uterus causes protrusion of the lower abdomen. Inspection of the abdomen may give information about the contours and peristalsis of the stomach if the patient is cachectic. In pathological cases (pyloric stenosis) peristalsis can be easily seen (ridges raising the abdominal wall). If a physician rubs or taps on the epigastric region peristalsis becomes more distinct. Sometimes, in neglected cases, the abdominal wall can be protruded by tumour.
The patient is asked to breathe "with his abdomen" to assess the mobility of the abdominal wall. The patient is unable to take a deep breath in the presence of pain, e.g. in an attack of acute appendicitis or cholecystitis. Divarication of the rectus abdominis muscles can be revealed if the patient raises his head. Regular application of hot-water bottle leaves its traces on the abdomen; these, together with postoperative scars, often help the physician to interpret correctly the present patient's complaints. Antiperistaltic movements in the epigastrium or by the course of the intestine can give a hint on the presence of an obstacle to propulsion of food masses in the intestine.
If an abdomen is inflated, the causes should be established. These may be obesity, accumulation of liquid, or meteorism. Slight distension of the abdomen may be due to a tumour, encapsulated fluid, or meteorism associated with intestinal stenosis. The latter suggestion is confirmed by visible peristalsis over the constricted portion of the intestine where the flatulence is observed.
Character and localization of postoperative scars enable rather precisely to establish the organ on which operation has been made. Survey of an abdomen in a vertical position comes to an end with survey of a white line, inguinal and femoral canals where find out the hernias producing strong pains in an abdomen. For detection of hernias it is necessary palpate hernial rings by the index finger which dilating promotes formation of hernias. The outside inguinal ring routinely loosely passes the index finger, intrinsic inguinal ring - only its tip. In a vertical position of the patient it is possible to distinguish a separation of recti abdominis muscles by a palpation of a white line of an abdomen.
During research the patient should lay on the back with completely naked abdomen on a bad with a low pillow, the extended legs and hand are posed along the trunk. The doctor should sit by the right side from a patient on a chair which level is close to the level of bed, having face-to-face contact with a patient.
At the time of survey in horizontal position it is paid attention first of all to those changes which have taken place at the moment of a postural change of a body of the patient. In a horizontal position hernias are seen approximately routinely absent.
The abdomen can be enlarged significantly due to accumulation of free fluid (ascites). This occurs in liver cirrhosis concurrent with portal hypertension. The abdomen may be enlarged due to pronounced hepatoor
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splenomegaly. When the patient with ascites stands erect, his abdomen becomes pendulous due to the downward flow of fluid; in the lying position the abdomen is flattened (“frog belly”). The navel often becomes protruded in ascites when the patient stands erect. It is due to increased infra-abdominal pressure. This sign can be used to differentiate between enlargement of the abdomen in ascites (also large intraabdominal tumours) and pronounced obesity (the navel is retracted).
Percussion of abdomen
Percussion of the abdomen is only relatively informative. Percussion of the anterior abdominal wall at points of projection of the intestine gives tympany of various characters which depends on the uneven distribution of gaseous, liquid or solid intestinal contents.
Percussion of abdomen in vertical position of the patient is used for revealing free fluid in an abdominal cavity and definitions of its level. By percussion on midline and lateral flanks from top to down, it is possible to differentiate the tympanic sound above intestines and the dull sound lower than fluid level.
In horizontal position of the patient percussion of the abdomen is performed from umbilicus on midline to epigastrium and hypogastrium, and from umbilicus - to flanks in lateral directions. With the purpose of differentiation dull sounds originated from free fluid and contents of intestines the physician can repeat percussion from the umbilicus to flanks in lateral directions in position of the patient on the side of body. At presence of ascites the level of dull sound is changed in this position of patient.
By means of percussionary palpation method the symptom of fluctuation of fluid also is defined a presence of an ascites. For this purpose the palmar surface of the left arm is put on a right half of abdomen in region with detection of dullness. The right arm impacts one-digital percussion mild strikes on the left half of the abdomen according to V.P. Obraztcov. At presence of loose fluid in the abdominal cavity in a significant amount the palm of the left arm clearly accepts fluctuation - jerky fluctuations of fluid. For the prevention of transfer of oscillating motions on the anterior abdominal wall it is possible to put the edge of the arm or the book along the white line of the abdomen. If the patient cannot eat the full meal (the capacity of the stomach gradually decreases), it is necessary to determine the Traube's space, which can be markedly decreased. The presence of these two symptoms requires an X-ray examination to exclude cancer of the stomach. Short strokes of the hammer or the flexed fingers on the epigastrium (Mendel sign) are used to determine involvement of the parietal peritoneum: pain indicates affection of the peritoneum.
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Auscultation of abdomen
Auscultation of abdomen in vertical position of the patient it is performed for definition of a friction murmur of a peritoneum in the right and left hypogastrium in perihepatitis and episplenitis. The importance of auscultation for diagnosis of diseases of the liver and gall bladder is only relative. In only rare cases peritoneal friction can be heard over the liver and the gall bladder (in perihepatitis or pericholecystitis). This sound resembles pleural friction, and is a dangerous sign. It indicates deep extension of inflammation onto all walls of the gall bladder and possible perforation.
Auscultation of esophagus. Listening to epigastric range below xiphoid process or above it, at swallowing fluids by the healthy person it is possible to hear two murmurs: the first - at once after swallowing, and 6-9 seconds later the second - connected to transit of fluid through cardia. Delay or absence of the second murmur specifies an interrupting arised in the inferior third of an esophagus, in a cardiac department of a stomach.
Auscultation of abdomen in horisontal position
Auscultation of peristalsis intestinal tones gives information about the motor function of the intestine. During gastric digestion and movement of the chyme along the small intestine, long periodic rumbling can be heard. Rhythmic intestinal murmurs can be heard 2-3 per minute 5—7 hours after meals. The peristalsis intestinal tones are listened in the cecum (right inguinal range), in the small intestine (above the point of Porges – 2 sm from umbilicus in upper and left direction) and in sigmoid (left inguinal range). In mechanical obstruction of the intestine, its peristalsis is resonant (in large waves). Peristalsis disappears in paralytic obstruction of the intestine; the abdomen is absolutely "silent" in perforation of the ulcer with secondary paralysis of the intestine; peritoneal friction can be heard in patients with fibrinous peritonitis during respiratory movements.
Auscultation of stomach. Splashing sound (succussion) can be heard if the patient is lying on his back, while the examiner pushes the anterior wall of the peritoneum with four flexed fingers of the apt hand. The other hand of the physician should fix the muscles of the abdominal prelim against the sterna edge. The thrust of the hand is transmitted through the stomach wall to the liquid and air contained inside it to cause a readily audible splashing sound which is inaudible outside the inferior borders of the stomach. This technique for outlining the inferior border of the stomach is effective in cases where the stomach border formed by the greater curvature is at the normal level or lowered. Succession gives information about the evacuator function of the stomach: the splashing sounds in healthy subjects can only be heard after meals. Splashing sounds heard 7-8 hours after meals suggest evacuator dysfunction of the stomach (mostly in pyloric stenos is) or its pronounced hypersecretion (gastrosuccorrhea). Splashing sounds heard to the right of the
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median line of the abdomen indicate dilatation of the prepyloric part of the stomach (Vasilenko's symptom).
Auscultation of the stomach is helpful when used together with palpation of the stomach to outline its inferior border. Auscultative (stethacoustic) palpation is performed as follows: stethoscope is placed beneath the left costal arch below the Traube's space. The examiner rubs the abdominal wall overlying the stomach by the finger of left arm and gradually moves the finger away from the stethoscope bell. As long as the finger rubs the skin overlying the stomach, the physician hears the friction, but when the finger moves outside the stomach borders, the sound disappears. This method is very simple but the findings are sometimes inaccurate.
Auscultation of abdominal aorta is performed on midline 5-7 sm above umbilicus. Systolic murmurs can be listened in abdominal aorta aneurysm, atherosclerosis of abdominal aorta and its branches.
Palpation of abdomen:
Surface tentative palpation and deep sliding palpation of abdomen (according to Obraztsov and Strazhesko)
Palpation of abdomen: history of the method
Palpation is the main method of physical examination in diagnosis of diseases of the abdominal organs. This method was first appreciated by French physicians (Glenard) in 80-years of XIX century. Later the Russian internists (Obraztsov, Strazhesko, Gausmann and others) further developed this useful method.
Glenard proposed palpation of the abdomen and believed that this method should systematically be used for clinical examination of the abdominal cavity. He maintained that palpation can be used to examine not only the abdominal organs but also various portions of the intestine. Having established that the cecum, transverse colon, sigmoid, and the colon proper can sometimes be palpated, he believed erroneously that their palpability indicated their pathology.
Independently of Glenard, Obraztsov developed methods for palpation of the gastro-intestinal tract and proved that some parts of the stomach and the intestine can be palpated in the absence of any pathology. He gave a detailed description of physical properties of each part of the abdominal organs in normal conditions. He substantiated thus usefulness of palpation in clinical practice along with other physical methods of examination; secondly he stimulated the study of the topographic relationships in the abdominal cavity before X-rays were discovered; and thirdly his teaching made it possible to compare the physical properties of organs and their topographic
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relations in health with those in pathology, which has become an important tool in the diagnosis of diseases of the abdominal cavity.
Later Obraztsov and his disciples developed in detail palpation techniques for examination of the abdominal cavity; they studied the organs and their separate parts that can be palpated under various conditions, and also gave a detailed description of normal palpatory signs of organs and their changes in various pathological conditions. They have proved finally the importance of palpation as an invaluable method of examination of the abdominal organs. It should however be emphasized that it is very difficult to master properly the palpation techniques for diagnostic purposes. It requires much experience and training. The palpation method described below has been proposed by Obraztsov and Strazhesko.
The common rules of the surface and the deep palpation
It is necessary that the abdominal cavity should be accessible to palpation, i.e. that its muscles of the anterior abdominal wall (prelum) be relaxed, and that the examiner should not provoke their straining by his manipulations. The patient should relax in his bed. (The bed should not be too soft.) His legs should be stretched and the arms flexed on the chest. The patient's breathing should not be deep; his head should rest against a small firm pillow. This position ensures relaxation of the abdominal muscles. The physician takes his place by the right side of the bed, facing the patient. The chair should be firm and level with the patient's bed. The ambient temperature should be comfortable for the patient, and the hands of the doctor should be warm and dry, nails must be short. A palpation is performed only after an auscultation and a percussion of the abdominal cavity.
The examining movements should be careful and gentle so as not to hurt the patient. Touching the abdomen roughly with cold hands will cause reflex contraction of the prelum to interfere with palpation of the abdomen. The patient with distended abdomen should first be given laxative or enema to empty the bowels. These are the conditions for palpation of the patient in the recumbent position. But some organs or their parts can only be palpated when they hang by gravity with the patient in the vertical position. Thus the left lobe of the liver, the lesser curvature of the stomach, the spleen, the kidneys, the cecum, or tumours can become palpable. The epigastrium and the lateral parts of the abdominal cavity should also be palpated with the patient in the vertical position.
Surface and deep palpation are used. The surface palpation examines condition of the anterior abdominal wall. The deep palpation is used to establish normal topographic relations between the abdominal organs and their normal physical condition; the other object is to detect any possible pathology that changes the morphological condition of the organs and their topographic relations responsible for their dysfunction, to locate the defect,
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