and to determine its nature. In other words, the deep palpation gives information on the topography of the abdominal cavity (topographic palpation).
The surface tentative palpation of abdomen
The physician assumes his position by the bedside as described above and places his right hand flat on the abdomen of the patient (the fingers may be slightly flexed) to examine carefully and gradually the entire abdomen without trying to penetrate the deep parts of the abdomen. By this examination the physician should establish the strain of the prelum, its tenderness, and location of the painful site. The left inguinal area should be examined first, provided the patient does not complain of pain in this region. The surface tentative palpation of an abdomen is performed in a direction against a course of a wrist-watch, i.e. after the left inguinal range palpation is continued on left flank from below upwards up to the left hypochondrium, then epigastric range, right hypochondrium and right flank from top to down up to right inguinal range. After that a right arm is placed in epigastric range to a surface tentative palpation of median zone from a xiphoid process down to the suprapubic area.
It is also a procedure of a surface tentative palpation of symmetrically areas of an abdomen. In this case after of the left inguinal area palpation is then continued by examining symmetrical points of the abdomen on its left and right sides to end in the epigastric region.
If the patient complains of pain in the left inguinal area, the sequence of palpation should be so changed that the least painful site on the anterior abdomen should first be examined.
The surface tentative palpation of an abdomen reveals a presence of morbidity, a resistance of a forward abdominal wall or its muscle strain, to probe the inspissations formed in a wall, hernias, tumours, to distinguish puffiness of a skin from augmentation of a hypodermic fatty tissue. For an establishment of morbidity before a palpation it is necessary to warn the patient that he has told when at him the pain sensation will be maximal, will appear and stop. Pay attention also to a look of the patient.
The physician should simultaneously assess the condition of the abdominal skin and subcutaneous connective tissue, the strain of the abdominal wall, the zones of superficial and deeper painful areas to locate them accurately. Hernial separation of muscles and protrusions, and also other anatomical changes should be revealed. Resistance and marked strain of muscles of the abdominal wall are usually palpated over the organ affected by inflammation, especially so if the peritoneum is involved. In the presence of acute inflammation of the peritoneum (local inflammation included, e.g. in purulent appendicitis, cholecystitis, and the like), local pressure causes strong pain but it becomes even more severe when the pressure is released
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(Shchetkin-Blumberg symptom). In the presence of pronounced enlargement of the parenchymatous organs, in strained abdomen or intestinal loops, and also in the presence of large tumours, even surface palpation can give much diagnostic information. But only deep systematic palpation can give full information about the condition of the abdominal cavity and its organs, as well as their topography.
The deep sliding methodical topographic palpation (according to Obraztsov and Strazhesko)
When starting deep palpation the examiner should always be aware of the anatomical relations in the abdominal cavity, the shape and physical properties of the organs, their supporting structures and possible deviations in topographical relations that may depend on the constitution of the patient, his special condition, nutrition, relaxation of the abdominal muscles, etc.
Obraztsov used the double-checking principle in his examinations. For example, in order to make sure that a given section of the intestine is actually ileum terminale it is necessary to locate the cecum; to determine the size of the stomach, the palpatory findings are checked by percussion and percussive palpation of the stomach. Respiratory excursions of the organs should be taken into consideration during palpation according to a strictly predetermined plan, beginning with more readily accessible parts.
The rules and techniques of deep palpation of abdomen
The success of a deep sliding palpation of an abdomen depends on strict observation of the rules, a convenient and easy position of the patient and the doctor, correct respiration of the first and a position and state of arms of the second, rational palpation tactics of investigator and the conforming readiness to a palpation of researched patient.
Necessary condition is the maximal relaxation of muscles, especially front abdominal wall. The optimal for palpation of abdomen is the diaphragmatic respiration at which during an inspiration muscles of a abdominal wall exert a little, and during an expiration - are as much as possible relaxed. The deep sliding palpation of an abdomen provides necessity of a palpation of members of the abdominal cavity for fixed sequence and good knowledge of clinical topographical anatomy.
The following sequence of deep palpation is recommended: the left ileum area – the sigmoid and the descending colon, the right ileum area – the cecum with the terminal end of the ileum and the ascending colon, further the epigastric and paraumbilical regions - the stomach with its parts (greater curvature and pylorus) and the transverse colon; the following stage - palpation of the liver, the spleen and kidneys.
The deep sliding palpation is performed only after the surface tentative palpation of an abdomen. The posture of the patient and the physician should
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be the same as in surface palpation. Palpation should be carried out by the right hand. In some cases the other hand should be placed on the examining hand to increase pressure. Palpation can also be bimanual (palpation with both hands simultaneously). If only one hand is used, the other hand presses the prelum laterally to the palpated zone in order to lessen or overcome resistance of the abdominal wall and hence to promote relaxation of the prelum in the palpated zone. The other hand can be used to move the palpated organ closer to the examining hand or in order to perform bimanual palpation.
The deep sliding palpation technique includes the following four steps. First: proper positioning of the physician's hands. The right hand is placed flat on the anterior abdominal wall parallel to the axis of the examined part or the edge of the examined organ. Second: formation of a skin fold to facilitate further movements of the examining hand. Third: moving the hand inside the abdomen. Deep palpation is performed when the fingers are moved gradually with each of expirations, into the abdomen when the abdominal wall is relaxed. The examining hand thus reaches the posterior wall of the abdomen or the underlying organ. Fourth: sliding movement of the fingertips in the direction perpendicular to the transverse axis of the examined organ. The organ is pressed against the posterior wall and the examining fingers continue moving over the examined intestine or the stomach curvature. Depending on the position of the organ, the sliding movement should be either from inside, in the outward direction (the sigmoid, cecum) or in the downward direction (the stomach, transverse colon); the movements should then be more oblique in accordance with the deviation of the organ from the horizontal or vertical course. The examining hand should always move
together with the skin and not over its surface.
By palpating the intestine, the physician establishes its localization, mobility, tenderness, consistency, and diameter, the condition of the surface (smooth, tubercular), the absence or presence of rumbling sounds during palpation. All these signs indicate the presence or absence of pathology.
Palpation of sigmoid
The sigmoid is palpated from top right to medial left, downward and laterally, perpendicularly to the axis of the intestine which runs obliquely in the left iliac space at the border of the median and the outer third of the linea umbilico-iliacae. Palpation is performed by four fingers, placed together and slightly flexed. The fingers are placed medially of the expected position of the intestine and as soon as the posterior wall of the abdomen is reached, the fingers slide along the intestine in the given direction, i.e. laterally and downward. The intestine is pressed against the posterior wall and first slides along it (to the extent allowed by the mesenteric length) but later it slips from under the examining fingers. The sigmoid can be palpated by the described
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technique in 90-95 per cent of cases. The sigmoid is only impalpable in excess inflation of the abdomen and in obese patients. If the sigmoid is not found where it belongs, it may be displaced to some other location because of long mesenterium which accounts for the high sigmoid mobility. It is then usually displaced closer to the navel and to the right. The sigmoid can usually be found by deep palpation of the infraumbilical and suprapubic areas. Normally the sigmoid can be palpated over the length of 20—25 cm as a smooth firm cylinder, its thickness being that of a thumb or an index finger; the sigmoid is painless to palpation, it does not produce rumbling sounds, its peristalsis is rather flaccid and infrequent. The sigmoid can be displaced 3—5 cm to either side.
Palpation of cecum
The cecum is palpated by the same technique, except that the direction is different. Since the cecum is situated at the border of the median and lateral third of the umbilico-iliac line (5 cm by the iliac spine), the palpation is carried along this line or parallel to it. Palpation is used not only to locate the cecum but also a certain part of the ascending colon (10-12 cm of its length), i.e. the part of the large intestine which is known in the clinic as typhlon. A normal cecum can be palpated in 80—85 per cent of cases as a moderately strained cylinder (widening to the round bottom), 2—3 cm in diameter; when pressed upon, it rumbles. Palpation is painless. It reveals a certain passive mobility of the cecum (to 2—3 cm). The lower-edge of the cecum is 0.5 cm above the biiliac in man and 1—1.5 cm below it in women.
Palpation of the terminal end of the ileum
Further the terminal end of the ileum can be palpated in the depth of the right iliac space as a soft, easily peristalting and passively mobile cylinder, the thickness of the little finger (or a pencil); it slips out from under the examining fingers and rumbles distinctly. Fingers of palpating arm are installed at the border external and medium third of linea biliaca under the angle 15-20º. The terminal end of an ileum is palpated as the sleek dense cylinder in diameter of 0,5-1,0 sm in case of reduction of a muscle layer of an intestine, or as an impressed thin-walled mild tubule which palpation is accompanied by a rumble in case of a release phenomenon of a musculation of an intestine and its fluid contents. The palpated part of a small bowel is routinely moderately mobile (up to 5-7 sm) and tolerant. Quite often during a palpation it is possible to establish transferring of an intestine from the weakened state in spasm condition when it as though «plays» near at hand.
The cecum and the terminal part of the ileum are palpated by four fingers of the right hand; the fingers should be held together and slightly flexed. If the prelum is tense, the muscles in the palpation zone can be relaxed by pressing the umbilical area with the radial edge of the left hand.
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Palpation of the ascending and descending colons
The ascending and descending colons are palpated by two hands. The left hand is placed under the left and then the right lumbar side, while the fingers of the right hand press on the anterior wall of the abdominal cavity until the examiner feels his right and left hands meet. The examining fingers then slide laterally, perpendicularly to the axis of the intestine (Vasilenko).
The descending colon is palpated immediately after palpation of the sigmoid. The fingers of the right arm are installed in the left flank paralelly to midline on 3-5 sm above the position of sigmoid. The descending colon is similar to sigmoid, the difference consists in relatively slight mobility.
The ascending colon palpation follows the palpation of the cecum. The fingers of the right arm are installed in the right flank paralelly to midline on 3-5 sm above the position of cecum.
Palpation of the stomach
The stomach should be palpated in both the vertical and horizontal position of the patient because the lesser curvature of the stomach and its high standing tumours are impalpable in the lying position. First palpation should be superficial and tentative. Its aim is to establish tenderness of the epigastrium, irritation of the peritoneum (Shchetkin-Blumberg symptom), divarication of the abdominal muscles, the presence of hernia of the linea alba, tension in the abdominal wall in the region of the stomach, and the presence of muscular defence (defense musculaire).
The deep palpation of the stomach should be carried out according to Obraztsov and Strazhesko. In connection with feature of its location, character of a surface and a consistence of various departments the stomach entirely almost is never palpated. More often the big curvature of a stomach and its pylorus are palpated.
The deep palpation of the greater curvature of the stomach begins at epigastric range from a xiphoid process downwards on 3-5 sm. The examiner pulls up the skin on the abdomen and presses carefully the anterior wall of the abdomen to penetrate the depth until the examining fingers reach the posterior wall. When pressed against the posterior wall of the abdomen, the stomach slips from under the examining fingers. If the first attempt of a palpation appeared unsuccessful, i.e. the sensation of sliding was not, it is necessary to repeat all over again, having established tips of fingers of a right arm is lower on 3-5 sm. And so the palpating arm is displaced down while the greater curvature will not be palpated, down to suprapubic range.
In absence of the stomach pathology the greater curvature of the stomach is posed at men on 3-4 sm above a level of a navel, at the woman of 1-2 sm are higher than a navel or at its level. The surface of a stomach is smooth, and the big curvature is represented as elastic, thin, smooth fold. Palpation of a stomach is painlessly in healthy men.
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