With the help of percussionary palpation method the symptom of fluctuation of fluid is defined also the presence of an ascites. For this purpose the palmar surface of the left arm is put on the right half of abdomen in region of dullness. The right arm one-digital percussion mild impacts strike on the left half of abdomen according to V.P. Obraztcov. In the presence of a significant amount of loose fluid in an abdominal cavity the palm of the left arm clearly accepts fluctuation - jerky fluctuations of fluid. For a prevention of transfer of oscillating motions on the front abdominal wall it is possible to put a rib of an arm or the book along white line of the abdomen.
Percussion and palpation of liver and lien
Percussion of liver
Percussion is used to determine the borders, size and configuration of the liver. The superior and inferior borders of the liver are outlined. Two superior borders of liver dullness are distinguished: relative dullness, which is the true upper border of the liver, and the absolute dullness, i.e. the upper border of that part of the anterior surface of the liver which is directly adjacent to the chest and is not covered by the lungs. Practically, absolute dullness is determined only because a position of the superior border varies depending on the size and configuration of the chest, the height of the right cupula of diaphragm, and also because the upper edge of the liver is deeply hidden behind the lungs. Finally, the liver usually becomes enlarged in the downward direction. This is determined by the position of its inferior edge.
Liver (as the dense organ) produces a percussion dull sound; right lung adjoining above - a clear pulmonary sound; stomach and intestine, adjoining below - a tympanic sound. As the right pulmonary inferior edge locates into space between anterior chest wall and liver, filling a costal-diaphragmatic sinus, the high border of the dulled sound coincides with true edge of a liver, and appearance of a dull sound corresponds to its part which is not covered with edge of lung. The border between a dulled and dull sound is designated as a high border of absolute hepatic dullness.
The upper border of a liver determined by percussion is always below the true anatomical border. The quiet percussion is applied to revealing of a high border of absolute hepatic dullness.
Percussion of the liver is performed according to the general rules of topographic percussion, i.e. a position of the pleximeter-finger should be collateral to the border which is necessary for determining, percussion from a clear sound to dull, border designate from the side of a clear sound. Quiet percussion is used to determine the absolute liver dullness. The direction of percussion is from top to bottom, along the vertical lines, like in determining the borders of the right lung. The border is detected by contrast between the
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clear pulmonary resonance and liver dullness. The found border for each vertical line is marked on the skin by dots by the upper edge of the pleximeter-finger.
Superior border of absolute hepatic dullness is determined on parasternalis, midclavicular, right anterior axillary lines by percussion on intercostal spaces. On the parasternalis line a position of the border is specified by percussion on two overlying ribs above the dullness. Having received different percussion sound above them, a physician marks the border on the upper edge of the subjacent rib from them (routinely the 6-th).
In norm the superior border of absolute hepatic dullness passes on right parasternalis line at the level of the upper edge of the 6-th rib, on the midclavicular line - at the level of inferior edge of the 6-th rib, on anterior axillary line - at the level of inferior edge of the 7-th rib. The superior bound of relative dullness of a liver is posed on one rib above absolute dullness of the liver. The superior border of the liver can be determined posteriorly, but normally the determination ends by percussion in the three mentioned lines.
Delimitation of the inferior border of absolute hepatic dullness is difficult because of the presence of hollow organs in the vicinity of the liver. The stomach and the intestine give high tympanic sound that masks the liver dullness. The lightest (quietest) percussion should therefore be used.
The inferior border of absolute dullness of a liver is defined on anterior axillary, midclavicular, parasternalis right lines, anterior midline and parasternalis left lines. Determination of the inferior border of absolute dullness (according to Obraztsov and Strazhesko) should begin from the right part of the abdomen along the right anterior axillary line with the patient in the horizontal position. The pleximeter-finger is placed parallel to the expected inferior border of the liver, some distance away from it, so that tympany might first be heard (at the umbilical level or slightly below the navel). As the pleximeter-finger is then moved upwards, tympany is followed by absolute dullness. The point of disappearance of tympany is marked in each vertical line on the inferior edge of the pleximeter-finger.
When determining the left border of liver dullness, the pleximeterfinger is placed perpendicularly to the edge of the left costal arch, at the level of the 8-9-th ribs, and percussion is carried out to the right, directly over the edge of the costal arch, to the point where tympany changes to dullness (in the region of Traube's space).
Normally the inferior border of absolute dullness of a lying patient with normosthenic chest passes at the level of upper edge of 10-th rib in the right anterior axillary line, at the inferior edge of the right arch in the midclavicular line, 2 cm below the interior edge of the right costal arch in the right parasternal line, and 3-6 cm away from the inferior edge of the xiphoid process (at the border of the upper third of the distance from the base of the
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xiphoid process to the navel) on the anterior median line; on the left parasternalis line - at the level of the inferior edge of a costal arch.
The lower margin of the liver in norm can be very depending on the shape of the chest and constitution of the patient, but it has only effect on the position in the anterior median line. The lower margin of the liver in a hypersthenic chest is slightly above the mentioned level, while in an asthenic chest below it, approximately midway between the base of the xiphoid process and the navel. If the patient is in the upright posture, the lower margin of the liver descends 1-1.5 cm. If the liver is enlarged, its lower margin is measured in centimeters from the costal arch and the xiphoid process.
Percussion gives information about the vertical dimensions of the area of liver dullness. The distance between the superior and inferior borders of absolute dullness is measured on the three vertical lines. The distance between the superior and inferior borders of absolute dullness of a liver compounds the height of absolute hepatic dullness. This distance in the right anterior axillary line is normally 10-12 cm, in the right midclavicular line - 9—11 cm, and in the right parasternal line - 8—10 m. The increase of the height of absolute hepatic dullness has relation mainly to enlargement of the right lobe of liver.
It is difficult to determine liver dullness on the back because it is masked by dullness of the thick layer of lumbar muscles, the kidneys, and the pancreas. In some cases, a 4—6 cm wide band of liver dullness can be determined. This precludes erroneous diagnosis of liver enlargement in cases where the liver descends below the right costal arch, or where it is turned anteriorly round its axis; dullness then becomes narrower. Definition of height of hepatic dullness enables to distinguish the enlarged liver from its shift which is observed at low standing a diaphragm owing to pulmonary emphysema or the general enteroptosis.
Outlining the liver by percussion is diagnostically important. But ascending or descending of the superior margin of the liver is usually associated with extrahepatic changes (high or low diaphragm, subdiaphragmatic abscess, pneumothorax, or pleurisy with effusion). The superior margin of the liver can ascend only in echynococcosis or cancer of the liver. Elevation of the inferior margin indicates diminution of the liver; it can also occur in meteorism and ascites which displace the liver upwards. The lower border usually descends when the liver is enlarged (due to hepatitis, cirrhosis, cancer, echynococcosis, blood congestion associated with heart failure, etc.). But it can sometimes be explained by low position of the diaphragm. Systematic observation of the liver borders and changes in the liver dullness gives information on changes in its size during the disease.
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Examination of the size of liver according to M.G. Kurlov method
The size determination of a liver according to M.G. Kurlov's method is widely used in clinical practice. According to this method five points are marked, and three dimensions are taken. The first and second points of Kurlov correspond to superior and inferior borders of absolute liver dullness on the right midclavicular line, the first dimension of liver according to M.G. Kurlov is measured between them (in norm of 9 sm).
The third point of Kurlov is marked at intersection of the anterior midline and the perpendicular line installed from the first point of Kurlov (the level of superior border of absolute liver dullness on the right midclavicular line). This point conventionally corresponds to the superior border of a liver on the anterior midline. The fourth point according to Kurlov is marked on the inferior border of a liver on the anterior midline. The second dimension of a liver according to M.G. Kurlov is measured between the superior and inferior borders of the liver on the anterior midline (in norm 8 sm).
The fifth point according to M.G. Kurlov corresponds to the left border of liver dullness. The pleximeter-finger is placed perpendicularly to the edge of the left costal arch, at the level of the 8-9-th ribs between the left anterior axillary and midclavicular lines, and quiet percussion is performed to the right, directly over the edge of the costal arch, to the point where tympany changes to dullness (in the region of Traube's space). The third dimension of liver according to M.G. Kurlov is measured between the third and fifth point of Kurlov (superior border on anterior midline and left border of liver dullness on a costal arch - in norm 7 sm). An increase of the second and third dimensions testifies a pathological process of the left hepatic lobe, an increase of the first dimension – of right hepatic lobe.
Percussion of gallbladder
The gallbladder cannot be determined by percussion as a rule. But if its enlargement is pronounced, it can be determined by very light percussion.
Percussion is used not only to determine the borders of the liver and the gallbladder (topographic percussion) but also to assess their condition: careful percussion of the area overlying an enlarged liver or the gall bladder causes painful sensations in the presence of inflammation (hepatitis, cholecystitis, pericholecystitis, etc.). Succussion on the right costal arch also causes pain in diseases of the liver and the bile ducts, especially in cholelithiasis (Ortner's symptom).
Palpation of liver
Surface palpation in diseases of the liver can reveal a tender zone in the right hypochondrium and epigastrium. Especially severe local pain (caused even by a slight touch on the anterior abdominal wall in the zone overlying the gallbladder) is observed in acute cholecystitis and biliary colic. In chronic
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cholecystitis slight or moderate tenderness is only revealed at the point of projection of the gall bladder fundus onto the anterior abdominal wall. In healthy subjects this point is found immediately below the right costal arch by the lateral edge of the right rectus abdominis muscle.
Palpation of a liver purposes detection of the inferior edge, definition of its localization, form, lineament, consistence, character of surface and tenderness. Percussion of hepatic inferior borders on all lines foreruns always to palpation of the liver.
The liver is palpated by the Obraztsov and Strazhesko method. As the lower edge of the liver descends to meet the examining fingers during a deep inspiration it slides over the fingers and thus becomes detectable. It should be remembered that the respiratory mobility of the liver is the highest compared with that of the other abdominal organs because the liver is the closest to the diaphragm. It follows therefore that during palpation of the liver, the active role belongs to its respiratory mobility rather than to the palpating fingers (as is the case with palpation of the intestine).
Position of the patient. The patient should lay horizontally with slightly raised head and the stretched legs. The hands routinely settle down along a trunk or are crossed on a chest with the purpose of restriction of mobility of a chest in the sides on an inspiration. It promotes increase of diaphragm motility according to a liver in the upper-inferior direction that is important for a palpation of a lower edge of a liver.
The patient should stand or lie during palpation of the liver and the gall bladder. But in certain cases the liver can be easier palpated if the patient lies on his left side: the liver hangs by gravity from under the hypochondrium and its inferio-anterior edge can thus be better palpated.
Position of the doctor. The examiner sits by the right side, facing the patient. He places four fingers of his left hand on the right costal arch of the patient chest and uses his left thumb to press on the costal arch to move the liver closer to the palpating fingers of the right hand and to prevent expansion of the chest during inspiration. It stimulates greater excursions of the right cupula of diaphragm. The palm of the right hand is placed flat on the abdomen below the costal arch between the right parasternalis and midclavicular lines. The slightly flexed fingers press lightly on the abdominal wall.
Procedure of palpation of the liver. The patient is asked to take a deep breath; the liver descends to touch the palpating fingers and then slides to bypass them. The examiner's hand remains motionless. The procedure is repeated several times. The position of the liver margin varies depending on conditions. It is therefore necessary first to determine the lower margin of the liver by percussion before positioning the palpating fingers.
Common rules should be followed during palpation of the liver and the gall bladder. Special attention should be paid to the antero-inferior margin of
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