Patient preparation and examination conditions
Before touching the patient's abdomen, the physician must observe a number of strict conditions. The primary task at this stage is to achieve maximum relaxation of the abdominal wall muscles.
First, the examiner's hands must be warm. Touching with cold skin immediately causes a reflexive muscle spasm, making further examination extremely difficult. Second, the patient must be placed in the correct position. They should lie on their back with their arms extended along the torso. Either nothing is placed under the head, or the lowest possible pillow is used.
If the patient's abdomen remains tense, a simple maneuver is used: the patient is asked to bend their legs at the knees and rest their feet flat on the couch. Throughout the entire process, the physician does not just look at the abdomen, but closely monitors the examinee's facial expressions. This is necessary to instantly register the slightest pain reaction or grimace that may appear before the patient reports pain.
Main diagnostic goals
Regardless of which type of palpation is used at a particular stage, the clinician always faces three fundamental tasks:
- Detection of tenderness. The precise localization of pain and its intensity in various abdominal regions are assessed.
- Determination of muscular defense. In clinical practice, this phenomenon is called défense musculaire. Its appearance indicates the development of an inflammatory process in the projection of the palpated organ and very often points to the involvement of the peritoneal leaflets in the pathological process.
- Detection of masses. The physician searches for enlarged internal organs, tumor nodes, or hernia protrusions (which can be located both in the tissues of the anterior abdominal wall and within the cavity itself).
Superficial (exploratory) palpation
Inspection always begins with the exploratory stage. It precedes deep tissue immersion and is performed as gently as possible, without strong pressure.
- Comparative palpation. Performed with both hands. The physician simultaneously or alternately assesses symmetrical areas of the abdomen to quickly identify zones of local tension or asymmetry.
- Systematic palpation. Performed with one hand. The palm is placed flat, fingers are slightly bent, and contact with the skin is made only with their tips. The physician does not attempt to penetrate deeply.
The main movement algorithm here follows the strict logic of "from healthy to diseased". Palpation starts in the area farthest from the site of complaints. If there are no complaints, the route is standardized: from the left iliac region to the right, then moving upwards and finishing in the epigastrium.
It is at this stage that superficial pain, diastasis of the rectus abdominis muscles, umbilical hernias, and hernias of the linea alba are detected.
Deep palpation according to V.P. Obraztsov
The methodological basis for deep examination was established by V.P. Obraztsov. He developed a technique that allows the differentiation of various parts of the intestine through the abdominal wall, which are felt under the fingers as dense cylinders.
The method is known as "methodical deep sliding palpation". Its essence lies in a specific movement mechanics. The physician's fingers must be slightly bent. The key rule is that the hand movement must be performed strictly together with the abdominal skin and underlying tissues. Friction of the palpating fingers against the skin surface is unacceptable.
The diagnostic picture is formed by a combination of sensations:
- Static sensations — primary contact with the skin and the anterior wall of the organ being examined.
- Dynamic sensations — occur at the moment of careful penetration into the depth, gentle compression of the organ against the posterior abdominal wall, and at the very moment the fingers slide off the intestinal "cylinder".
Briefly: answers to topical questions
What is the strict sequence for performing deep sliding palpation of the intestinal segments?
Deep sliding palpation of the intestinal segments is performed in a strict order from the most accessible areas to the more complex ones. Sequence of execution:
- Sigmoid colon (colon sigmoideum)
- Cecum (caecum)
- Ileum (ileum)
- Ascending and descending colons — palpated bimanually.
- Transverse colon — palpated below the previously identified lower border of the stomach.
Which specific properties of the intestinal loop are evaluated during deep sliding palpation?
Based on available data, deep sliding palpation allows the evaluation of the following features of the intestinal segment:
- Shape and size: the intestinal segment may be identified through the abdominal wall as a cylinder; the palpable area, likely the sigmoid colon, is described as a cylinder 2–3 cm thick.
- Tenderness: the localization and intensity of tenderness are evaluated; sources describe a painless area, generalized tenderness along the course of the colon, moderate tenderness in the lower abdomen, and tenderness in the projection of the sigmoid colon.
- Consistency, spasm, or distension: the sigmoid colon may be palpated as a spastic, dense cord; the cecum may be distended.
- Gurgling on palpation: gurgling upon palpation is characteristic; gurgling on palpation is also indicated for the cecum.
The "Warm hands, attentive gaze" rule: always warm your hands to avoid false muscle spasm in the patient, and watch their face intently so as not to miss a grimace of pain.
Class and exam questions
Why start from the healthy area during superficial palpation?
To avoid provoking reflex muscle spasm and increasing pain at the very beginning of the examination. The "from healthy to affected" movement allows the patient to get used to the physician's touch.
Why ask the patient to bend their knees?
This position helps to maximally relax the muscles of the anterior abdominal wall, which is critically important for unobstructed deep palpation.
What does the appearance of défense musculaire indicate?
This is protective tension of the abdominal wall muscles. It is a classic sign of an inflammatory process in the organ's projection and often indicates peritoneal irritation.
What else to study on this topic
- Technique for detecting hernias of the linea alba and the umbilical ring
- Determination of the degree of rectus abdominis diastasis
- The physician's sensation when sliding off the intestinal cylinder
- How to distinguish static touch from dynamic touch
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