The gallbladder, localized in the lower part of the right lobe of the liver, has small( up to 14 cm in length and 5 cm in width) dimensions and a soft consistency. Speaking from under the liver no more than a centimeter, in healthy people, he practically is not probed. Its availability of palpation is always a sign of pathology.
The factors contributing to the pathological consolidation of the gallbladder walls are most often chronic inflammatory processes( for example, cholecystitis), tumors or surrounding multiple adhesions that occur after peri-cholecystitis( inflammation of the serous membranes of this organ).
The unnaturally enlarged gallbladder is most often managed in patients suffering from:
- by its tumor lesion( cancer);
- with pancreatic head cancer;
- cholelithiasis( accompanied by the formation of multiple stones in the gallbladder and blockage of the bile ducts);
- empyema( purulent inflammation, accompanied by a cluster of purulent contents in the cavity of the gallbladder, triggered by a bacterial infection).
A specialist performing gallbladder palpation, gropes him under the lower surface of the liver, outside of the lateral( lateral) edge of the rectus abdominis( right), approximately at the intersection of the horizontal line passing at the level of the ninth pair of ribs, with the right mid-clavicular line projectedon the anterior abdominal wall.
The pathologically altered gallbladder is palpated in the form of a fairly dense pear-shaped or ovoid form on the surface of the liver, but palpation of this organ is necessary also in those cases when he himself is not probed, but there are certain( presented, in the first place, severe soreness) palpation signs, indicating the presence of changes in it.
For example, the presence of the so-called symptom Ortner( characterized by the appearance of pain at the time of an easy tapping with the edge of the palm along the edge of the costal arch at the site of the gallbladder) confirms the fact of its inflammatory lesion.
In such cases, as a rule, the symptoms of Zakharyin( characterized by the appearance of sharp pain accompanying effleurage in the gallbladder) and Obraztsov-Murphy are also revealed.
For the manifestation of the latter, a specialist performing palpation, slowly and deeply immersing his hand in the area of the right hypochondrium( manipulation is performed at the time of exhalation), asks the patient to take a deep breath;while in the patient the pain either arises or sharply increases.
Palpation of the gallbladder can reveal a number of painful points( indicating the presence of pathologies of this organ and biliary tract), represented by:
- Epigastric zone.
- A point of the gallbladder localized at the point of fixation of the lateral edge of the rectus abdominis to the cartilage of the costal arch.
- Choledochokpankreaticheskoy zone, located five centimeters to the right of the navel.
- The point of the diaphragmatic nerve of the cervical plexus located between the legs of the sternocleidomastoid muscle( pressing this point causes pain under the clavicle, in the shoulder, and in some cases in the right hypochondrium).This phenomenon is called the "frenicus-symptom".
- The acromial( most projecting towards the lateral surface of the acromial process of the scapula) is the point located on the right shoulder.
- Shoulder point localized near the bottom angle of the right scapula.
- Points of VIII, IX, X vertebrae.
Soreness is often observed with pressure applied to the right side of the X-XII vertebrae. The same effect is obtained by tapping with the edge of the palm or pressing a little to the right of the IX-XI vertebrae of the thoracic spine.
How do I palpate the gallbladder?
Given the anatomical features of the localization of the gallbladder, his palpation is carried out by the same methods as palpation of the liver.
Experienced specialists often use this method in a very simple and convenient way, which, although not described in any training manual, sometimes gives even more information than the classical palpation performed in the position of the patient lying down.
- We are talking about palpation of the gallbladder in a patient who has seated position. The patient is seated on a chair or a hard couch and ask him to lean slightly forward, leaning his hands in its edges. This position helps to relax the abdominal muscles. During the study, the angle of the torso may change, and the respiratory movements must be carried out by the abdomen.
The doctor places his right palm at the outer edge of the straight( right) abdominal muscle perpendicular to the anterior abdominal wall. With each exhalation of the patient( within two or three respiratory cycles), the fingers of the doctor, not changing their position, will sink inside the hypochondria to the very back of the wall.
Once this happens, the patient is instructed to take a very deep and slow breath. Thanks to this, the liver, lowered, falls on the explorer's palm with its lower surface, giving it an excellent opportunity for feeling.
Slightly bending fingers, the specialist performs a sliding motion from the edge of the liver to the costal arch, receiving information about the elasticity of the liver, the sensitivity and the nature of its edge and lower part. Consistently moving the arm, the doctor receives a fairly complete picture of the condition of almost the entire lower surface of the liver and its edge.
At the time of palpation of the liver at the very edge of the rectus abdominis, sometimes it is possible to probe the gallbladder or to detect the presence of local soreness. Most often this occurs in the owners of a weakened abdominal wall or an enlarged gallbladder. The classical method of palpation provides such an opportunity much less often.
Another drawback of the classical method of palpation is the fact that the fingers of a specialist performing it touch the organ being examined only with the very tips of the terminal phalanges, and only the most prominent parts of the liver are available for study.
Palpation in the sitting position allows you to feel the liver and gallbladder with the entire surface of the terminal phalanges, endowed with the greatest sensitivity. In addition, the area of the investigated organs is much larger.
With the help of this technique, it is quite often possible to differentiate the cause of the pain syndrome arising in the right hypochondrium region, regardless of whether it is caused by diseases of the gallbladder or liver, or a simultaneous lesion of these organs, or duodenal pathologies.
- There is another method of palpation of the gallbladder. In order to perform palpatory examination of this organ, the doctor puts his left palm on the patient's rib arch so that the terminal phalanx of the thumb is above the site of the localization of the gallbladder, and the remaining fingers are located on the surface of the chest. During the inspiration, the researcher's thumb should feel the area of the gallbladder, making multidirectional sliding movements and subsequently plunging into the hypochondrium.
For the diagnosis of pathological processes in the gallbladder, a number of palpatory techniques have been developed, the use of which provokes pain in the patient:
- To detect the symptoms of Obraztsov-Murphy and Kera, a penetrating palpation is used.
- Make sure the presence of the Grekov-Ortner symptom is helped by tapping the ulnar( adjacent to the little finger) side of the palm on the right side of the costal arch.
- It is possible to reveal the symptom-frenicus by pressing with your index finger at a point located between the legs of the right sternocleidomastric muscle.
A more detailed description of the above mentioned techniques is given in the next section of our article.
Video about palpation of the liver and gallbladder:
Definition of the pathological symptoms of
Quite often palpation, which did not lead to the detection of the gallbladder, helps to reveal in the area of its localization the presence of severe soreness and considerable muscle tension.
For example, a well-defined muscle tension in the area of the gallbladder projection may indicate that the inflammatory process has spread to the peritoneum.
It is established that the most characteristic areas of soreness are located at the site of the localization of the gallbladder and in the so-called Schoffar triangle, a region delineated by a horizontal line six centimeters above the navel, the median line of the body and a straight line drawn up and to the right of the navel( at an angle of fortyfive degrees).
What are the symptoms at the time of palpation will indicate the presence of an inflammatory process? First of all, these painful manifestations are presented:
- Symptom of Lepene , characterized by the emergence or aggravation of pain when the rib is struck in the right hypochondrium at the time of deep inspiration compared to the pain experienced during exhalation.
- Symptom of Murphy , consisting of interrupting breathing at the level of deep inspiration as a result of acute soreness in the abdomen, localized under the thumb of a doctor performing palpation. The brush of his right hand should be placed in such a way that the thumb is below the level of the costal arch, approximately at the site of the localization of the gallbladder, and the other fingers are located at the very edge of it. Variation of Murphy's symptom is observed when palpation is made in relation to the patient in a sitting position( the researcher must stand behind the patient, placing the fingers of the right hand on the area of the gall bladder).In this case, palpation, which provokes acute soreness, interrupts the patient's breathing at the time of deep inspiration. Some patients may experience spontaneous pain in the area of the gall bladder during the inspiratory phase.
- Symptom of Lida , which appears against the backdrop of chronic cholecystitis and manifested by flabbiness and atrophy of muscles in the region of the right hypochondrium.
- Symptom of Boas , which is a sign of acute cholecystitis and characterized by the appearance of pain in response to pressure in the region of the XII thoracic vertebra, produced with tissue displacement and a small( four to five centimeters) indentation to the right.
- Symptoms of Kera and Lepene , making themselves known for their increased sensitivity to pain during the performance of classical palpation of the gallbladder during the inspiratory phase.
- Symptom of Skvirsky , indicating the presence of cholecystitis and manifested by the appearance of pain during palpation or gentle percussion, performed by the palm ridge slightly to the right of the spine at the level of IX-XI vertebrae( thoracic).
- Symptom of Mussi-Georgievsky ( synonymous with the term "frenicus-symptom"), observed in patients suffering from liver and gallbladder diseases. This pathology is characterized by the appearance of acute soreness at the moment when the doctor's fingers press a point located between the legs of the sternocleidomus muscle( right) located at the upper edge of the clavicle. High pain sensitivity is due to the fact that the diaphragmatic nerve runs through this area, which irritates the diseases of the above organs.
- Symptom Ortner-Grekov , indicating the presence of an inflammatory process that takes place in the gallbladder and is characterized by the appearance of pain when the edge is rubbed on the lower surface of the right costal arch.
Norms and pathologies of
It is rather difficult to palpate a healthy gallbladder, while the detection of a pathologically enlarged or altered organ is not particularly problematic.
The pathology of this organ palpably manifests itself by its increase, arising from the multiplication of its contents, represented by:
- by the presence of stones;
- with an increasing amount of bile;
- by the accumulation of an inflammatory fluid that is purulent or serous.
The consistency, volume and nature of the surface of the gallbladder involved in the pathological process are dependent on its content and wall state:
- If the common bile duct has been clogged with a stone, the gallbladder quite rarely acquires significant dimensions of the , since the extensibility of its walls is limited by the inevitably slow and prolonged inflammatory process. Having become very dense and tuberous, the walls of the organ acquire soreness. A similar symptomatology is characteristic in the presence of stones or in the case of tumor damage.
- If the obstruction( blockage) of the common bile duct occurred through the fault of the tumor, the patient experiences gall bladder dilatation due to his overflow with bile. In this case, palpation of the affected organ indicates that it has acquired the appearance of a pear-shaped sac with an elastic consistency. This phenomenon is called the symptom of Courvoisier-Terrier.
- Virtually all patients with palpation of the gallbladder are quite significant pain, radiating to the area of the right scapula and right shoulder. An exception is the case of compression of the main bile duct with a tumor of the pancreas head. In these cases, the organ under examination takes the form of a practically painless and often tense pear-shaped body with an elastic and smooth structure that shifts in the course of respiratory movements. Another characteristic manifestation that indicates the tumor of the head of the pancreas is the presence of persistent mechanical jaundice, as a result of which the urine and skin integuments of the patient acquire a yellow - with a greenish tint - color.