Palpation is one of the most informative diagnostic methods carried out by a doctor at the stage of the initial examination of the patient. We will talk about him today.
Anatomy of the liver
Before proceeding to the study of the issue of palpation of the liver, it is necessary to determine the anatomy and functions of the organ. The liver is located immediately below the diaphragm, on the right side at the very top of the abdominal cavity, and only a small part of the organ in an adult is located on the left (in accordance with the midline). In newborns, the liver occupies a significant part of the abdominal cavity.
Topographically, the liver has two surfaces and two edges. The anteroposterior (upper) surface is adjacent to the surface of the diaphragm and protrudes in accordance with its curvature. The lower one is located behind and below, having several impressions from adjacent organs. The lower and upper surfaces are separated by a lower sharp edge, the other edge (posterior superior), on the contrary, is very blunt, and therefore it can be attributed to the posterior surface of the organ.
There are two lobes in the liver: a large right and a smaller left, separated by a falciform ligament, in the free part of which lies a fibrous dense cord - the so-called circular ligament, which stretches from the navel and is notnothing but an overgrown umbilical vein.
The right lobe is divided by furrows into several secondary lobes. In one of these grooves are the gallbladder and vena cava (inferior), separated by a piece of liver tissue, which is called the caudate process.
One of the important parts of the organ is a transverse deep groove, which is called the gates of the liver. Through this formation, large hepatic arteries, the portal vein and nerves enter the organ, and the efferent hepatic duct (evacuation of bile to the gallbladder) and lymphatic vessels leave it.
In the right lobe of the organ, a square lobe is isolated, which is limited by the gates of the liver, a round ligament and a fossa from the gallbladder, and a caudate lobe, located between the gates of the liver and the portal vein.
Liver Functions
- Metabolic (control over the exchange of fluid, trace elements and vitamins, hormones, amino acids, lipids, proteins, carbohydrates).
- Depositing (BJU, vitamins, trace elements, hormones accumulate in the body).
- Secretory (bile production).
- Detoxification (carried out thanks to the natural baked filter - hepatic macrophages).
- Excretory (due to the binding of toxic substances by glucuronic and sulfuric acids: indole, tyramine, scotol).
- Homeostatic (participation of the liver in the control of antigenic and metabolic hemostasis of the body).
Due to morphological and functional featuresthe liver is quite often affected in a variety of non-communicable and infectious diseases. That is why, at the first visit of the patient, it is necessary to palpate this organ.
Palpation and percussion of the liver
Before probing the liver, it is recommended to determine its boundaries using percussion. This will allow not only to assume an increase in the organ, but also to understand where exactly the palpation should begin. During percussion, the liver tissue gives a dull (deaf) sound, but due to the fact that the lower part of the lung partly covers it, it is possible to determine two boundaries: true and absolute hepatic dullness, but more often only the boundary (lower and upper) of absolute dullness is determined.
Palpation of the organ (technique)
When probing the liver, certain rules must be observed:
- The position of the subject is lying on his back, while the head is slightly raised, and the legs are barely bent at the knees or straightened. Hands rest on the chest to limit its mobility during inhalation and relax the abdominal muscles.
- The doctor is positioned to the right, facing the patient.
- The doctor places his slightly bent right palm flat on the patient's stomach in the region of the right hypochondrium, three to five centimeters lower than the border of the liver, previously determined by percussion. With his left hand, the doctor covers the chest (its lower part on the right), while four fingers must be placed behind, and one (thumb) finger should be placed on the costal arch. This technique will ensure the immobility of the chest during inspiration and increase the downward displacement of the diaphragm.
When the patient exhales, the doctor effortlessly pulls down the skin and, plunging the fingers of his right hand into the abdominal cavity, asks the patient to take a deep breath. At this time, the edge (lower part) of the organ descends, penetrates into the created pocket and slides over the fingers. In this case, the probing hand should remain motionless. If for some reason it was not possible to palpate the liver, the procedure is repeated, but the fingers are shifted a few centimeters up. This manipulation is performed, moving higher and higher until the right hand stumbles on the costal arch, or until the hepatic edge is palpated
Features
- The liver is usually palpated along the rectus abdominis muscle (its outer edge) or the mid-clavicular right line. But if such a need arises, palpation is performed along five lines (from the anterior axillary on the right to the peristernal left).
- In case of accumulation of large volumes of fluid in the abdomen, palpation is difficult. Then they resort to balloting jerky probing of the organ. To do this, the second, third and fourth fingers of the right hand perform shock-shocks on the front wall of the abdomen, starting from the bottom and ending with the costal arch until a dense formation is found - the liver. During the push, the organ first goes deep, and then returns and bumps into the fingers (the symptom is called "floating ice").
Interpretation of results (norm)
What results should liver palpation show?
- BNormally, in 88% of patients, the lower edge of the organ is located near the costal arch, in accordance with the mid-clavicular line on the right.
- In a he althy person, the edge of the organ is sharp or slightly rounded. It is soft, painless, easily tucked in when touched, even.
Evaluation of received data (pathology)
- If the liver is enlarged, on palpation it will be located below the costal arch, which may also indicate its displacement. To confirm this or that statement, it is necessary to conduct percussion in order to determine the boundaries of the organ.
- If the size of the liver is not changed, but the boundaries of hepatic dullness are shifted down, this is a sign of organ prolapse.
- Displacement of only the lower border indicates an increase in the liver, which occurs with venous congestion, inflammation in the biliary tract and liver, acute infections (malaria, cholera, typhoid fever, dysentery), cirrhosis (at the initial stage).
- If the lower limit shifts upward, then a decrease in the size of the organ can be suspected (for example, in the terminal stages of cirrhosis).
- A change in the location of the upper hepatic border (down or up) rarely indicates damage to the organ itself (for example, with echinococcosis or liver cancer). This is more often observed due to the high position of the diaphragm during pregnancy, ascites, flatulence, due to the low location of the diaphragm in enteroptosis, pneumothorax, emphysema, and also in cases of separation of the diaphragm from the liver due to gas accumulation.
- Infarction of the lung, wrinkling of its lower part, pneumonia, right-sidedPleurisy can also mimic an upward displacement of the upper border of the organ.
- In some cases, not only palpation of the edge of the liver, but also of the whole organ is available. To do this, the fingers are placed directly under the right costal arch. The doctor, gently pressing, with sliding movements examines the liver, while evaluating its surface (lumpy, smooth, even), consistency (dense, soft), the presence / absence of pain.
- Soft, even, smooth surface and a rounded, painful edge on palpation are signs of inflammatory processes in the organ or a manifestation of acute blood stasis due to heart failure.
- Hilly, uneven, dense edge observed in echinococcosis and syphilis. A very dense ("wooden") liver is determined when the organ is damaged by cancer cells.
- Dense edge of the liver indicates hepatitis, and in combination with tuberosity - about cirrhosis.
- Pain on palpation of the liver may occur due to inflammatory processes or as a result of overstretching of its capsule (with congestive liver).
Palpation of the liver in children
Palpation of the liver of a newborn, as a rule, is carried out at the level of the mid-clavicular and anterior axillary lines by sliding palpation. At the same time, the hand of the examining pediatrician slides off the edge of the liver, which makes it possible not only to determine the size of the organ, but also to palpate its edge. The norm for newborns is the protrusion of the hepatic margin from under the costal arch.two (but not more) centimeters. The assessment is carried out along the midclavicular line. The edge of the organ should be painless, smooth, sharp and soft-elastic.
In he althy children under the age of seven, the edge of the liver, as a rule, protrudes from under the right costal arch and is accessible for palpation. For he althy children under three years old, it is considered normal to determine the edge of the liver 2 or 3 centimeters below the right hypochondrium. After seven years, the borders of the liver correspond to those in adults.
Examination of the liver using the Kurlov method
To confirm the diagnosis of a particular pathology, which leads to a distortion of the size of the organ, it is necessary to palpate the liver according to Kurlov. To do this, with the help of tapping (percussion), the upper limit is determined, and then the lower limit is determined by palpation (or percussion). Moreover, in accordance with the oblique course of the lower edge of its border, as well as the distance between the upper and lower borders, are determined by three points.
The first corresponds to the mid-clavicular line, the second - to the mid-clavicular line, and the third - to the costal left arch. In the room, the measurements should be 9, 8, 7 cm respectively.
