Palpation of the liver: the procedure, decoding and norms

Palpation - one of the most informative methods of diagnosis, carried out by a doctor at the stage of primary examination of the patient. Today we will talk about it.

Anatomy of the liver

Before starting to study the question 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 the adult is located on the left (in accordance with the middle line). In newborns, the liver occupies a significant part of the abdominal cavity.

Topographically, the liver has two surfaces and two edges. The anteroom (upper) surface is attached to the surface of the diaphragm and is bulged in accordance with its bend. The lower one is located behind and below, having several impressions from adjacent organs. The lower and upper surfaces are separated by the lower sharp edge, the other edge (the posterior surface), on the contrary, is very obtuse, and therefore it can be attributed to the posterior surface of the organ.

There are two parts in the liver: a large right and a smaller left, separated by a crescent ligament, in the free part of which lies a fibrous dense ligament - the so-called circular ligament that stretches from the navel and is nothing more than a overgrown umbilical vein.

The right share is divided by means of furrows into several secondary lobes. In one of these grooves are located the gallbladder and the hollow vein (inferior), separated by a piece of liver tissue, which is called the caudate process.

One of the important parts of the organ is the transverse deep furrow, which is called the portal of the liver. Through this formation, the organ includes large hepatic arteries, portal veins and nerves, and leaving it carrying the hepatic duct (evacuation of bile into the gallbladder) and lymphatic vessels.

In the right lobe of the organ, a square fraction is distinguished , which is limited by the gates of the liver, the round ligament and the pit from the gallbladder, and the caudate lobe located between the portal gates and the portal vein.

Functions of the liver

• Metabolic (control over the exchange of fluid, trace elements and vitamins, hormones, amino acids, lipids, proteins, carbohydrates).
• Depositing (in the body accumulate BZHU, vitamins, trace elements, hormones).
• Secretory (production of bile).
• Detoxication (carried out through a natural liver filter - hepatic macrophages).
• Excretory (due to the binding of glucuronic and sulfuric acids toxic substances: indole, tyramine, scotol).
• Homeostatic (the involvement of the liver in the control of the antigenic and metabolic hemostasis of the body).

Due to morphological and functional characteristics, the liver is often affected with a variety of non-infectious and infectious diseases. That is why at the first treatment of the patient it is necessary to perform palpation of this organ.

Palpation and percussion of the liver

Before conducting a palpation of the liver, it is recommended to define its boundaries using percussion. This will allow not only to suggest an increase in the organ, but also to understand exactly where the palpation should begin. With percussion, the hepatic tissue gives a dull sound, but due to the fact that the lower part of the lung partially covers it, it is possible to define two boundaries: true and absolute hepatic dullness, but more often determine only the border (lower and upper) of absolute stupidity.

Palpation of the body (technique)

When probing the liver, you must follow certain rules:

• The position of the subject is lying on the back, while the head is slightly raised, and the legs are hardly bent at the knees or straightened. The hands lie on the chest to limit its mobility when inhaled and relax the muscles of the abdomen.
• The doctor is on the right, facing the patient.
• The physician puts a slightly bent right hand flat on the abdomen of the patient in the region of the right hypochondrium, lower by three to five centimeters than the border of the liver, previously defined percussion. With his left hand, the doctor covers the chest (its lower part on the right), with four fingers to be placed behind, and one (big) finger put on the costal arch. This method will ensure the immobility of the chest during inspiration and will increase the diaphragm shift downwards.

• When the patient exhales, the doctor effortlessly pulls down the skin and, immersing the fingers of his right hand in the abdominal cavity, asks the patient to take a deep breath. At this time, the edge (lower part) of the organ drops, penetrates into the created pocket and slides on the fingers. At the same time, the palpable arm should remain stationary. If, for some reason, the liver was not palpated, the procedure is repeated, but the fingers are moved several centimeters upward. Produce this manipulation, moving higher and higher until the right hand stumbles onto the costal arch, or until the hepatic edge is felt.

Features

• The palpation of the liver is usually performed on the rectus muscle of the abdomen (its outer edge) or the mid-clavicular right line. But if there is such a need, probing is performed along five lines (from the anterior axilla to the right to the left breast).
• In the case of accumulation of large volumes of fluid in the abdomen, palpation becomes more difficult. Then they resort to a balloting jerky sensation 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 a rib arch until a dense formation is found - the liver. During the time of the body, the organ first retreats into the interior, and then returns and stumbles on the fingers (a symptom is called a "floating ice").

Interpretation of results (norm)

What results should palpation of the liver show?

• Normally, in 88% of patients, the lower edge of the organ is located near the costal arch, in accordance with the median-clavicular line on the right.
• In a healthy person, the edge of the organ is acute or slightly rounded. It is soft, painless, easy to turn when feeling, even.

Assessment of the findings (pathology)

• If the liver is enlarged, when palpated, it will be located below the costal arch, which may also indicate its displacement. In support of this or that assertion, percussion is necessary in order to determine the boundaries of the organ.
• If the dimensions of the liver are not changed, but the boundaries of the hepatic dullness are shifted downwards - this is a sign of omission of the organ.
• The displacement of only the lower border indicates an increase in the liver, which occurs with venous stasis, inflammation in the biliary tract and liver, acute infections (malaria, cholera, typhoid fever, dysentery), cirrhosis (at the initial stage).
• If the lower border is shifted upwards, it is possible to suspect a decrease in the size of the organ (for example, in terminal stages of cirrhosis).
• Changing the location of the upper hepatic border (down or up) rarely indicates damage to the organ itself (for example, with echinococcosis or liver cancer). Most often this is due to the high position of the diaphragm in pregnancy, ascites, flatulence, because of the low position of the diaphragm for enteroptosis, pneumothorax, emphysema, and also in cases of a diaphragm from the liver due to gas accumulation.
• An infarction of the lung, wrinkling of its lower part, pneumonia, right-sided pleurisy can also simulate a shift up the upper border of the organ.
• In some cases, not only the palpation of the liver edge, but also the whole organ is available. For this, the fingers are positioned directly under the costal right-hand arch. The doctor, gently pressing, examines the liver with sliding movements, while evaluating its surface (bumpy, smooth, even), consistency (dense, soft), presence / absence of soreness.

• Mild, smooth, smooth surface and rounded painful palpation of the edge - signs of inflammatory processes in the organ or manifestation of acute blood stasis due to heart failure.
• A hilly, uneven, dense margin is observed in echinococcosis and syphilis. A very dense ("wooden") liver is determined when the organ is injured by cancer cells.
• The fleshy edge of the liver indicates hepatitis, and in combination with tuberosity - of cirrhosis.
• Pain during palpation of the liver can occur due to inflammation or as a result of overstretch of its capsule (with a stagnant liver).

Palpation of the liver in children

The palpation of the liver of a newborn is usually performed at the level of the mid-clavicular as well as the anterior axillary line by sliding palpation. In this case, the hand of the examining pediatrician slides off the edge of the liver, so that it is possible not only to determine the size of the organ, but also the palpation evaluation of its edge. The norm for newborns is the appearance of the hepatic margin from beneath the costal arch for two (but not more) centimeter. Evaluation is carried out on the mid-inclusive line. The edge of the body should be painless, smooth, sharp and soft-elastic.

In healthy children up to the age of seven, the edge of the liver, as a rule, protrudes from the rib-right arch and is accessible for palpation. For healthy children up to three years, the norm is the definition of the edge of the liver at 2 or 3 centimeters below the right hypochondrium. After seven years, the boundaries of the liver correspond to those of adults.

Study of the liver by 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 perform palpation of the liver according to Kurlov. To do this, using the tapping (percussion) determine the upper limit, and then palpatory (or percussion) - the bottom. Moreover, in accordance with the oblique course of the lower edge of its boundary, as well as the distance between the upper and lower boundaries, are determined by three points. The first corresponds to the sredneklyuchichnoy line, the second - mid-clavicular, and the third - the costal left arch. In the room, the dimensions should be 9, 8, 7 cm, respectively.