The liver is not palpable, what does this mean. Palpation of the spleen: what is it, types and methods of carrying out How is palpation of the liver performed? Rules of procedure and interpretation of results

Spleen(C) - unpaired parenchymal organ, its length is 8.0-15.0 cm, width - 6.0-9.0 cm, thickness - 4.0-6.0 cm, weight is about 170 g. The shape of the spleen is ovoid with pointed lower pole.

Distinguish:

• external convex diaphragmatic surface adjacent to the costal part of the diaphragm, and
• visceral surface facing other organs of the abdominal cavity.

The anterior portion of the visceral surface of the spleen is adjacent to the stomach (gastric surface), the posterior-lower portion is adjacent to the kidney and adrenal gland (renal surface). From below, the spleen is in contact with the bend of the large intestine.

On the border of the anterior and posterior sections of the lower surface there are gates of the spleen - the place of entry of arteries, nerves and exit from it of veins, lymphatic vessels.

The spleen lies directly under the left dome of the diaphragm between the IX and XI ribs. The long axis of the spleen coincides with the X rib. Behind, the upper-posterior edge of the spleen does not reach the spine by 3-4 cm, in front - its anterior-lower edge does not extend beyond the anterior axillary line and costal arch.

Asthenics have a spleen more vertical and lower
in hypersthenics- more horizontal and higher.

The size, filling, position of the stomach and transverse colon significantly affect the position of the spleen.

The peritoneum covers the spleen from all sides, excluding the gate and the area to which the tail of the pancreas adjoins.

Duplicatures of the peritoneum form ligaments:

• gastro-splenic,
• diaphragmatic-splenic,
• spleno-renal.

Fixation of the spleen is provided by intra-abdominal pressure, diaphragmatic-splenic and diaphragmatic-colic ligaments. The spleen has its own fibrous capsule.

Blood supply to the spleen carried out by the splenic artery, the largest branch of the celiac trunk. The length of the artery is 8.0-30.0 cm, the diameter is 0.5-1.2 cm, the splenic vein is 1.5 times larger than the splenic artery. Lymph drainage of the spleen occurs through the lymphatic vessels and lymph nodes concentrated in the zone of its gate. Lymph flows into the celiac lymph nodes.

Innervated by the spleen branches of the celiac plexus and vagus nerves, forming a powerful subserous and thinner plexus in the area of ​​the hilum of the spleen.

Brief physiology of the spleen

The spleen is one of the vital organs.

She performs

• immunological,
• filtration,
• hematopoietic and
• depot function
• takes part in the metabolism, in particular, of iron, proteins, etc.

immune function The spleen consists in the capture and processing of harmful substances by macrophages, blood purification from various foreign agents: bacteria, viruses, endotoxins, as well as insoluble components of cellular detritus during burns, injuries, etc.

Spleen cells recognize foreign antibodies and synthesize specific antibodies.

The spleen controls circulating cells blood, aging and defective erythrocytes are destroyed in it, granular inclusions (Jolly and Heinz bodies, iron granules) are removed from erythrocytes.

Splenic macrophages recycle iron from destroyed red blood cells, turning it into transferrin.

There is an opinion that the death of leukocytes occurs not only in the lungs, liver, but also in the spleen; platelets are destroyed in the liver and spleen. The spleen not only destroys, but also accumulates blood cells - erythrocytes, leukocytes, platelets. From 30 to 50% of circulating platelets are deposited in the spleen and, if necessary, they can be released into the blood. Normally, the spleen contains no more than 20-40 ml of blood, however, under certain conditions, a depot can be created in it.

The spleen is involved in protein metabolism, synthesizes albumins, globin (the protein component of hemoglobin), factor VIII of the blood coagulation system. The participation of the spleen in the formation of immunoglobulins is important; it produces lymphocytes and monocytes.

Examination of the spleen

The study of the spleen begins with an assessment of the size of the abdomen, the symmetry of its left and right half, the assessment of the severity of the deepening of the abdomen at the edge of the left costal arch.

In a healthy person the size and shape of the abdomen corresponds to the type of constitution, sex, degree of fatness and physical development.

When examining the abdomen in a horizontal position a small depression is usually determined at the edge of the costal arches on the left and right.

Pathological processes of the spleen always accompanied by its increase from insignificant to colossal sizes, when the spleen can reach the iliac fossa.

With a large enlargement of the spleen the abdomen increases in size, acquires asymmetry with a bulging of the left half, and in the horizontal position of the patient through the abdominal wall, you can see the outlines of the enlarged spleen. This is especially noticeable in emaciated, cachectic patients. Along with this, the deepening of the abdomen at the left edge of the costal arch is smoothed out or disappears, and even protrusion of the lower part of the left half of the chest is possible.

Percussion of the spleen

When starting percussion of the spleen, it is important to remember that it is located in the posterior part of the left hypochondrium, that this organ is small in size, that 1/3 of the spleen lies very deep and percussion is not available. Only 2/3 of its diaphragmatic surface, lying directly under the chest wall, can be percussed.

Rice. 443. Projection of the oval of the spleen on the chest wall. The length of the oval lies on the X rib, the diameter is between the IX and XI ribs.

Projection area of ​​the spleen on the chest wall resembles an oval with a truncated back. An oval is projected onto the lateral surface of the chest between the IX and XI ribs, its length lies on the X rib (Fig. 443).

The part of the spleen accessible for percussion is surrounded by air-containing organs (lungs, stomach, intestines), therefore it is better to percuss it with quiet direct percussion according to G.F. Yanovsky, resulting in absolute stupidity. But you can also use deep mediocre percussion, while only dullness will be determined above the spleen due to the involvement of surrounding tissues in the percussion sphere, giving a loud tympanic sound.

Percussion of the spleen is performed in the vertical or horizontal position of the patient on the right side (Fig. 444). In these positions, the liquid contents of the stomach are displaced from the spleen either down or to the right, which improves the conditions of the study. The finger-plessimeter is installed both on the ribs and on the intercostal space.

After percussion, the length and diameter of the spleen are measured, normally the length is 6-8 cm, the diameter is 4-6 cm.

2 sizes of the oval of the spleen are determined - length and diameter.

Posterior-upper edge of the length percussed along the tenth rib or intercostal space. The study starts from the spine, the finger-plessimeter is installed parallel to the spine. When dullness or dullness appears, a mark is made along the outer edge of the finger.

For determining anterior-lower edge of the length spleen, percussion starts from the navel, placing a finger along the midline, and continues it towards the edge of the costal arch, until dullness or dullness appears.

Posterior superior margin of the spleen normally located along the X rib at the level of the scapular or posterior axillary line, the anterior-lower one does not go beyond the edge of the costal arch.

Diameter of the spleen is determined along the middle axillary line, from above, percussion starts from the V-VI rib, from below from the edge of the costal arch or slightly lower. This size can be determined by percussing along the perpendicular to the middle of the length of the spleen, going from the anterior and then from the posterior axillary line. The diameter of the spleen is usually located between the IX and XI ribs, although it may be displaced, depending on the type of constitution. Normally, the length of the spleen is 6-8 cm, the diameter is 4-6 cm.

In clinical practice, there are many situations where it is difficult to evaluate the results of percussion of the spleen.

Percussion data may differ from the true size of the spleen:

• with compaction of the lower lobe of the lung on the left or left-sided pleural effusion, a false increase in the size of the spleen will be detected;
• with emphysema, swollen lungs displace the spleen down and cover it, which “reduces” the size of the spleen;
• with a significant increase in the left lobe of the liver, the percussion dullness of the liver and spleen merges, creating a false impression of an increase in the spleen;
• with a strong overflow of the intestinal loops adjacent to the spleen with solid or liquid contents, an “increase” in the area of ​​\u200b\u200bsplenic dullness occurs;
• with swelling of the intestine, when its loops are located between the spleen and chest wall or swollen loops press the spleen under the diaphragm, the area of ​​​​splenic dullness decreases;
• with significant effusion into the abdominal cavity in the horizontal position of the patient, it is impossible to determine splenic dullness due to the merger of two dullness.

Thus, based on the above, an increase in the spleen can be judged only with a significant increase in the area of ​​its percussion dullness and under the condition that the organs surrounding the spleen are in a good condition.

True increase in percussion dullness of the spleen- an unconditional sign of pathology, and it occurs for many reasons, which will be discussed in the section on palpation of the spleen. In cases where obvious signs of splenomegaly are revealed during examination of the abdomen and superficial palpation of the abdomen, it makes no sense to determine the size of the spleen using percussion, its palpation will be more informative.

Palpation of the spleen

Palpation is one of the main methods of examination of the spleen. Carrying out superficial palpation of the abdomen, it is necessary to carefully examine the region of the left hypochondrium, since even with a slight increase in the spleen at the edge of the costal arch, it can be felt in the form of a dense cone-shaped formation emanating from the hypochondrium.

Palpation examination of the spleen is performed with the patient in the supine position and / or in a diagonal position on the right side at an angle of 45 ° (Fig. 445).

A - palpation with the patient in the supine position (top view),

The principle of palpation is the same in both cases. The position on the right side is considered more successful, it contributes to greater relaxation of the muscles of the left half of the abdomen and some displacement of the spleen down, however, at the same time, some inconvenience is created for the doctor: for better penetration of palpating fingers in the hypochondrium, the doctor is forced to sit down at the couch or kneel on the floor .

Palpation in the vertical position of the patient often difficult due to tension in the abdominal muscles. When palpation of the spleen in the position of the patient on his back, he should approach the right edge of the bed, it is better to keep the legs extended, and lay the arms along the body. The doctor takes the usual position by the bed. The doctor's left hand is placed on the left half of the patient's chest at the level of the anterior axillary line along the VII-X ribs with the fingers towards the spine. During the breathing of the subject, it should restrain the movements of the costal arch, creating conditions for a greater downward displacement of the spleen. The right hand with slightly bent terminal phalanges of the fingers is placed flat on the stomach with the fingers perpendicular to the costal arch at the level of the end of the X rib or the anterior axillary line directly at the edge of the costal arch or slightly retreating from it.

If there is already information about the position of the lower pole of the spleen based on the results of superficial palpation or percussion, then the fingers are placed 1-2 cm below it. Next, a skin fold is made with the fingers shifted 3-4 cm down from the costal arch.

With each exhalation of the patient, the fingers of the right hand are carefully immersed in the depth of the hypochondrium at an angle of 35-45 °, forming a pocket in the same way as it is done during palpation of the liver. Usually 2-3 dives are enough. If the fingers go superficially under the costal arch, they can push or push the spleen back into the depths of the hypochondrium, under the diaphragm. Therefore, we emphasize again - the fingers plunge forward and down.

Having penetrated deep into the hypochondrium, the doctor asks the patient to take a calm, deep breath with the “belly”. At the height of inhalation, the spleen descends as much as possible and enters the pocket between the costal arch and the back surface of the fingers. On exhalation, it returns to its previous position, sliding over the fingers. At this time, the doctor evaluates its qualities. It is better at the height of inspiration to make a sliding movement with your fingers towards the outer edge of the costal arch, that is, to actively exit the hypochondrium without retreating from the edge of the ribs.

In some cases, the spleen may not fall into the pocket, but only touch, bumping into the fingers of the doctor, and this is also valuable information.

On palpation of the spleen, in the patient's position on his side, he turns to the right up to 45 ° to the plane of the couch, puts both hands under his right cheek, his right leg is extended, and his left leg is half-bent to relax the abdominal muscles. The doctor can take the usual position, but if the couch is low and there is not enough plasticity in the wrist joint, then you need to squat or kneel on your right knee. This achieves a more comfortable position of the right hand, which, as in the study on the back, should lie flat on the abdomen of the subject. Further palpation technique does not differ from the above.

With any method of palpation in a healthy person, the spleen is not palpable. Only in rare cases, in asthenic women with a low position of the diaphragm, leading to a downward displacement of the spleen, can the lower pole of the spleen be palpated. It is defined as an elastic, painless, easily displaced tongue.

If the spleen is palpable in any other situation, then this is a sign of either its enlargement or prolapse. An enlarged spleen always becomes denser than normal.

If the spleen is large and protrudes significantly from under the costal arch, then the methods of its palpation presented above are not applied. Such a spleen is felt through the abdominal wall, the entire accessible surface and the entire contour are examined.

The palpable spleen should be described as follows:

• magnitude;
• form;
• density;
• the nature of the surface and edge;
• the presence of clippings along the front edge;
• mobility;
• soreness.

Some pathological processes of the spleen (traumatic injury, spontaneous rupture, abscess) are accompanied by reflex tension of the muscles of the anterior abdominal wall, which is detected already with superficial palpation, deep palpation in this case is not performed. Tension is usually localized in the left side of the abdomen and especially at the edge of the left costal arch.

Traumatic damage to the spleen occurs when a blow to the area of ​​the spleen, compression of the chest, fracture of the ribs on the left, falling on the left side. Spontaneous rupture of the spleen sometimes occurs with infectious mononucleosis, lymphosarcoma, myeloid leukemia, disintegration of the spleen tumor, overstretching of the capsule with splenomegaly. With a splenic abscess, the inflammatory process can spread to the spleen capsule with involvement of the peritoneum, local peritonitis develops.

Location of the spleen normal size (and enlarged) may be atypical. With the disposition of the internal organs, it is located on the right, and with its weak fixation by the ligamentous apparatus, the spleen descends below the costal arch, sometimes significantly. Sometimes it can be in the hernial sac of an umbilical hernia ("splenic hernia").

The enlarged spleen is easily palpable.

The increase is conventionally divided into:

• small or moderate;
• very big.

A small increase is such when the spleen protrudes from under the edge of the costal arch by 2-6 cm. Very large - when the lower pole of the spleen reaches the left iliac fossa and even passes to the right half of the abdomen.

A slight enlargement of the spleen is observed with acute infectious diseases (sepsis, typhoid, hepatitis, malaria, syphilis) and with some chronic infections (malaria, syphilis), with cirrhosis of the liver, with some blood diseases (some types of anemia, polycythemia, acute and chronic myelosis), as well as with tuberculosis of the spleen, lymphogranulomatosis, systemic connective tissue diseases, storage diseases.

Excessive enlargement of the spleen(splenomegaly) is observed in leukemia, amyloidosis, leishmaniasis, chronic malaria, liver cirrhosis, splenic vein thrombosis, spleen echinococcosis, and spleen abscess.

Enlarged spleen density may be different. There is a relationship between enlargement and density of the spleen, the larger the spleen, the denser it is. A slight compaction of the spleen is observed in acute infectious diseases, in chronic diseases the density increases. We draw attention to the special reaction of the spleen in acute infections - it increases slightly, slightly thickens and acquires a doughy texture. The woody density of the spleen is observed in amyloidosis, spleen cancer.

The surface of the enlarged spleen can be smooth and bumpy. Often, even with a significant increase, its surface remains even. The tuberous spleen becomes with perisplenitis as a result of the deposition of fibrin on its surface, with a gummous process (syphilis), with spleen cancer, after suffering spleen infarctions, sometimes with chronic leukemia. A limited protrusion on the anterior surface of the spleen is observed with single-chamber echinococcus, cyst and abscess of the spleen. Palpating the enlarged spleen, one or more, often deep horizontal notches, can be identified on its front edge. The presence of clippings confirms that it is a spleen and not a kidney or tumor.

Pain on palpation a normal and in most cases enlarged spleen is absent.

It only occurs when:

• a rapid increase in the spleen and, in connection with this, a rapid stretching of its sensitive capsule;
• inflammation of the peritoneum covering the spleen, as well as its rapid stretching;
• rupture of the spleen;
• twisting of the pedicle of the movable spleen.

A rapid increase in the spleen is more often noted in malaria and relapsing fever, in other infections it occurs slowly and the enlarged spleen is painless. Rapid stretching of the splenic capsule is possible with thrombosis of the splenic and hepatic veins, with an abscess of the spleen, subcapsular hematoma, which is always accompanied by pain on palpation. Slowly increasing enlargement of the spleen up to splenomegaly does not give palpation pain.

The spleen with an inflamed peritoneum covering it is always painful on palpation. The severity of pain can vary. Inflammation of the peritoneum - perisplenitis, develops when inflammation passes from the spleen or neighboring organs to the peritoneum. Pain due to irritation of the peritoneum occurs not only during palpation, but also when the patient changes position, takes a deep breath, coughs, or sneezes.

An enlarged spleen sometimes resembles an enlarged left kidney. For differentiation, it is necessary to use palpation of these organs in the upright position of the patient. Under these conditions, the spleen usually goes back to the hypochondrium and is palpated worse, while the kidney, on the contrary, drops somewhat and is palpated more clearly.

With ascites, it is difficult to palpate the spleen. If the effusion is large, it is better to use ballot palpation, as is done with palpation of the liver. The patient should be on his back, the doctor lays the right hand in the same way as during palpation of the spleen, the fingertips should be located at the edge of the costal arch. Without lifting the fingers from the skin, short jerky dives are made deep into the abdominal cavity in the direction of the proposed location of the spleen. If there is a sensation of hitting a solid body that goes deep after the push, and then pops up under the fingers, then there is reason to assume an enlarged spleen (“floating ice symptom”). Thus, the entire region of the left hypochondrium is examined, as well as lower down to the navel.

Auscultation of the spleen

It has limited value. It is carried out against the background of calm, and then deep diaphragmatic breathing (breathing "belly").

The phonendoscope is installed with a non-enlarged spleen at the edge of the costal arch, and with an enlarged one, directly above the spleen (Fig. 446).

Enough listening for 3-4 respiratory cycles. The entire surface accessible to palpation is examined. In a healthy person, during auscultation of the spleen area, the friction noise of the sheets of the peritoneum is not audible, only intestinal peristalsis is heard. With the development of perisplenitis over the spleen, you can listen to the friction noise of the peritoneum, reminiscent of the friction noise of the pleura.

The spleen is an unpaired organ located on the left side of the abdominal cavity. The anterior part of the organ is adjacent to the stomach, and the posterior part to the kidney, adrenal gland and intestines.

The structure of the spleen

The composition of the spleen is determined by the serous cover and its own capsule, the latter is formed by a combination of connective tissue, muscle and elastic fibers.

The capsule passes into the skeleton of the organ, dividing the pulp (parenchyma) into separate "islands" with the help of trabeculae. In the pulp (on the walls of the arterioles) there are round or oval nodules of the follicle). The pulp is based on what is filled with a variety of cells: erythrocytes (mostly decaying), leukocytes and lymphocytes.

Organ functions

• The spleen is involved in lymphopoiesis (that is, it is a source of lymphocytes).
• Participates in the hematopoietic and immune functions of the body.
• Destruction of used platelets and red blood cells.
• Deposition of blood.
• In the early stages of embryogenesis, it works as a hematopoietic organ.

That is, the organ performs many important functions, and therefore, in order to determine pathologies at the initial stages of the examination, it is necessary, first of all, to perform palpation and percussion of the spleen.

The sequence of palpation of internal organs

After collecting complaints, anamnesis and a general examination, the doctor, as a rule, proceeds to physical research methods, which include palpation and percussion.

Distinguish:

• Superficial palpation, which reveals pain in a particular area, tension in the abdominal muscles, swelling, various seals and formations (hernias, tumors, nodes). It is carried out by light pressure with half-bent fingers, starting from the left iliac region counterclockwise.
• Deep palpation, carried out in the following sequence: blind (its final part), colon (ascending and descending sections), transverse colon, stomach, liver, pancreas, spleen, kidneys, is carried out using deep penetration of the doctor's fingers into the abdominal cavity .

In case of suspicion of the presence of diseases of the spleen (or its increase due to liver diseases), percussion, palpation of the liver and spleen are mandatory.

General rules for palpation

The spleen is one of the most informative physical research methods conducted by a doctor. In the case of a slight increase in the organ, when the spleen is not easy to feel, the doctor will definitely recommend an ultrasound scan to confirm / refute the alleged pathology in a child or an adult.

Patient position:

• Lying on your back (in this position, palpation of the liver and spleen is performed).
• Lying on the right side. The right hand is located under the head, and the left should be bent at the elbow and laid on the chest (this technique is called Sali palpation of the spleen). Moreover, the patient's head should be slightly tilted to the chest, the right leg is straight, and the left leg should be bent at the hip and knee joints.

Palpation of the spleen: algorithm

1. The doctor should place his left hand so that it is on the left side of the subject's chest, between the 7th and 10th ribs in accordance with the axillary lines, and apply slight pressure. In this case, the fingers of the right hand should be half-bent and located on the left costal arch so that the middle finger is adjacent to the 10th rib.
2. When the patient inhales, the skin is pulled down to form a skin fold.
3. After exhalation, the doctor's hand penetrates deep into the abdomen (abdominal cavity).
4. The patient, at the request of the doctor, inhales deeply, while under the influence of the diaphragm, the spleen moves down. In the case of its increase, the doctor's fingers will come across its lower pole. This action must be repeated several times.

Interpretation of results

Under normal conditions (in healthy people), the spleen is not palpable. An exception is asthenics (usually women). In other cases, it is possible to feel the spleen when the diaphragm is lowered (pneumothorax, pleurisy) and splenomegaly, that is, an increase in the size of the organ. This condition is more often observed in the following conditions:

• Blood diseases.
• Chronic pathologies of the liver (here splenomegaly is a sign of portal hypertension or
• Chronic and acute infectious processes (infectious endocarditis, malaria, typhoid, sepsis).
• Connective tissue diseases.
• heart attacks or

Most often, palpation of even an enlarged spleen is painless. The exceptions are organ infarcts, rapid expansion of the capsule, perisplenitis. In these cases, the spleen becomes extremely sensitive (that is, painful on palpation).

With cirrhosis of the liver and other chronic pathologies, the edge of the spleen is dense, while in acute processes it is soft.

The consistency is usually soft in acute infections, becoming firm in chronic infections and cirrhosis of the liver.

According to the degree of enlargement of the organ, the palpable part may be smaller or larger, and the extent to which the spleen has come out from under the ribs may indicate the true degree of enlargement of the organ. So, a relatively small increase is indicated by the exit of the edge of the organ from under the costal arch by 2-7 centimeters, which is observed in acute infections (typhus, meningitis, sepsis, lobar pneumonia, and so on) or chronic pathologies (heart disease, cirrhosis, erythremia, leukemia, anemia) and unknown etiology, which occurs more often in young people (possibly with hereditary syphilis, rickets)

Accordingly, the density of the palpable edge of the spleen (with its increase), it is possible to draw conclusions about the age of the process. That is, the longer inflammation is present in the organ, the denser and harder its parenchyma, from which it follows that in acute processes the edge of the spleen is softer and more elastic than in chronic ones.

If the organ is too large, when the lower edge is determined in the pelvic cavity, it is very easy to palpate the spleen, and no special skills are required.

In the case of splenomegaly, as a result of a neoplasm, palpation of the spleen (more precisely, its margo crenatus) determines notches (from 1 to 4). A similar diagnostic sign indicates the presence of amyloidosis, leukemia (chronic myelogenous or pseudoleukemia), malaria, cysts and endothelioma.

That is, when performing palpation of the spleen, the doctor has the opportunity to assess the condition of its surface, detect fibrin deposits (as, for example, with perisplenitis), various protrusions (which happens, for example, with abscesses, hemorrhagic and serous cysts, echinococcosis) and determine the density of tissues. With abscesses, swell is often found. All information determined by palpation is extremely valuable both for diagnosing the disease of the spleen itself, and for determining diseases that could lead to splenomegaly.

Normally, the spleen is located in the region of the left hypochondrium, its long axis is located along the tenth rib. The organ has an oval (bean-shaped) shape.

The spleen in childhood

The size of the spleen is normal depending on age:

• Newborns: width - up to 38 millimeters, length - up to 40 millimeters.
• 1-3 years: length - up to 68 millimeters, width - up to 50 millimeters.
• 7 years: length - up to 80 millimeters, width - up to 55 millimeters.
• 8-12 years: width - up to 60 millimeters, length - up to 90 millimeters.
• 15 years: width - up to 60 millimeters, and length - 100-120 millimeters.

It should be remembered that palpation of the spleen in children, as well as in adults, should be painless, in addition, normally the spleen in a child is not determined. The sizes described above are not absolute, that is, small deviations towards a decrease / increase in the size of an organ should not be regarded as a pathology.

Percussion of the spleen

This method is used to estimate the size (boundaries) of the body.

The patient is placed in the right semi-lateral position with the arms located above the head, while the legs are slightly bent at the hip and knee joints. Percussion should be done by moving from a clear to a dull sound, using quiet percussion strokes.

Conducting percussion

1. The plessimeter finger must be placed on the edge of the costal arch on the left side of the body, perpendicular to the 10th rib.
2. A weak percussion is performed along the 10th rib, first from the costal arch (left) until a dull sound (dullness) appears. A mark is made on the skin at the point of sound transition. Then they percuss from the axillary line (back) anteriorly until the sound becomes dull and also put a mark on the skin.
3. The length of the segment between the marks is the length of the spleen (corresponding to the 10th rib). Normally, this indicator is 6-8 centimeters.
4. From the middle of the length, perpendiculars are drawn to the tenth rib and further percussion is performed along them to determine the diameter of the spleen, which normally ranges from 4 to 6 centimeters.
5. Normally, the anterior part of the spleen (that is, its edge) should not go medial to the line that connects the free end of the 11th rib and the sternoclavicular joint. It is worth noting that the calculation of the size of the spleen using percussion is a very approximate indicator. The size of the organ is written as a fraction, where the numerator is the length, and the denominator is the diameter of the spleen.

The principle of palpation of the spleen is similar to palpation of the liver. The study begins to be carried out in the position of the patient on the back, and then it is necessarily carried out in the position on the right side.

The patient should lie on the right side with the left leg slightly bent at the knee and hip joints and the left arm bent at the elbow joint. The doctor sits on a chair to the right of the patient's bed, facing him. Palpation of the spleen is bimanual: the left hand is placed flat on the lower part of the chest on the left costal arch and slightly squeezes this area to limit the movement of the chest to the sides during inspiration and increase the downward movement of the diaphragm and spleen. The terminal phalanges of 2-5 fingers of the right hand are placed parallel to the anterior edge of the spleen 3 cm below its location found during percussion. The second and third moments of palpation are the formation of a skin fold and “pockets”: during exhalation, when the anterior abdominal wall relaxes, the fingertips of the palpating hand pull the skin towards the navel (formation of a skin fold), and then they are immersed deep into the abdomen towards the left hypochondrium (pocket formation). The fourth point is the palpation of the spleen: upon completion of the formation of a "pocket", which is carried out at the end of exhalation, the patient is asked to take a deep breath. The left hand at this time slightly presses on the lower part of the chest and the left costal arch, and the fingers of the palpating hand somewhat straighten out and make a slight oncoming movement towards the spleen. If the spleen is enlarged, then it falls into the pocket and gives a certain tactile sensation (Fig. 77). In the case of palpation of the spleen, its localization (in centimeters from the edge of the costal arch), consistency, shape and soreness are noted.

In a healthy person, the spleen is inaccessible to palpation, since its anterior edge is 3-4 cm above the costal arch, but if the spleen is palpated even at the edge of the costal arch, it is already 1.5 times enlarged.

Fig.77. Palpation of the spleen.

Enlargement of the spleen (splenomegaly) is observed in hepatitis, cirrhosis of the liver, cholangitis, typhoid fever, malaria, leukemia, hemolytic anemia, thrombosis of the splenic vein, etc. In acute infectious diseases, such as typhoid fever, or acute stagnation of blood in the spleen, it retains its soft texture , and in chronic diseases with its involvement in the pathological process, it becomes dense.

The edge of the spleen, with its enlargement, most often retains a slightly rounded shape and, in the vast majority of cases, is painless on palpation. Pain sensations appear during the acute development of the pathological process in the form of a traumatic injury to the spleen or a thromboembolic process.

The spleen is an unpaired organ located in the left upper part of the abdominal cavity. It performs several important functions in the body, being a storehouse of blood reserves and producing immune cells - lymphocytes. With diseases of this organ, various changes occur in its structure. And to recognize them, palpation of the spleen is performed. At the moment, there are several methods that allow palpation and percussion to determine various pathologies of the structure of the spleen. The results of diagnostics largely depend on the correctness of their implementation.

When palpation of the spleen, the patient should lie on his right side or on his back, his arms should be located along the body, legs extended

Palpation is a procedure for probing an organ through the skin of the abdominal cavity. For many years, this technique has been the basis for diagnosing diseases of the spleen. It is on the basis of palpation that the specialist makes a preliminary diagnosis and directs the patient for additional examination.

Before the invention of hardware diagnostic techniques (ultrasound, MRI, CT), the doctor examined the patient's abdominal organs exclusively with his fingers, performing palpation and percussion (tapping).

The spleen is located on the left side of the abdominal cavity and is almost completely hidden by the ribs. But, despite this, an experienced specialist will easily carry out the palpation procedure. In case of inflammation, the organ increases in size. In some cases, we are talking about an increase in two or three times. In this case, even the patient himself can feel the spleen, but to determine the degree of pathology, you should contact a professional.

Professional palpation of the spleen has the following goals:

1. Allows you to evaluate the size and shape of the body. If these indicators deviate from the norm, the specialist may assume the development of a particular disease.
2. Consistency. If the spleen becomes hard, then this indicates the presence of an inflammatory process.
3. Mobility. Normally, the organ is elastic and quite mobile. Decreased mobility may indicate the development of a serious pathology.
4. Pain syndrome. The manifestation of pain on palpation, physical exertion, or at rest is a bad sign.

Before proceeding to palpation, the doctor can collect an anamnesis, thanks to which he will be able to suggest the probable cause of the malfunction of the organ. Further, by feeling the affected area, the specialist confirms or rejects the preliminary diagnosis.

An experienced doctor is able to touch the following conditions:

• an increase in the body against the background of the fight against an infectious lesion of the body;
• heart attack;
• rupture of the spleen, etc.

Palpation allows the specialist to determine the amount of fluid accumulated in the organ, suggesting the development of internal bleeding. In addition, palpation can reveal other pathologies of the gastrointestinal tract.

Types of physical examination of the spleen and methods for their implementation

After the specialist completes the history, he proceeds to a physical examination of the spleen. There are two types of this technique:

1. Superficial palpation. It involves the identification of soreness of a particular area of ​​\u200b\u200bthe organ, as well as the degree of tension in the abdominal muscles. Allows you to determine the swelling of tissues, the presence of seals and neoplasms. Thus, it is possible to identify nodes, hernias and tumors. The procedure is performed with half-bent fingers and is carried out counterclockwise.
2. Deep palpation. Assumes a stronger mechanical effect on the body. Thus, the specialist manages to probe the tissues located close to the spleen, revealing a number of functional disorders.

If the doctor suspects the development of diseases of the spleen, then the patient undergoes several similar techniques:

• direct palpation of the spleen;
• palpation of the liver;
• percussion of the spleen.

Technique of superficial palpation

Palpation is performed either with the right hand or with both hands at the same time.

It is carried out when the body has increased in size or its boundaries have changed. Experts call this type of palpation examination indicative. The technique allows checking the status of the following criteria:

• muscle tone of the abdominal wall;
• the degree of divergence of the paraumbilical muscles;
• soreness;
• shape and boundaries of the spleen.

Before the procedure is started, the patient lies on his back and stretches his arms along the torso. In some cases, the patient should lie on the right side. The procedure has the following features:

• palpation is carried out on an empty stomach and after complete emptying of the intestine;
• the patient should breathe evenly and deeply, inhaling through the mouth, while there should be no tension in the abdominal wall;
• the doctor puts his hands on the patient's abdominal area, after which he begins to gently probe the various parts of the abdomen;
• palpation is carried out either with the right hand, or with both hands at the same time;
• the impact on the tissues of the abdomen should be carried out with a palm with closed and straightened fingers, while the hand remains soft and flexible, almost relaxed;
• movements should be smooth, sliding, terminal phalanges are used for palpation;
• it is very important that only the brush takes part in the palpation process.

Percussion according to Kurlov

This technique is used to determine the boundaries of the body. To do this, the patient should be laid on his side, his hands are placed above his head, and his legs are slightly bent at the knee and hip joints. The doctor taps the location of the spleen with his fingers, listening for a change in sound.

The basis of percussion is the change in sound from clear to dull. In this case, the specialist should use quiet percussion beats. For the correct determination of the size of the organ, a carefully worked out intensity of blows is very important.

The percussion algorithm involves the following steps:

1. The finger on which the blows will be carried out is called the plessimeter. It is installed on the edge of the costal arch, located on the left side of the sternum. It is important to keep it strictly perpendicular to the 10th rib. The doctor strikes this finger with the finger of the other hand. Changing the resulting sound allows you to determine the boundaries of the internal organ.
2. Next, the performance of weak percussion begins, the intensity of which increases until a clear dull sound appears. In the place where such a transition appeared, a corresponding mark is made on the patient's skin. It is she who defines the border of the body.
3. The next zone of percussion is the axillary line. The plessimeter finger is held along it until the sound is dulled. The mark is also set here.
4. The segment between the obtained marks is the length of the spleen. Usually the measurement is taken along the tenth rib.
5. From the middle of the resulting length, perpendicular to the tenth rib, further tapping is performed. Thus, it is possible to determine the diameter of the organ.

If the patient's spleen is not inflamed and enlarged from birth, then its edge should not reach the midline of the abdomen.

Percussion determination of the boundaries of the organ gives only approximate results, therefore the doctor always directs the patient to undergo an additional examination. These studies are written as a fraction, where the numerator is the length of the spleen, and the denominator is its diameter.

What are the symptoms of palpation?

If pain occurs in the left side of the abdomen, the spleen should be checked

Palpation is the basis for diagnosing diseases of the spleen. This procedure allows the specialist to determine a course of action. It is carried out in the following cases:

• if the patient complains of pain in the left side of the abdomen;
• with a visual increase in the body;
• in case of skin color change.

In addition, there are a number of diseases, the course of which is complicated. If the patient is suspected of developing such an ailment, palpation of the spleen is also performed.

Dimensions are ok

Knowing the normal size of this organ, the specialist accurately determines the presence of a particular pathology. In children and adults, these data are significantly different.

The size of the spleen in children

Depending on age, the size of this organ in children varies:

• in newborns, the length of the spleen should not exceed 40 mm with a width of 3.8 cm;
• for children of three years of age, the normal dimensions are about 7 cm long and 5 wide;
• in seven-year-old children, the spleen has a length of 78-80 mm, the width of the organ should not exceed 55 mm;
• in the period from 8 to 12 years, the normal size of the spleen can reach up to 60 mm in width with a length of about 90 mm;
• the width of the organ in adolescents of 15 years old remains the same, and the length increases to 120 mm.

In adults, the indicators are almost the same as the size of the organ in adolescence. The size of the spleen according to Kurlov allows an increase in the organ by another couple of centimeters.

How to palpate the spleen at home?

If the spleen is well palpated, this indicates its omission and increase in size.

Palpation and percussion of the spleen are rather complex techniques, which, if performed incorrectly, can cause significant harm to the human body. With inflammation of this organ, it is better not to exert unnecessary mechanical influences on it, and therefore only a specialist should deal with palpation.

Many patients tend to independently palpate the organ, which is not recommended. Before the procedure, the patient must take a certain position and completely relax, which cannot be achieved with self-palpation of the organ.

It should be understood that normally, palpating this organ is a rather complicated process, and in most healthy people the spleen is not palpable.

If the organ is well palpated, then this indicates its omission and increase in size. This can be observed with an infectious lesion of the body, cirrhosis of the liver and leukemia, therefore, if you suspect the development of a pathology, you should immediately contact a specialist.

Superficial palpation in liver diseases can reveal a zone of pain in the right hypochondrium and epigastric region. Especially severe local pain, even with a light touch to the anterior abdominal wall in the area of ​​the projection of the gallbladder, is observed in acute cholecystitis and biliary colic. In chronic cholecystitis, only mild or moderate pain is usually determined at the so-called point of the gallbladder: it corresponds to the projection of its bottom onto the anterior abdominal wall and is normally localized in most cases directly under the right costal arch along the outer edge of the right rectus abdominis muscle.

Palpation of the liver is carried out according to the Obraztsov-Strazhesko method. The principle of the method is that with a deep breath, the lower edge of the liver descends towards the palpating fingers and then, bumping into them and sliding off them, becomes palpable. It is known that the liver, due to its close proximity to the diaphragm, has the highest respiratory mobility among the abdominal organs. Consequently, during palpation of the liver, an active role belongs to its own respiratory mobility, and not to palpating fingers, as during palpation of the intestine.

Palpation of the liver and gallbladder is performed with the patient standing or lying on his back (however, in some cases, palpation of the liver is facilitated when the patient is on the left side; in this case, the liver, under the influence of gravity, comes out of the hypochondrium and then it is easier to probe its lower front edge). The palpation of the liver and gallbladder is performed according to the general rules of palpation, and most of all they pay attention to the anteroinferior edge of the liver, by the properties of which (contours, shape, soreness, consistency) they judge the physical state of the liver itself, its position and shape. In many cases (especially when the organ is lowered or enlarged), in addition to the edge of the liver, which can often be traced by palpation from the left hypochondrium to the right, it is also possible to palpate the upper anterior surface of the liver.

The examiner sits on the right next to the bed on a chair or on a stool facing the subject, puts the palm and four fingers of the left hand on the right lumbar region, and with the thumb of the left hand presses the costal arch from the side and front, which contributes to the approach of the liver to the palpating right hand and, making it difficult to expand the chest during inspiration, it helps to increase the excursions of the right dome of the diaphragm. The palm of the right hand is placed flat, with fingers slightly bent, on the patient's stomach directly under the costal arch along the mid-clavicular line and slightly pressed with fingertips on the abdominal wall. After such an installation of the hands, the subject is offered to take a deep breath; the liver, descending, first approaches the fingers, then bypasses them and slips out from under the fingers, that is, it is palpated. The hand of the researcher remains motionless all the time, the technique is repeated several times.

The position of the edge of the liver can be different depending on various circumstances, therefore, in order to know where to place the fingers of the right hand, it is useful to first determine the position of the lower edge of the liver by percussion.

According to V.P. Obraztsov, a normal liver is palpable in 88% of cases. Palpation sensations obtained from the lower edge of the liver, allow you to determine its physical properties (soft, dense, uneven, sharp, rounded, sensitive, etc.). The edge of the unchanged liver, palpable at the end of a deep breath 1-2 cm below the costal arch, is soft, sharp, easily folded and insensitive.

The lower edge of the normal liver is usually palpable along the right mid-clavicular line; to the right of it, the liver cannot be palpated, since it is hidden by the hypochondrium, and on the left, palpation is often difficult due to the severity of the abdominal muscles. With an increase and compaction of the liver, it can be felt along all lines. Patients with bloating should be examined on an empty stomach to facilitate palpation. With the accumulation of fluid in the abdominal cavity (ascites), it is not always possible to palpate the liver in the horizontal position of the patient. In these cases, the indicated technique is used, but palpation is performed in an upright position or in the position of the patient on the left side. With the accumulation of a very large amount of fluid, it is first released using paracentesis. If there is a large accumulation of fluid in the abdominal cavity, the liver is also palpated with jerky ballot palpation. To do this, the right hand with slightly bent II IV fingers is placed at the bottom of the right half of the abdomen, perpendicular to the supposed lower edge of the liver. With the closed fingers of the right hand, jerky blows are applied to the abdominal wall and moved in the direction from the bottom up until the dense body of the liver is felt, which, when the fingers are struck, first goes into the depths of the abdominal cavity, and then hits them and becomes palpable (a symptom of a floating ice floe).

Soreness is characteristic of inflammatory liver damage with the transition of the inflammatory process to the liver capsule or to stretch it (for example, with stagnation of blood in the liver due to heart failure).

The liver of a healthy person, if it is accessible to palpation, has a soft texture, with hepatitis, hepatosis, cardiac decompensation, it is more dense. The liver is especially dense with its cirrhosis (at the same time, its edge is sharp, and the surface is even or finely bumpy), tumor lesions of multiple cancer metastases (in these cases, sometimes the surface of the liver is rough-hilly, corresponding to superficially located metastases, and the lower edge is uneven), with amyloidosis. Sometimes it is possible to palpate a relatively small tumor or echinococcal cyst.

The protrusion of the lower edge of the enlarged liver is determined in relation to the costal arch along the right anterior axillary, right near the sternal and left parasternal lines. Palpation data clarify the idea of ​​the size of the liver, obtained by percussion.

The gallbladder is normally not palpable, as it is soft and practically does not protrude from under the edge of the liver. But with an increase in the gallbladder (dropsy, filling with stones, cancer, etc.), it becomes accessible to palpation. Palpation of the bladder is carried out in the same position of the patient as palpation of the liver. The edge of the liver is found and directly below it, at the outer edge of the right rectus muscle, the gallbladder is palpated according to the rules of palpation of the liver itself. It can be most easily detected when moving the fingers transversely to the axis of the gallbladder The gallbladder is determined by palpation as a pear-shaped body of various sizes, density and soreness, depending on the nature of the pathological process in itself or in the organs surrounding it (for example, an enlarged soft-elastic bladder when the common bile duct is blocked by a tumor - a sign of Courvoisier - Terrier; dense - tuberous bladder with neoplasms in its wall, with overflowing with stones, with inflammation of the wall, etc.).The enlarged bladder is mobile during breathing and makes pendulum movements.Mobility of the gallbladder is lost during inflammation of the peritoneum covering it with pericholecystitis.In cholecystitis and cholelithiasis, severe pain and reflex tension of the muscles of the anterior abdominal wall in the region of the right hypochondrium makes palpation difficult.

This technique of palpation of the liver and gallbladder is the simplest, most convenient and gives the best results. The difficulty of palpation and, at the same time, the consciousness that only it allows obtaining valuable data for diagnosis, forced us to look for the best method of palpation. Various techniques have been proposed, mainly reduced to a variety of positions of the examiner's hands or a change in the position of the examiner in relation to the patient. However, these methods do not have any advantages in the study of the liver and gallbladder. The point is not in the variety of techniques, but in the experience of the researcher and his systematic implementation of the study plan for the abdominal cavity as a whole.