Preparation and basic examination parameters
To obtain reliable results, strict conditions for the examination must be observed. The room must be warm so that the patient feels comfortable and can maximally relax the muscles of the anterior abdominal wall. The patient lies supine, and the examiner stands on the right side. The abdomen is completely exposed, with the upper boundary being the xiphoid process of the sternum and the lower boundary being the inguinal regions.
During the initial inspection, the physician evaluates the basic visual characteristics:
- Size and shape: how well they correspond to the general body constitution, and whether there are visible deformations.
- Symmetry: comparison of the left and right halves of the anterior abdominal wall.
- Relief: search for local protrusions or irregularities.
- Skin integument: identification of scars, rashes, dilated blood vessels, and striae (striae).
- Respiratory dynamics: even participation of the abdomen in the act of inspiration and expiration.
Differential diagnosis of abdominal enlargement
If the abdomen is visually enlarged, the examiner must determine the cause of this condition. Enlargement can be associated with both pathological and physiological processes (e.g., pregnancy).
Main causes of pathological volume increase:
- Fat deposits: can manifest as general obesity, isolated visceral obesity, or selective accumulation of adipose tissue (characteristic of Cushing's syndrome and disease).
- Gas accumulation: massive accumulation of gas in the intestinal lumen, leading to flatulence.
- Free fluid: development of ascites.
- Mass lesions: presence of tumor processes in the abdominal cavity.
- Organomegaly: significant enlargement of internal organs (hepatomegaly with liver enlargement, splenomegaly in splenic pathology, polycystic kidney disease, or rarely encountered gallbladder enlargement).
Clinical assessment of ascites
The accumulation of free fluid in the abdominal cavity (ascites) requires determining the etiology and identifying specific physical signs.
According to its origin, ascites is divided into two groups:
- Manifestation of generalized edema syndrome. It occurs in congestive heart failure or against the background of severe hypoproteinemia (nephrotic syndrome, malabsorption syndrome, nutritional marasmus).
- Isolated character. Most often indicates the development of portal hypertension caused by liver cirrhosis or portal vein thrombosis.
Upon percussion of the abdomen with ascites, a dull sound or shortening of the percussive sound is determined in dependent areas (flanks). If the fluid accumulation is massive, dullness is determined over the entire surface of the abdomen. The main palpable sign of fluid presence is the fluid thrill sign (so-called fluctuation).
Pulsation, peristalsis, and venous network
Sometimes during inspection, movements of the abdominal wall can be observed. Visible peristalsis of the small intestine is considered normal only for individuals with a pronounced asthenic body type or severe emaciation.
Pulsation in the epigastric region has various origins:
- Aortic: caused by contractions of the abdominal aorta, often noticeable in asthenics.
- Cardiac: associated with right ventricular hypertrophy. This sign has high diagnostic value and is detected regardless of body constitution.
When inspecting the skin, special attention is paid to the venous pattern. Dilatation of the superficial veins of the anterior abdominal wall occurs due to impaired blood flow in the portal vein (often in liver cirrhosis). A severe form of portal hypertension manifests as the Caput Medusae sign («Head of Medusa») — pronounced dilatation and branching of veins around the umbilicus. To assess the direction of blood flow through the dilated vessels, the compression method on the venous anastomosis is used, observing its subsequent filling.
Local protrusions — hernias — may also be visually determined. Their typical localization is the umbilical and inguinal regions, as well as the linea alba. However, for accurate verification of a hernia, visual inspection is insufficient; palpation is mandatory.
Historical background: transition to palpation
After completing the inspection, the examiner proceeds to palpation, which is recognized as one of the main methods of physical examination of the abdominal cavity. The founder of targeted palpation is the outstanding domestic clinician V.P. Obraztsov. The first detailed description of the results of his method dates back to 1887. These data were presented in a fundamental work devoted to palpating the patient's abdomen in the horizontal position.
Briefly: answers to topical questions
What is the methodology for performing superficial preliminary abdominal palpation?
Superficial preliminary palpation precedes deep palpation and is performed without significant pressure.
The methodology includes two stages:
- Comparative palpation — performed with both hands on symmetrical areas of the abdomen to identify areas of tenderness and tension.
- Systematic palpation — performed with one hand at a superficial depth. Hand position: palm flat, fingers slightly bent, touching with fingertips.
The movement algorithm follows the logic «from healthy to diseased». The examination begins in the area furthest away from the complaint site. If there are no complaints, the order is observed: left iliac region, right iliac region, moving higher, and finishing in the epigastrium.
In what sequence is deep methodical gliding palpation of the intestine according to Obraztsov-Strazhesko performed?
Deep palpation is performed in strict order from the most accessible intestinal segments to the more complex ones.
The examination is performed in the following sequence:
- Sigmoid colon (colon sigmoideum) — examined first.
- Caecum (caecum) — palpated second.
- Ileum (ileum) — examined third.
- Ascending and descending colons — palpated at the fourth stage.
- Transverse colon — examined fifth.
- Liver (hepar) and spleen (lien) — palpated last.
How to determine liver dimensions using Kurlov's topographic percussion?
The determination of liver dimensions according to Kurlov is based on measuring three linear dimensions between the boundaries found by percussion.
Methodology for determining dimensions:
- First dimension — measured along the right midclavicular line. The lower point is determined by percussion from the umbilicus upwards, the upper point from the lung sound downwards (norm ~9 cm).
- Second dimension — measured along the midline. The lower point is determined from the umbilicus upwards, and the upper point is conventional and projected horizontally from the upper point of the first dimension (norm ~8 cm).
- Third dimension — measured along the left costal margin. Percussion is performed along the margin of the arch from the anterior axillary line (norm ~7 cm).
The boundary of sound transition is always marked at the edge of the pleximeter finger facing the clear sound.
Class and exam questions
What is the "Caput Medusae" sign (Caput Medusae)?
This is a pathological sign characterized by severe dilatation and radial branching of subcutaneous veins around the umbilicus. It occurs due to impaired blood flow in the portal vein (portal hypertension), most often against the background of liver cirrhosis.
Is visual inspection alone sufficient to diagnose a hernia?
No, that is not sufficient. Visually, hernias (umbilical, inguinal, linea alba hernias) appear only as local protrusions. Palpation is mandatory to confirm and verify the diagnosis.
What else to study on this topic
- Detailed palpation technique according to V.P. Obraztsov
- Pathogenesis of portal hypertension in liver cirrhosis
- Mechanisms of localized and generalized ascites formation
- Differential diagnosis of hepatomegaly and splenomegaly
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