The liver, which performs a number of important functions in the human body, is the largest( its mass ranges from one and a half to two kilograms) with the gland of the digestive system.
Functions of the hepatic tissue
The structures of this organ carry out:
- Bile production.
- Detoxication of toxic and foreign substances that enter the body.
- Exchange of nutrients( represented by vitamins, fats, proteins and carbohydrates).
- Accumulation of glycogen, which is the main form of storage of glucose in the human body. Deferred in the cytoplasm of the hepatic cells, glycogen is an energy reserve, which, if necessary, can quickly resume the acute shortage of glucose.
Pain sensations, as a rule, appear together with an increase in the body and the capsules that were provoked by it. In particular, the duration of the incubation period of hepatitis viral etiology can be at least six months.
Clinical symptoms at this stage are still absent, but pathological changes in the structures of the liver are already taking place.
The first task of the doctor is to carefully collect information, including an analysis of complaints and an assessment of the general condition of the patient. The next stage of diagnosis is a physical examination of the patient, which requires the mandatory performance of percussion and palpation of the liver.
These diagnostic techniques, which are not time consuming and do not require any preliminary preparation of the patient, help to establish the true size of the affected organ, which is extremely important for the timely diagnosis and the appointment of the correct treatment tactics.
Given the high prevalence of diseases leading to liver damage, the problem of their timely diagnosis continues to remain relevant in our days. The most significant contribution to the development of techniques for palpation and percussion study of the liver was made by the therapists Obraztsov, Kurlov and Strazhesko.
Percussion
The method of percussion, which allows to determine the location, condition and various violations in the functioning of internal organs, consists of tapping the abdominal cavity or chest. The diverse nature of the sounds arising in this case is due to the different density of internal organs.
On the ability of a doctor to correctly analyze information obtained during the performance of percussion, the setting of a preliminary diagnosis depends.
There are two types of percussion:
- Immediate, consisting in the implementation of tapping on the surface of the chest or wall of the abdominal cavity.
- Mediocre, performed with a plessimeter, whose role can be played by a special plate( metal or bone) or the fingers of the doctor himself. All the time changing the amplitude of percussion manipulations, an experienced specialist is able to determine the functional capabilities of internal organs lying at a depth of up to seven centimeters. The results of percussion examination may be affected by factors such as: the thickness of the anterior abdominal wall, the accumulation of gases or free fluid in the abdominal cavity.
With percussion of the liver, it is clinically important to determine the absolute stupidity of those parts of it that are not covered by pulmonary tissues. Defining the boundaries of the organ under examination, the doctor is guided by a change in the nature of the percussion sounds, the range of which can vary from clear( pulmonary) to blunt.
To determine the upper and lower border of the liver, as a visual reference, the specialist uses three vertical lines:
- anterior axillary;
- parietal;
- mid-clavicular.
In a person who has a normostenic physique and does not have external signs of internal organ damage, the area of absolute dullness can be detected using the anterior axillary line: it will be localized on the right side, approximately at the level of the tenth rib.
The next landmark - mid-clavicular line - will indicate that the border of the liver continues along the lower edge of the right costal arch. Having reached the next line( right okolohradinnoy), it will go down a couple of centimeters below the mark just mentioned.
At the point of intersection with the anterior median line, the organ border by a few centimeters does not reach the end of the xiphoid process. At the point of intersection with the peritometric line, the border of the liver, moving to the left half of the body, reaches the level of the left costal arch.
When analyzing the results of percussion, it is necessary to take into account the patient's age, since in small patients all boundaries are shifted downwards.
For example, in an adult patient, the liver accounts for not more than 3% of the total body weight, while in a newborn baby this figure is at least 6%.Thus, the younger the child, the greater the place in his abdominal cavity is occupied by the organ of interest to us.
The video shows the procedure for percussion of the liver according to Kurlov:
Dimensions according to Kurlov
The essence of the Kurlov method for determining the size of the liver is as follows: the boundaries and the size of this organ are revealed using percussion - a diagnostic manipulation, which involves the tapping of this organ and the analysis of emergingthus sound phenomena.
Due to the high density of the liver and the lack of air in its tissues, blunt sounds occur during the percussion;when tapping part of the body, covered with lung tissue, percussion sound is significantly shortened.
The Kurlov method, which is the most informative way to determine the boundaries of the liver, is based on the identification of several points that allow us to designate its true dimensions:
- The first point, denoting the upper boundary of the hepatic dullness, should be at the lower edge of the fifth rib.
- The second point, corresponding to the lower boundary of the hepatic dullness, is localized either at a level or one centimeter above the costal arch( relative to the mid-clavicular line).
- The third point must correspond to the level of the first point( relative to the front median line).
- The fourth point marking the lower border of the liver is usually located at the turn of the upper and middle third of the segment between the navel and the xiphoid segment.
- The fifth point denoting the lower edge of a tapered tapering organ should be located at the level of the seventh-eighth rib.
After defining the boundaries of the above points, they begin to determine three sizes of the organ under investigation( this technique is usually applied to adults and children over seven years of age):
- The distance between the first and second points is the first size. Its normal value in adults ranges from nine to eleven, in preschool children it is six to seven centimeters.
- The second size, determined by the difference in the nature of percussion sounds , gives the distance between the third and fourth points. In adults, he is eight or nine, preschoolers have five to six centimeters.
- The third - oblique - the size is measured along the diagonal of , connecting the fourth and fifth points. In adult patients, it is normally seven to eight, in children - no more than five centimeters.
Norms in children and adults
In modern clinics, the results obtained during palpation and percussion of the liver can be clarified with the help of high-tech equipment used for ultrasound, magnetic resonance and computed tomography.
All these procedures provide comprehensive information on the boundaries, size, scope of the organ under investigation and possible violations in its work.
Measurement of the right and left lobe of the liver is carried out separately, while focusing on three main indicators: oblique vertical size, height and thickness.
- Anteroposterior size ( thickness) of the left lobe of an organ in a healthy adult should not exceed eight centimeters, the right one - twelve.
- The craniocaudal dimension ( height) of the right lobe may range between 8.5-12.5 cm, the left one - 10 cm.
- The value of the oblique vertical dimension of for the right lobe of the body is normally fifteen centimeters, for the left - no more than thirteen.
The parameters of the liver in a child are significantly different from those of an adult. The dimensions of both of its lobes( along with the diameter of the portal vein) constantly change with the growth of his body.
For example, the length of the right lobe of the liver in a one-year-old child is six, the left lobe is three and a half centimeters, the diameter of the portal vein can range from three to five centimeters. By the age of fifteen( at this age, the growth of the gland is completed), these parameters are respectively twelve, five and seven to twelve centimeters.
Preparation for probing
In Russian medical institutions, the palpation of the liver structures in adult patients and children is most often performed according to the classic Obraztsov-Strazhesko technique. It is called bimanual palpation, this technique is based on feeling the lower edge of the liver at the time of deep inspiration.
Before carrying out this research, the doctor should correctly prepare the patient( especially a small child), convincing him to completely relax, relieving tension from the abdominal muscles. Given the high morbidity of the affected organ, this is not at all easy.
The palpation of the liver can be performed with both the vertical and the horizontal position of the patient, however, taking a lying position, it will feel more comfortable. This statement is especially true in relation to young children.
- Before performing palpation of the liver, the specialist should be located on the right side of the patient, facing him.
- The patient is offered to lie on his back( on the couch with a slightly raised headboard).His forearms and hands should lie on his chest;legs can be straightened or half-bent.
- The left hand of a specialist performing palpation should fix the lower part of the right half of the patient's chest. Keeping the costal arch and thereby limiting her excursion at the time of inspiration, the doctor provokes a larger shift of the organ under investigation downward. The palpable( right) hand flat fits at the level of the navel on the right side of the anterior abdominal wall, slightly to the side of the outer edge of the rectus muscle. The middle finger of the right hand should be slightly bent.
Technique for performing palpation of the liver
When examining the liver of a patient, the doctor uses deep-palpation techniques applied to the organs of the abdominal cavity.
For palpation, the patient most often assumes a reclining position, much less often it is performed with the vertical position of the body.
Some specialists prior to palpation seat their patients or lay them on the left side. Let's consider several methods of palpation in more detail.
- Palpation of the liver, performed in the position of the patient lying , is performed synchronously with the patient's breathing( detailed description of the patient's posture and the position of the doctor's hand is given in the previous section of our article).At the phase of his exhalation, the doctor immerses the palpable hand in the patient's abdominal cavity, holding it perpendicular to the anterior wall of the abdomen and parallel to the edge of the liver.
Due to the correct preparation of the patient, the doctor manages to achieve the maximum displacement of the examined gland down during the deep inspiration and exit it from the area of the hypochondrium, which makes the organ more accessible to the study.
In the inspiratory phase, the palpable hand moves forward and upward, forming a skin fold called an "artificial pocket".At the time of very cautious and gradual immersion of the fingers deep into the abdominal cavity the doctor asks the patient to perform slow breaths and exhalations of average depth.
With each exhalation, the fingers of the researcher are steadily moving downward and slightly forward - under the examined gland. At the time of inspiration, the fingers of the doctor, which resist the ascending wall of the abdomen, remain immersed in the region of the right hypochondrium.
After two or three breathing cycles, contact is made with the edge of the organ under examination, thanks to which the specialist can obtain information about the outlines, boundaries, dimensions and quality of its surface.
- The edge of a healthy, painless gland that has a flat surface and a soft, elastic consistency should be located at the level of the costal arch.
- Loss of the liver leads to a shift and its upper limit, determined during percussion. This phenomenon usually accompanies the enlargement of the gland that occurs in patients suffering from acute and chronic hepatitis, obstruction of the bile duct, cirrhosis, cysts and tumor lesions of the liver.
- The stagnant liver has a soft consistency and a sharp or rounded edge.
- Patients with cirrhosis or chronic hepatitis are the owners of the gland with a more dense, pointed, painful and uneven edge.
- The presence of a tumor provokes the formation of a scalloped edge.
- In patients with rapidly developing hepatoma( the primary malignant tumor of the organ under investigation) or the presence of metastases, palpation reveals the presence of an enlarged dense liver with large nodes on the surface.
- The presence of decompensated cirrhosis is indicated by the small size of a considerably compacted organ with a tuberous surface. Palpation is extremely painful.
- The granular surface of the affected organ is observed in the development of an abscess and in patients suffering from syphilis or atrophic cirrhosis.
- If the rapid decrease in the liver continues and some time later, the doctor can make an assumption about the development of severe hepatitis or massive necrosis.
The above described palpation technique is applied several times, gradually increasing the depth of immersion of the fingers inside the hypochondrium. If possible, it is advisable to investigate the edge of the organ of interest to us throughout its entire length.
If, despite all efforts, to grope the edge of the gland can not, you need to change the position of the fingers of the palpable hand, slightly moving them up or down. This way you can palpate the liver in almost 90% of perfectly healthy people.
After completing the palpation procedure, the patient should be held in a supine position for a while, and then gently and slowly help him to rise. Elderly patients who have undergone this procedure are advised to sit for a while: this will help prevent dizziness and other negative consequences.
- Palpation of the liver is also possible in a patient who has a sitting position. For maximum relaxation of the abdominal muscles, he should lean slightly forward, with his hands on the edge of a hard chair or couch.
Having reached the back wall, the specialist asks the patient to take a slow and deep breath. At this moment, the lower surface of the organ under examination will lie on the palm of the doctor, giving him the opportunity to thoroughly feel his surface. Slightly bending the fingers and making them sliding movements, a specialist can assess the degree of elasticity of the organ, the sensitivity and character of its edge and lower surface.
Palpation performed in the sitting position( unlike the classical method described above, which makes it possible to touch the liver only with the very tips of the fingers), allows the doctor to feel the gland of interest to us by the entire surface of the end phalanges, endowed with maximum sensitivity to humans.
- In patients with severe ascites( a pathological condition accompanied by accumulation of free fluid in the abdominal cavity), palpation of the liver with the above-described methods is not always possible. In such cases, specialists apply the technique of jerky( or "balloting") palpation.
Having squeezed together three fingers of the right hand( second, third and fourth), the doctor puts them on the abdominal wall - over the site of liver localization - and makes a series of short, jerky movements directed into the abdominal cavity. The depth of immersion of fingers should be from three to five centimeters.
Starting a study with the lower third of the abdomen, the doctor gradually, adhering to special topographic lines, advances towards the liver.
At the moment of impact on it, the fingers of the researcher feel the presence of a dense body, easily submerged in ascitic fluid and soon returning to its former position( this phenomenon was called the symptom of a "floating ice").
Thick palpation can also be applied to patients without ascites, but with an enlarged liver and a very weak abdominal wall, in order to detect the edge of the affected organ.
Having tightly squeezed two or three fingers on the right hand, the doctor begins to perform light jerky or sliding movements down from the end of the xiphoid process and from the edge of the costal arch. In the event of a collision with the liver, the fingers will feel resistance, at the point of its termination, the fingers, without encountering resistance, simply fall into the depth of the abdominal cavity.
The video shows the technique of palpation of the liver according to Obraztsov-Strazhesko:
What diseases are indicated by the change of borders?
The displacement of the upper border of the liver upwards can be triggered:
- tumor;
- high-standing diaphragm;
- echinococcal cyst;
- subfunctional abscess.
The movement of the upper organ downward can occur due to:
- pneumothorax - accumulation of gases or air in the pleural cavity;
- emphysema - a chronic disease leading to a pathological expansion of the distal branches of the bronchi;
- visceroptosis( synonymous name - splanchnoptosis) - ablation of abdominal organs.
Shifting the lower border of the liver upwards may result from:
- of acute dystrophy;
- tissue atrophy;
- of cirrhosis of the liver that has reached the terminal stage;
- ascites( abdominal dropsy);
- of increased flatulence.
The lower border of the liver can move downward in patients suffering from:
- heart failure;
- with hepatitis;
- with liver cancer;
- liver damage caused by stagnation of blood as a result of increased pressure in the right atrium( this pathology is called a "stagnant" liver).
Culprits of significant liver enlargement may include:
- chronic infectious diseases;
- right ventricular heart failure;
- different types of anemia;
- her chronic diseases;
- cirrhosis;
- lymphogranulomatosis;
- malignant neoplasms;
- leukemia;
- disorders of bile outflow;
- hepatitis.