The spleen is an unpaired parenchymal organ having a ovoid form and a pointed lower pole.
Located in the very depth of the left hypochondrium, the anterior portion of its gastric( visceral) surface is adjacent to the stomach, and the posterior part( renal surface) to the adrenal and kidney. From below, the organ of interest touches the bend of the large intestine.
Being located under the left dome of the diaphragm( between the ninth and eleventh rib), the spleen is endowed with respiratory mobility. Its long axis( the so-called "long") coincides in norm with the course of the tenth edge.
In people with an asthenic physique, the spleen is located just below and more vertically, in the case of those with hypersthenic builds, higher and horizontal.
Inspection tasks
Palpation of the spleen has several tasks at once. With its help you can:
- determine the form of the organ under study;
- assess the state of its surface structures;
- establish the consistency of fabrics;
- assess the degree of organ mobility;
- to reveal the presence of soreness and other clinical manifestations indicating a deviation from the norm.
External examination of
The first step in the study of the spleen is an external examination of the abdomen, including:
- an assessment of its magnitude;
- establishing the symmetry of the right and left halves;
- an evaluation of the degree of severity of the depression present in the edge region of the costal left arch.
In a healthy person, the appearance of the abdomen( its shape and size) always corresponds to sex, body type, level of physical development and fatness.
The presence of pathological processes in the spleen inevitably provokes its increase, which can be both insignificant and colossal( in the most severe cases, the organ can reach the level of the ileum).
Excessive enlargement of the spleen increases the size of the abdomen, at which it becomes asymmetric( due to the apparent bulging of the left half).
The patient, who has taken a horizontal position, through the abdominal wall, you can see the contours of the pathologically enlarged spleen. To a greater extent, this is characteristic of extremely depleted patients suffering from cachexia.
An increase in the abdomen is accompanied by a smoothing or disappearance of the indentation, which every healthy person has from the left edge of the costal arch. In some patients, even the lower part of the thorax( on the left side) can protrude.
Percussion
Every specialist performing percussion( tapping) of the spleen is aware of the small size of this organ located in the left hypochondrium so deep that only two-thirds of its diaphragmal surface located beneath the chest wall can be affected by this manipulation.
Because the area of the spleen, available for tapping, is surrounded by organs containing air( lungs, intestines, stomach), the best option for its investigation is an immediate quiet percussion on Yanovsky, resulting in an absolute dullness.
In the case of performing mediocre deep percussion( this option is quite possible), a specialist will determine only dullness caused by the involvement of air-containing tissues in the percussion zone, which give a ringing tymponic sounds when tapping.
With the help of quiet percussion, you can determine the approximate size of the spleen. During the manipulation, the patient can:
- Accept the vertical position by extending the arms forward.
- Lie on the right side, bending the left arm in the elbow joint and placing it on the external surface of the chest( its right hand should be under the head).The right leg of the patient should be stretched, and the left leg - bent at the knee and in the hip joint. This position promotes maximum relaxation of the muscles of the anterior wall of the abdomen.
It is in these positions of the body that the liquid gastric contents move to the right or down from the spleen, significantly improving the conditions and results of palpation.
To determine the upper limit of the organ, the finger, acting as a pleximeter, is placed at the intersection of the middle axillary line and the level of the sixth-seventh intercostal space and proceed to percussion, moving down the intercostal spaces.
To establish the lower border of the spleen, the finger-plessimeter should be placed on the middle axillary line in a direction parallel to the expected border( just below the costal arch).The direction of percussion is from the bottom up: from clear sound to the beginning of blunting. The mark of passing the border is made from the side of clear sound.
Determining the front boundary of the organ of interest, the finger-plessimeter is placed on the anterior wall of the abdomen( to the left of the navel, at the level of the tenth intercostal space) parallel to the assumed boundary. Percutate follows, moving to the transverse axis of splenic dullness until the appearance of the first signs of blunting.
The border mark is placed on the side where a clear sound comes from. The anterior border of the spleen should normally be one to two centimeters from the anterior axillary line( to the left of it).
To reveal the posterior border of the organ, the finger-plessimeter is set perpendicular to the tenth rib( the direction of percussion should be parallel to the sought boundary).Moving between the two lines( back axillary and scapular), perform percussion until the appearance of a slightly dull sound( from the front in the back).
Having established the upper and lower boundaries of the organ under investigation, the distance between them is measured, resulting in the total length of its diameter located between the ninth and eleventh fins. A length of between four and six centimeters is considered normal.
Measuring the distance separating the front and back border of the spleen, the value of its length is obtained( in healthy people it is six to eight centimeters).
The increased values of the transverse and long axis of splenic dullness are conclusive evidence of an increase in this organ that occurs in patients suffering from:
- diseases of hemopoietic organs( hemolytic anemia, thrombocytopenic purpura, leukemia, lymphogranulomatosis);
- metabolic disorders( amyloidosis, diabetes, etc.);
- infectious diseases( malaria, abdominal, typhus and recurrent typhus, sepsis, brucellosis);
- by circulatory disorders( thrombosis of portal or splenic veins);
- with liver diseases( cirrhosis, hepatitis);
- with spleen involvement( echinococcosis, inflammatory process, tumor, traumatic injury).
In the presence of acute infectious diseases( especially with sepsis) the spleen acquires a soft consistency. The expressed compaction of the organ is observed in cases of amyloidosis, chronic infectious processes, blood diseases, oncological lesions, portal hypertension.
Due to cysts, heart attacks, syphilitic gum, echinococcosis, the surface of the spleen becomes uneven. Soreness of the body arises as a result of its infarction, inflammation, as well as thrombosis of the splenic vein.
How the percussion of the spleen is performed is described in this video:
Norms in children and adults
The protocol for ultrasound examination of the spleen must include the specific values of its three linear dimensions( information that the organ is enlarged, unsupported by numbers, is an unsubscription).
The normal size of the spleen( on average) in adult patients is presented in the following list:
- its length can range from eight to fourteen centimeters;
- width - from five to seven centimeters;
- thickness - from three to five centimeters.
It should be understood that the above values are averaged, since the size of any internal organs is individual for each person.
The parameters of healthy spleen in children all the time change( in full accordance with the age and size of the continuously growing body).
The average body size for children of different age categories is indicated in the list:
- In newborn infants, the length of the spleen is 40 mm, the thickness is 20 mm, and the width is 38 mm.
- In children from one year to three years, the length of the organ is 68 mm, thickness - 30 mm, width - 50 mm.
- By the age of seven, the length of the spleen is increased to 80 mm, thickness - up to 40 mm, width - up to 55 mm.
- In children of eight to twelve years, the length of the organ is 90 mm, the thickness is 45 mm, the width is 60 mm.
- By the age of fifteen, the length can be from 100 to 120 mm, the thickness - 55 mm, and the width remains at the same level.
Based on the data of the list, it is possible to establish whether the size of the spleen obtained during its ultrasound examination is appropriate for the age-appropriate rate.
In the event of a mismatch in the indicators, the doctor may suspect that the small patient has:
- leukemia;
- Hematologic Syndrome;
- tuberculosis;
- congenital heart disease;
- anemia;
- of typhoid fever;
- liver disease.
Methods of palpation of the spleen
Palpation( palpation) is one of the main methods of spleen research.
When performing a superficial palpation of the abdomen, the study of the left hypochondrium region needs to be given special attention, since even a slight increase in this organ allows one to grope a sufficiently dense conical formation located at the edge of the costal arch.
If the patient has splenomegaly( pronounced enlargement of the spleen), which provokes the bulging of most of it from under the edge of the costal arch, there is no need for deep palpation, since in this case it is quite enough surface probing.
Since palpation of the spleen, performed with the patient's vertical position, in most cases is difficult due to the strong tension of the musculature of the stomach, it is performed:
- in the position of the patient on the back;
- in its diagonal( at an angle of 45 degrees) position on the right side.
At the same time, this provision involves some inconveniences for the doctor. To carry out a palpitation of the spleen, he must either squat on the couch, or stand on one knee next to her.
- First perform bimanual palpation in the position of the patient lying on his back on a not too soft bed with a low headboard. His legs should be stretched, and his hands are laid along the trunk. Approaching the bed on the right side, the doctor occupies the usual position next to her.
The doctor places the right palm brush on the left side of the abdomen in such a way that its base is turned toward the pubic region, and the terminal phalanges of closed and slightly bent fingers are located at the same level at the edge of the costal arch( left).
The end phalanx of the middle finger should be located in the corner formed by the lower edge of the tenth rib and the tip of the eleventh rib. The thumb of the right hand does not participate in this manipulation.
The left hand brush is placed on the left side of the chest of the patient along the seventh to tenth ribs at the level of the anterior axillary( axillary) line. Her fingers should be deployed in the direction of the spinal column.
During respiratory movements, the left hand of the doctor should slightly restrict lateral movements of the costal arch, creating the conditions for an increase in the respiratory excursion of the diaphragm, which helps to move the spleen downward. In the process of palpation, the investigator performing it regulates the patient's breathing.
If in the course of percussion or surface palpation information was received about the localization of the lower border of the spleen, the fingers of the palpating brush are set one to two centimeters below it. After that, the doctor makes a skin fold, shifting the skin of the anterior abdominal wall by three to four centimeters in the direction opposite to the costal arch.
Thanks to this method, the doctor creates a skin reserve under his fingers, which facilitates their unproblematic advancement deep into the left hypochondrium. After this, the patient exhales, and the palpation specialist, together with the lowering of the abdominal wall, carefully immerses the fingers of the right hand inside the abdominal cavity( at an angle of 35-45 degrees), leaving the arm in this position until the end of the next inspiration.
The space left between the back surface of the hand and the costal arch should be sufficient to pass the lower pole of the spleen. Suggesting the patient to make a deep and unhurried breathing movement of the belly, the doctor presses the left arch with the fingers of his left hand, somewhat limiting its mobility.
At this point, the fingers of the palpable hand, being still, remain in the depth of the abdominal cavity, counteracting the pushing movement of the abdominal wall.
Sometimes the spleen can not get into the pocket, just by touching its lower edge with the terminal phalanges of the fingers. In such cases, a specialist seeking to probe this organ should, at the time of inspiration, slightly move the palpating hand forward, straightening the fingers, making them either stroking( from above) or poddevayuschie( bottom) movement.
It should be remembered that careless execution of palpation is fraught with damage to this extremely vulnerable organ.
- Repeating the study several times with ( usually for two to three breathing cycles), palpation is performed in the patient's right side position, named after the Swiss diagnostician who proposed it and the clinician Herman Sali.
On the side, the patient should turn to the right side( at an angle of 45 degrees) to the surface of the couch, placing the palms folded together under the right cheek. The right leg of the patient should be stretched, and the left one - to relax the musculature of the abdomen - is bent at the knee joint and slightly brought to the trunk.
The specialist can take the usual position, however, if the couch is too low and there is insufficient flexibility of the wrist joints, he will have to palpate squatting or dropping in front of the bed on his right knee. It is this position that enables his right arm to flatten himself on the patient's stomach.
The further technique of palpation of the spleen according to Sali practically does not differ from the above described method of bimanual examination of it, carried out in the position of the patient lying on the back.
- In order not to confuse an enlarged spleen with an enlarged kidney, additional palpation is required in the patient's standing position. This position on the one hand provokes the spleen to retreat to the back, in connection with which the procedure of its palpation is difficult, and on the other hand it helps to lower the kidney and facilitates palpation of this organ.
Splenomegaly allows you to feel at the forefront of the organ of interest, the presence of characteristic scraps that are absent in the kidney, endowed with a number of inherent only its specific features.
- In the presence of ascites( accumulation of free fluid in the abdominal cavity), palpation of the spleen may be difficult. In such cases, her palpation is carried out in the position of the patient lying on the right side( as in the study of Sali).It is possible to establish the presence of splenomegaly in patients with severe ascites using a ballot palpation technique performed in the supine position.
The manipulative specialist, the end phalanxes of the fingers of the palpated hand, which are bent together and slightly bent, performs a series of short, jerky and jerky strokes along the front wall of the abdomen( the fingers do not come off the surface of the skin).
The direction of the applied jerks undertaken to hit the test organ must be perpendicular to its expected lower edge.
This movement continues until there is a sensation of collision with a solid body that extends down deep into the abdominal cavity, and then pops up and again hits the end phalanges of the researcher's fingers.
This phenomenon was called the symptom of a "floating ice". It is at moments of such collisions that the surface of the organ under investigation is felt.
Video shows the technique of palpation of the spleen:
Norms and pathologies
The spleen, which takes part in the formation of the immune system, in the fight against pathologies of the bone marrow and blood, in all types of carbohydrate and lipid metabolism, plays a very important role in the human body.
That's why even minor malfunctions in the work of this body( and especially its increase in size) are grounds for serious concern.
In these cases, the patient is referred for ultrasound. The norm is:
- The location of the spleen on the left side, under the lower part of the diaphragm. The middle of a healthy organ should be adjacent to the stomach, and the tail of the pancreas - localize at the center of the spleen's gates( the so-called place of entry of nerves and arteries into it and the release of lymphatic vessels and veins).
- Presence of a parenchyma having a fine-grained, uniform structure.
- Diameter of splenic vein not exceeding 0.5 cm.
- Presence of homogeneous echostructure.
- Complete absence of any impregnations.
- Presence of external outlines resembling a crescent moon.
Symptoms of pathology can be represented:
- The presence of an inhomogeneous structure( as a rule, benign tumors result).
- Increased echogenicity( except for some oncological diseases of the blood, not accompanied by increased echogenicity, but necessarily provoking the appearance of splenomegaly).
- The presence of pronounced splenomegaly - a pathological increase in the size of the spleen.
- Wrong form of the organ.
Detection of even minor deviations from standard parameters has an important diagnostic value, requiring the obligatory consultation of a qualified specialist.