware examination, the doctor performs palpation - a diagnostic method, if performed correctly, it is possible to accurately determine the state of the peritoneal organs.

This is not just a responsible method of studying the patient's condition, but also establishing a trusting contact with him, as this is a joint work. The doctor will not be able to obtain reliable data until the patient relaxes the abdominal cavity and allows himself to be examined. Since palpation of the abdomen allows you to put with great accuracy correct diagnosis, which is especially important if the examination is carried out outside the walls of the hospital, and for example, in an ambulance, then such a diagnosis often saves a person's life.

Palpation as a research method

Usually, physical method examinations are carried out simultaneously with the collection of anamnesis. This allows the doctor to identify more complete picture diseases of the gastrointestinal tract. In order for the process to go according to the rules, some factors that preceded it must be observed:

• The surface of the table or couch should be flat, and the head should be slightly raised.
• The light source should be opposite the place where the inspection will be carried out.
• The doctor's hands should be warm, because otherwise, the patient's abdominal muscles will involuntarily contract, which will prevent a full examination.

Fulfilling the main rule of palpation, which is to examine the painful area last, the doctor, by the nature of the patient's reaction, can draw preliminary conclusions and only then proceed to feeling the diseased organ.

If the patient has painful stomach, then the examination is carried out from all sides, which will allow not only to correctly assess the patient's condition, but also to determine the points where the concentration of pain is the strongest. Often the doctor has to use distraction tactics by asking the person questions, sometimes even unrelated to his state of health. In this way, the doctor breaks the mindset that touching the stomach = pain.

Palpation as a research method:

In addition to examining the abdominal cavity itself, the doctor simultaneously examines the condition of the patient's skin, its appearance, for example, excessive thinness and other signs often indicate pathologies in the digestive tract.

There are several methods of physical examination of the human peritoneum, each of which is used in accordance with the tasks that must be identified.

In the human peritoneum are its main organs, such as the stomach, intestines, liver, spleen, gallbladder and pancreas. Superficial palpation, also called indicative, allows you to determine where the pain is localized, how tight the muscles of the abdominal cavity are and whether there is an increase in organs.

Such an examination is carried out by the doctor by lightly pressing the fingers of the hand lying on the patient's stomach. It starts on the left inguinal region the patient, who must report any pain at the site of the study.

The next area to study is located 4-5 cm higher, and then the palpating hand passes into epigastric region and in the region of the ilium on the right side.

When comparative palpation is performed, the doctor sequentially moves from the left side of the peritoneum to its right side:

• in the beginning, the iliac region;
• navel area;
• lateral areas of the abdomen (left and right);
• the hypochondrium is examined next;
• epigastric (left) part and to the right of the so-called "white line".

If the patient is healthy, then superficial palpation will not cause him pain. In the event that they are, then by their nature the doctor can identify the disease. For example, soreness over the entire surface of the abdomen, accompanied by muscle tension speaks of acute peritonitis. With cholecystitis, the body will respond with pain when lightly pressed in the right hypochondrium, and with appendicitis - on the right side of the iliac region. Often the doctor determines the disease by the level of tension in the abdominal wall.

Thus, superficial palpation allows you to determine:

• where exactly the muscles are tense;
• places where the muscles diverge, and a hernia appears;
• localization of pain;
• the presence or vice versa the absence of tumors or seals;
• determine whether the internal organs are enlarged and, if so, how much.

After analyzing the data obtained, and correlating them with the anamnesis, the doctor will be able to make a preliminary diagnosis, which will subsequently be rechecked using a hardware examination.

This type of physical examination of the patient is performed only after a superficial examination. It is carried out in a slightly different way. The doctor bends the fingers of the palpating hand and presses on the stomach with its second phalanges. The examination is carried out parallel to the diseased organ with a preliminary grip of the skin, which will allow the hand to slide over the abdomen without causing its tension.

The fingers plunge deep into the peritoneum, but only when the patient exhales. All movements should be soft and unhurried. As a rule, 3-4 breaths and exhalations are enough to study the organ, while the doctor dips his fingers to rear wall, but so that they are located a little away from the diseased organ, gradually approaching it.

During the examination, the doctor tries to perform the following tasks:

• identify the location of internal organs;
• determine their size and possible displacement;
• condition assessment hollow organs for the presence of sounds, for example, rumbling;
• determining whether there are seals, tumors or any other neoplasms, their size and location.

This is a rather complicated examination technique, since factors such as body fat or strongly developed abdominal muscles can affect its results. If during the procedure the patient experiences pain of any nature, he must report it to the doctor.

Palpation of the child's tummy is carried out in the same way and in the same sequence as in adults.

Palpation of the stomach

Before proceeding directly to the physical examination of the digestive organ, the doctor conducts ausculto-percussion and ausculto-affrication.

In the first case, he installs a phonendoscope between the sternum and navel of the patient lying on the couch. At the same time, he easily taps the area around the device with one finger. The purpose of the method is to establish exact dimensions stomach.

In the second method, the doctor does not hit, but gently runs his finger along the abdominal wall around the phonendoscope. At the same time, rustling is heard in the apparatus at the border of the digestive organ, which stops as soon as the doctor's finger goes beyond the organ.

Having determined where it is located, the doctor can proceed directly to deep palpation. In this way, it is possible to detect the curvature of the digestive organ and the presence of tumors or seals in it.

What does pain on palpation mean?

As a rule, exactly pain or their absence, the doctor is able to detect the presence of pathologies in internal organs. Pain on palpation means:

• When they appear in the lower abdomen in women, it can be:
• organ diseases genitourinary system, for example, fibroids or cysts;
• neoplasms;
• inflammation in the gallbladder or appendicitis;
• if the pain manifested itself in a pregnant patient, then possible cause there may be placental abruption or the threat of miscarriage;
• bending of the uterus or bleeding in it.

Most often, pain in the lower abdomen in women is associated with inflammatory processes e.g. endometritis, uterine fibroids, cystitis or cholecystitis.

• When the lower abdomen hurts in men, then this is a sign:
• prostatitis;
• inflammation of the appendages;
• appearance of neoplasms.

Pain in other areas signal problems in the liver, pancreas, spleen, or stomach. By their localization, the doctor can quite accurately determine in which particular organ the problem is located and what it is. Although palpation is only initial examination, often it allows you to identify the disease and during further checks to pay maximum attention to it.

First time moving deep palpation was applied by V.P. Obraztsov, who proved that such a study can be carried out not only in patients with pronounced pathologies, but also healthy people. In this way, you can examine any area of ​​​​the abdominal cavity. Today this method is called sliding palpation according to Obraztsov-Strazhesko.

Video example of deep palpation:

Primary diagnosis and history taking should be carried out for each patient in order to identify the condition of the organs, their location, size and possible deviations from the norm. After that, you can assign the patient a further examination, paying maximum attention to the areas of localization of the disease.