Intestinal diseases make up the lion's share of all diseases gastrointestinal tract. have already been described by us earlier. In this article we will talk about diagnostic methods, treatment principles and measures to prevent the occurrence of intestinal diseases.
In the diagnosis of intestinal diseases, an important role is given to an objective examination of the patient by a doctor. After the doctor listens to the patient’s complaints, the history of his illness and life, the patient will be asked to undress to the waist and the abdomen will be examined: it may be retracted (during fasting, intestinal spasms), increased in size (during bloating, tumors, ascites) , a protrusion may be detected in one of the areas of the abdomen, which is a sign of a hernia or tumor in abdominal cavity. The main method for diagnosing intestinal diseases is palpation. For this study the patient will be asked to lie on the couch on his back and bend his knees slightly - it is in this position that the examination will be as informative as possible. When palpating, the doctor pays attention to:
Palpation in the projection of the inflamed intestine is painful to varying degrees; the intestine is palpated as a compacted, often rumbling, roller. Some bowel diseases can be diagnosed by assessing symptoms of peritoneal tension - for example, a positive Shchetkin-Blumberg sign ( sharp pain in the abdomen when the palpating hand is immediately removed from the abdominal wall after pressing) indicates an inflammatory process in the underlying organ involving the adjacent peritoneum. In particular, a positive Shchetkin-Blumberg sign upon palpation in the right iliac region is diagnostic criterion acute appendicitis. When percussing (tapping) the anterior abdominal wall, the doctor will evaluate the nature of the sound, which can also be a sign of problems in the intestines (for example, flatulence). A stool analysis can tell a lot about the state of the intestines, and all its characteristics matter - consistency, color, smell, the presence of all kinds of impurities in it:
After assessing the macroscopic characteristics of stool in order to more detailed analysis it is examined under a microscope. In order for the stool examination to be as informative as possible, the patient needs to know the technique for correctly collecting this material:
X-ray examination is of great importance in the diagnosis of certain intestinal diseases, during which it is determined motor function organ, expansion or narrowing of its lumen up to obstruction, the presence of tumors and even individual species helminths (usually roundworms). An important method for diagnosing diseases of the colon is the method of its endoscopic examination - colonoscopy, of the lower intestines (sigmoid and rectum) - sigmoidoscopy.
The main component is not drug treatment intestinal diseases is proper nutrition - a therapeutic diet. Nutrition most often has no effect on inflammation, but it is not difficult to reduce certain symptoms that are unpleasant for the patient by following a diet. At inflammatory diseases intestines, dairy products should be excluded from the diet and the amount of fiber consumed should be reduced. It is worth noting that complete fasting for several days - a fasting break - will help speed up the healing of ulcers of the mucous membrane. Preventing stressful situations and reacting to stimuli as calmly as possible is the second important point in the treatment of intestinal diseases, since a direct connection has been proven between psycho-emotional stress and the degree of inflammatory activity in the intestinal mucosa. The main goal of drug treatment of inflammatory bowel diseases is anti-inflammatory therapy, which includes the following groups of drugs:
To alleviate the patient’s condition and correct certain disorders associated with intestinal disease, symptomatic therapy is prescribed:
To prevent the development of intestinal diseases, special attention should be paid proper nutrition. Measures to prevent the development of intestinal diseases are very simple and are actually known to many. This:
When examining the right iliac region, the location of the cecum in healthy person no deviations are noted, it is symmetrical to the left iliac region, does not bulge, does not sink, no visible peristalsis is noticeable.
At pathological conditions the cecum may bulge at its location or closer to the navel, which is especially characteristic of intestinal obstruction. In such cases, the intestine takes on a sausage shape and is not located in a typical place, but closer to the navel.
Peristalsis of the cecum even when it is full and swollen, it is difficult to see; it is felt only by palpation.
Percussion is normal over the cecum Tympanitis is always heard. When it is sharply swollen, tympanitis becomes high; when it is overfilled with feces or affected by a tumor, a dull tympanic sound will be detected.
Palpation of the cecum The procedure is carried out in two positions of the patient - in the usual position on the back and in the position on the left side. The doctor resorts to examination on the left side when there is a need to clarify the displacement of the cecum, the localization of pain during palpation, to differentiate the pathological condition of the cecum and neighboring organs.
On palpation of the cecum, as well as the sigmoid colon, it is necessary to evaluate its properties such as:
Principles of palpation of the cecum the same as the sigmoid colon. The cecum is located in the right iliac region, its vertical extension is up to 6 cm, the long axis of the intestine is located obliquely - to the right and from top to bottom and to the left. Usually the cecum lies on the border of the middle and outer third of the right umbilical-spine line, this is approximately 5-6 cm from the right anterior superior spine ilium(Fig. 407).
A. Scheme of the topography of the cecum. The dotted line indicates the umbilical-spine line. The cecum lies at the level of the middle and outer third of this line.
B. Position of the doctor’s hand during palpation. The fingers are placed at a distance of 5-6 cm from the upper iliac spine, parallel to the axis of the intestine. Finger movement - outward
The 4 palpating fingers are placed at the indicated point parallel to the long axis of the intestine in the direction of the navel, with the palm touching the iliac crest. The fingers should be slightly bent as when palpating the sigmoid colon, but not pressed too hard against each other. After shifting the skin towards the navel and plunging the fingers deep into back wall(to the bottom of the iliac fossa), taking into account the patient’s breathing, a sliding movement of the fingers is made outward. If the intestine is not palpable, then the maneuver is repeated. This is done because the intestine with relaxed muscles may not normally be palpable. Mechanical irritation by palpation causes its contraction and thickening, after which it becomes noticeable, although not always.
A normal cecum is palpable in approximately 80% of healthy people. It is perceived as a smooth soft cylinder 2-3 cm thick (less often 4-5 cm), painless, slightly rumbling, with a smooth surface, with displacement up to 2-2.5 cm, with a small pear-shaped blind extension downwards (the cecum itself). The lower end of the cecum in men is usually located at a level 1 cm above the line connecting the upper anterior spines, in women - at its level. In some cases, a higher location of the cecum is possible, with its upward displacement of 5-8 cm. Such a colon can only be palpated using the so-called bimanual palpation. The solid base to which the intestine will be pressed when palpating will be the doctor’s left hand, placed across the body from the back at the edge of the ilium. The actions of the palpating hand are similar to normal palpation; the placement of the fingers should be progressive above the zone of normal location of the intestine. When palpating the cecum, we usually palpate the initial part of the ascending colon at a distance of 10-12 cm. This entire segment of the intestine is called “typhlon”.
If palpation of the cecum fails Due to muscle tension, it is useful to use pressure on the abdominal wall with the doctor's left hand (thumb and thenar) at the navel on the right. This achieves some relaxation of the abdominal wall muscles. If this technique is unsuccessful, you can try to palpate the intestine with the patient positioned on the left side. Palpation techniques are standard.
A healthy person has a cecum during palpation, it can shift laterally and medially by a total of 5-6 cm. Due to the long mesentery, it can be located closer to the navel and even further (“wandering cecum”). Therefore, if it is not palpable in the usual place, a palpation search is necessary with a shift in the place of palpation in different directions, especially towards the navel. With the help of a pressor technique with the doctor's left hand, it is sometimes possible to return the intestine to its normal place.
Pathological signs revealed by palpation of the cecum, may be the following:
Wide cecum(5-7 cm) may occur when its tone decreases, as well as when it is overfilled with feces due to a violation of the evacuation ability of the large intestine or the occurrence of obstruction below the intestine.
Narrow, thin and the compacted cecum, as thick as a pencil or even thinner, is palpated during prolonged fasting of the patient, with diarrhea, or after taking laxatives. This condition of the intestine is caused by spasm.
Dense cecum, but not wide and not overcrowded, occurs when it is affected by tuberculosis; often it also acquires tuberosity. The intestine becomes dense and increased in volume due to the accumulation of dense fecal masses and the formation of fecal stones. Such intestines are often lumpy.
Tuberous surface of the cecum is determined by its neoplasms, accumulation of fecal stones in it, and tuberculosis of the intestine (tuberculous typhlitis).
Displaceability of the cecum caused by elongation of the mesentery and insufficient fixation to the posterior wall. Restriction or absence of intestinal mobility occurs due to the development of adhesions (peritiphlitis), which is always combined with the appearance of pain in the Nazi position on the left side (displacement of the intestine due to the gravity and tension of adhesions), as well as the occurrence of pain when palpating the intestine in the same position .
Increased peristalsis of the cecum is determined in the form of alternating compaction and relaxation under palpating fingers. It occurs when there is a narrowing below the cecum (scars, swelling, compression, obstruction).
Loud rumbling, splashing on palpation indicates the presence of gas and liquid contents in the cecum, which occurs during inflammation small intestine- enteritis, when liquid chyme and inflammatory exudate enter the cecum. Rumbling and splashing in the cecum is noted when typhoid fever.
Mild soreness of the cecum palpation is possible and normal, pronounced and significant - characteristic of inflammation inner shell intestines and for inflammation of the peritoneum covering the intestines. However, pain on palpation of the iliac region may be due to the involvement of neighboring organs, such as the appendix, ureter, ovary in women, jejunum and ascending colon.
The transverse colon, its length is 25-30 cm, is often located in the umbilical region and has the shape of a garland.
Rising part colon has a length of up to 12 cm, it is located in the right lateral region of the abdomen.
Descending colon has a length of about 10 cm, its localization is the left lateral region of the abdomen.
When examining the areas where these parts of the colon are located in a healthy person, no noticeable bulges, retractions or peristalsis are observed. Their appearance in any part indicates a pathology, the causes of which were mentioned when describing studies of the sigmoid and cecum.
Among the methods physical research these parts of the colon highest value has palpation, although its capabilities are limited due to their special location in the abdominal cavity.
Palpation is carried out sequentially:
The principles for assessing the results of palpation are the same as for palpation of other parts of the large intestine: localization, thickness, length, consistency, surface character, peristalsis, mobility, rumbling, splashing, pain.
When palpating this section of the large intestine, it is necessary to take into account the fact that it lies behind the thick anterior abdominal wall, and is covered in front by the omentum, which significantly reduces accessibility to it during examination. The location of the POC largely depends on the position of the stomach and small intestine. The POC is connected to the stomach through the gastrointestinal ligament, the length of which ranges from 2 to 8 cm, on average 3-4 cm. The small intestine is located below the POC. Consequently, the degree of filling of the stomach, the position of its greater curvature, the length of the ligament, the filling of the small intestine, as well as the filling of the POC itself will determine its localization in the abdominal cavity
The position of the patient and the doctor during palpation of the intestine is usual. Palpation of the intestine is carried out either with two hands simultaneously bilaterally, or with one hand - first on one side of the midline, then on the other (Fig. 408).
A. Scheme of the topography of the transverse colon. Pay attention to the position of the intestinal garland, its relationship with the greater curvature of the stomach, and the position of the hepatic and splenic curvature of the intestine
B. Palpation of the intestine with both hands at the same time.
B. Palpation with one hand.
Both hands with bent fingers are placed on the anterior abdominal wall so that the terminal phalanges are located along the long axis of the intestine 1-2 cm below the found border of the stomach on both sides of the midline. More often it is 2-3 cm above the navel. If the lower limit of the greater curvature is not known, then it must be determined and a mark made on the skin.
With highly developed rectus abdominis muscles attempts to examine the SOC beneath them do not yield results; it is better to immediately place the fingers of both hands at the outer edges of the rectus muscles at the same level and carry out the examination. During 2-3 breathing cycles, as you exhale, the fingers of both hands carefully plunge deep into the abdomen all the way to the back wall, and then on the next exhalation, a calm sliding movement is made downwards. The SOC is palpated in 60-70% of cases and is perceived as an easily displaceable cylinder located behind a thick layer of muscle and omentum. Usually the intestine is determined at the level of the navel in men and 1-3 cm below the navel in women, which is 2-3 cm below the greater curvature of the stomach. The localization of the intestine is very individual and variable. The diameter of the cylinder is 2-3 cm, its surface is smooth, elastic, palpation is painless, the intestine moves easily, and does not rumble when palpated.
Intestine filled with feces becomes dense, sometimes its density is uneven, lumpy. After a cleansing enema, the density and tuberosity of such intestines disappears.
Empty gut, especially after diarrhea and an enema, is palpable in the form of a thin dense cord, and in the presence of inflammation it is painful.
To increase the contact of fingers with the intestine during palpation they should be slightly spaced. After examining the POC at the midline, the doctor’s hands move laterally on each side along the POC to the hypochondrium up to the splenic angle on the left and the hepatic angle on the right by about 6-10 cm in each direction, but taking into account the deflection of the intestine.
If after 2-3 times palpation the POC is not palpable, then it is necessary to search for it, starting from xiphoid process up to the pubic symphysis. The POC can lie horizontally and resemble the letter P with its ascending and descending sections, but it can have a significant deflection and resemble Latin letter U.
Sometimes the greater curvature of the stomach can be mistaken for POC; their differences are as follows:
1. Greater curvature is perceived as a fold from which the fingers slip. When palpated, the POK bends around the fingers from above and below.
2. The greater curvature is palpable only on the left, the POK - on both sides of the navel.
3. The most reliable principle is simultaneous palpation of both the greater curvature and the SOC.
Palpation of the hepatic curvature and splenic curvature of the colon (Fig. 409)
It is always difficult to palpate these parts of the colon, which is due to their deep location, as well as the lack of a dense surface to which they could be pressed for palpation. Therefore, palpation of both curvatures is carried out bimanually.
When palpating the hepatic curvature, the doctor left hand places it under the patient’s lower back so that the index finger touches the 12th rib, and the fingertips rest against the back muscles. The right hand is placed at the edge of the liver parallel to the rectus muscle, the fingers should be slightly bent. As the patient exhales, both hands move towards each other. At the final stage, on the next exhalation, fingers right hand make a downward sliding movement.
Normally, the hepatic curvature is often palpated in the form of a spherical, elastic, painless, displaceable formation.
The hepatic curvature of the POC can be confused with right kidney And gallbladder. The difference is that the kidney lies deeper, has a denser consistency, is less displaceable, and does not rumble. The difference from the gallbladder is the more lateral and superficial location of the intestine, the tympanic sound above it, and the often changing properties of the intestine during palpation due to the evacuation of contents from it. When palpating the splenic curvature, the doctor’s left hand is inserted under the patient to the left lumbar region, located at the same level as on the right. The right hand is placed at the edge of the costal arch parallel to the rectus abdominis muscle. Further actions are similar to those performed when studying the hepatic curvature. You can palpate with your left hand and place your right hand under your back (Fig. 409).
Normally, the splenic curvature is not palpable due to its deep location (approximately at the level of the IX-X rib along the axillary line) and its more rigid fixation with the help of the diaphragmatic-intestinal ligament. If it is palpable, then this is already a sign of pathology. Palpation of the ascending colon (Fig. 410).
A. Diagram of a cross section of the abdomen at the level of the navel and palpation of the ascending colon. The function of the hard surface against which the palpated intestine is pressed is performed by the doctor’s left hand
B. Position of the doctor’s hands during palpation
The intestine is located in the right flank of the abdomen; there is no dense surface behind it, so palpation is carried out bimanually. The doctor’s left hand with closed fingers is placed on the right lumbar region so that the fingertips rest against the edge long muscles back, creating rigidity for the palpating right hand. The right hand is placed above the right flank parallel to the left hand, the fingers of the right hand should rest against the outer edge of the rectus muscle. Taking into account the patient’s breathing, the doctor’s right hand is immersed in the flank of the abdomen; the left hand should also shift as much as possible towards the right hand. On the 2-3rd exhalation, the right hand, reaching the back wall, makes a sliding movement outward. Palpation of the descending colon is also performed bimanually (Fig. 411).
The doctor's left hand is inserted by the patient to the left lumbar region at the same level as on the right, the right hand is placed on the left flank parallel to the left hand so that the fingertips are at the outer edge of the left flank and lie parallel to the long axis of the intestine. After they are immersed deep to the back wall, taking into account the Nazi’s breathing, the fingers make a sliding movement towards the spine. There is another, slightly modified way of palpating the descending colon. The doctor’s left hand is positioned as in the previous method, and the right hand is placed with the fingers not outward, but medially, touching the edge of the rectus muscles or retreating from them by 2 cm. After immersion in the abdominal cavity, the fingers slide to the outer edge of the left flank. Palpate the ascending and descending sections of the colon. guts are difficult. This is only successful in people with a weak abdominal wall and in thin people. The intestine is perceived as a mobile, tender, soft, painless, non-rumbling (although not always) cord up to 1.5-2 cm in diameter. In pathological conditions, changes physical properties sections of the colon will be similar to those described in the sections on the study of the sigmoid and cecum.
When diagnosing diseases of the gastrointestinal tract, intestinal palpation is performed. This method allows you to make a preliminary diagnosis and determine the presence of pathology. When palpated, the localization of symptoms and the degree of pain are detected, the doctor determines the temperature and the presence or absence of seals, checks general state internal organs, appearance of the abdomen.
Prescribed if the patient has complaints in the abdominal area. Acute or persistent attacks of pain, delayed or upset bowel movements, gas formation, suspicion of the presence of a cyst or tumor and other pathologies are indications for a primary external examination of the peritoneum. Palpation is the main method in detecting pathological changes in the abdominal cavity and abdominal organs. After an external examination, the doctor prescribes additional tests, based on the preliminary conclusion.
The procedure must be carried out on an empty stomach. It is divided into 2 types: approximate and deep. First, the doctor conducts an indicative examination, and then proceeds to deep palpation. This inspection pattern is specifically defined and unchangeable. The doctor moves from one examined organ to another in the required sequence. If the patient has severe abdominal pain, the doctor takes great care when applying pressure. It is carried out on an empty stomach, after bowel movements.
With its help, the doctor determines body temperature and the state of the peritoneum - whether it is asleep or inflated. The pain and location of tense organs, muscle tone, and level of sensitivity are palpated. The procedure is carried out with the patient lying down, limbs extended along the body. The patient's breathing is deep and even. The doctor on the right places his hands on the patient's abdomen and allows him to get used to his hand. Superficial palpation carried out with both hands.
IN in good condition the surface of the abdominal cavity does not hurt, is soft, healthy mobility of organs is palpable. In case of pathologies in the place where the disease is localized, the muscles are tense, and involuntary resistance is felt when pressing. If the anterior wall of the abdomen is bulging or protruded, the doctor determines the cause of this condition using indicative palpation.
Using the deep palpation method, you can palpate neoplasms in the gastrointestinal tract. Upon completion of the initial palpation, the doctor begins a deep examination. Using this method, pathologies of internal organs, muscle tissue and the anterior inner wall of the abdomen are determined. In the presence of pathologies, neoplasms, tumors, hematomas and swellings are palpated. Such a detailed examination allows you to assess the condition of the location of organs and their displacement. When feeling the hollow organs, the doctor pays special attention to the nature of the sounds - their absence means that the organ is healthy.
When a painful tumor or cyst is detected, its size, location, shape, density, level of pain and other characteristics are determined by palpation. Special attention is given to sounds - rumbling, noise, splashing. The technique of carrying out the method is complex; palpation is carried out starting from left to right, from bottom to top. The wall of the abdominal cavity with a thick layer of fat, swelling or with developed muscle tissue represents an obstacle to a full examination.
By following all the rules of the procedure technique, you can accurately determine muscle tone. Palpation is carried out when the patient lies on his back, arms and legs are extended along the body, breathing is deep and even. The doctor sits to the right of the patient, his hands are dry and warm, the room is warm and quiet. Place the right wrist on the left side of the patient's iliac abdomen, applying light pressure with straight 4 fingers. This method evaluates the tone and degree of muscle tension. The brush moves to the right, and then up to the epistrium, also first to the left, and then to the right side of the abdomen along the intestines.
The deep palpation technique is carried out according to the Strazhesko-Obraztsov method. With its help, the condition of the internal organs and peritoneum is examined. This palpation is also called sliding and methodical, because the condition of the organ is felt at the moment when the researcher’s hand slides off it. There are strictly prescribed rules in what order they are examined abdominal organs.
The inflamed sigmoid colon causes pain upon palpation. During palpation, the condition of the surface, mobility, intestinal diameter and other characteristics are determined. If the organ is healthy, the intestine feels like a dense, smooth cylinder; when pressed, there are no pain symptoms, it slips easily under your fingers. If you hear rumbling, this is a sign of gas formation and fluid accumulation, which usually occurs during inflammatory processes. Palpation causes pain. With malignant tumors or constipation, the intestine feels dense, immobile and enlarged.
In the groin area, where the navel and the ilium connect, a fold of skin is formed with the hands and the cecum is felt with a sliding movement from the navel to the upper part of the ilium. In 80% of cases the procedure is successful. A healthy colon feels like a smooth, pear-shaped cylinder. Pain and strong rumbling when pressed, they indicate inflammation. The mobility of this intestine should normally not exceed 3 cm. If the range is greater, there is a risk of volvulus and obstruction.
The main methods used in the diagnosis of intestinal diseases:
Questioning
When questioning, it is necessary to clarify in detail questions about the presence, nature and localization of pain and changes in stool. For example, cramping pain or colic that ends with the passage of gas or stool makes one suspect an intestinal obstruction. When a duodenal ulcer is perforated, an extremely strong pain(“a blow with a dagger”), sometimes even leading to loss of consciousness.
It is very important to establish as accurately as possible the localization of pain. Pain in the right upper quadrant of the abdomen is characteristic of a duodenal ulcer. Pain in the area of the right iliac fossa is observed with appendicitis, cancer, and tuberculosis of the cecum. In the left lower abdomen sharp pains often appear with intestinal obstruction or inflammation of the sigmoid colon. Pain in the navel area is observed with narrowing of the intestine, lead colic, colon cancer, fermentative dyspepsia and inflammation small intestines(enteritis).
Changes in stool are significant diagnostic value. Stool retention is observed with habitual constipation, tumors in the intestines, nervous diseases central origin. Complete constipation, i.e. not only the absence of bowel movements, but also the cessation of the passage of gases, is characteristic of intestinal obstruction. Diarrhea is observed with catarrh of the intestines, with fermentative and putrefactive dyspepsia, dysentery, etc. It is important to determine the presence of so-called false diarrhea, in which the bowel movements mostly consist of mucus, blood and pus, while the feces themselves are retained; stool appears with painful tenesmus 10-20 times a day; false diarrhea is mostly a consequence of severe changes in the sigmoid and rectum (rectal cancer, sigmoiditis, proctitis). You should also ask about the appearance of the stool and whether worms are expelled.
From past diseases, it is important to find out about diseases localized in the intestines (dysentery), about diseases of other organs that often lead to reflex intestinal disorders (cholecystitis), about the possibility of occupational poisoning (lead, arsenic, etc.), in women about sexually transmitted diseases. apparatus (ovarian inflammation, parametritis, etc.), as they can cause changes in the intestines.
Data regarding the nature of nutrition, habits, meal times, working conditions, abuse of alcohol, tobacco, etc. are also of great importance.
Inspection
Examination of the abdomen for intestinal diseases can provide very valuable results for diagnosis. Particularly characteristic is a change in the shape of the abdomen with prolapse of the abdominal viscera in general and the intestines in particular (with enteroptosis). Top part At the same time, the abdomen sinks, while the lower part, on the contrary, protrudes.
A retracted abdomen is observed when the intestines are empty due, for example, to pyloric stenosis or with prolonged diarrhea. Scaphoid retraction of the abdomen is characteristic of a reflex spasm of the intestines during meningitis.
Uniform bloating observed with intestinal flatulence (bloating of the intestines with gases). Stenosis of the rectum or sigmoid colon can also cause uniform bloating. Acute peritonitis after abdominal operations, acute flatulence in hysterical people and paralysis of the intestines due to poisoning or infectious diseases can cause a spherical protrusion of the abdomen.
Asymmetric local abdominal protrusions depend on limited flatulence in some loop of the intestines when their patency is impaired due to strangulation, volvulus, or strangulated hernias.
Strengthened visible peristaltic movements of the intestines; they give the most bizarre changes in the relief of the abdomen. They are always associated with a feeling of pain and often stop with rumbling and the release of gas. They are an expression of chronic narrowing of the intestines, and when acute blockages may be missing. Often you have to wait a long time for a long time until you can see similar enhanced intestinal peristalsis; but if it is present, then the diagnosis of impaired intestinal patency becomes undoubted. Locate an obstacle by simple observation increased peristalsis Intestinal loops are often not possible because the caliber of distended intestinal loops can be so large that they can easily be confused with distended colon.
Palpation
Palpation is the most important technique to clarify pathological processes in the intestines.
First, an indicative palpation of the abdomen is performed, which aims to determine the general properties of the abdominal walls, the degree of their tension and sensitivity in various areas. Then they begin a more detailed study, resorting to superficial and deep palpation.
During deep sliding palpation of the abdomen, place the hand flat and, with slightly bent fingers, try to penetrate to the posterior abdominal wall of the organ or tumor being examined during exhalation. Having reached the posterior abdominal wall or the organ being examined, they slide the tips of the fingers in a direction transverse to the axis of the organ being examined or to its edge. When palpating the intestines, the fingers roll across the intestine, pressing it against the posterior abdominal wall. Depending on the position of the various parts of the colon, the abdomen is felt in different directions. The sliding movements of the palpating fingers should not occur along the skin of the abdomen, but together with it, i.e., shifting the skin; in most cases, place your fingers on one side of the intestinal loop being examined and then slide your fingers across it, lightly pressing it against the posterior abdominal wall.
Palpation of the intestines begins with the sigmoid colon, as the part that is more accessible to palpation and most often palpated (in 90% of all cases); then, according to Strazhesko, they move on to the cecum, to the final segment of the ileum and appendix, after which the transverse colon is examined.
Usually the sigmoid colon is palpable in the left iliac region. Since it has the direction from the left above and from the outside to the right down and inwards, it is palpated from the right from top to bottom and to the left or, conversely, from the left from below and to the right up. The sigmoid colon in a normal state is palpable in the form of a smooth, dense cylinder the thickness of a thumb, is painless, rarely peristaltes and has a passive mobility of 3-5 cm.
Under various pathological conditions, these properties of the intestine change, and it can become lumpy (with the development of a neoplasm or the deposition of dense fibrinous exudate around it), painful (with an inflammatory process in the intestine itself or mesentery), strongly and often peristaltically (with inflammation of the intestine or with the existence of some obstacle below it) and lose its normal mobility (during adhesions or wrinkling and development of scars in its mesentery). On the other hand, the mobility of the sigmoid colon may be increased (with elongation of the intestine itself and its mesentery due to congenital anomalies), and, finally, rumbling may be detected in the intestine (with the accumulation of liquid contents and gases in it).
The cecum under normal conditions is palpable in the right ileum. Palpation should be carried out, as always, perpendicular to the axis of the intestine, i.e. from left and top to right and down. In most cases, the cecum is easily palpable with normal deep palpation with four slightly bent fingers. However, when the abdominal tension is tense, to reduce resistance at the site of examination of the cecum, it is useful to transfer the resistance of the abdominal wall to another place. For this purpose, according to Obraztsov, you should apply pressure near the navel with your free left hand during the examination. If the cecum is located high, place the left hand flat under the right lumbar region in order to create support instead of the ilium (bimanual palpation). Together with the cecum, it is palpable and lower section ascending colon. Under normal conditions, the cecum is usually palpated “in the form of a smooth, two-finger-wide, rumbling, painless on palpation, moderately mobile cylinder with a small pear-shaped blind extension downwards, with moderately elastic walls” (Strazhesko).
Under various pathological conditions, the cecum changes its palpation properties. If it is insufficiently fixed to the posterior wall of the abdominal cavity or with congenital elongation or enlargement of its mesentery, it appears to be excessively mobile (coecum mobile), and, conversely, after a former inflammatory process around the intestine (local peritonitis), it becomes fixed and loses its mobility. When the cecum becomes inflamed, it acquires a dense consistency and becomes painful. In tuberculosis and cancer of the cecum, it is palpable in the form of a hard, tuberous tumor. If there is liquid content in the cecum and large quantity gases (with enteritis) a loud rumbling is detected.
As for palpating the small intestines, only the final segment of the ileum (pars coecalis ilei) is amenable to palpation. This segment rises from the small pelvis to the large one in the direction from the left and from bottom to right and up and flows into inside into the cecum slightly above its blind end. Palpation is carried out according to the general rules in a direction perpendicular to the axis of the intestine, i.e. from above and from left to below and to the right. It is more convenient to palpate here with four slightly bent fingers of one right hand.
In the normal position of the cecum, this segment of the ileum is usually palpable for 10-12 cm in the depth of the right ileum in the form of a soft thin-walled tube that gives a loud rumbling, or in the form of a dense cord the thickness of the little finger. It is moderately mobile, contracts frequently and is completely insensitive.
In various pathological conditions (in severe cases of typhoid fever, with tuberculous ulcers), this part of the intestine can be palpated as lumpy and painful. In cases of stenosis in the area of the cecum, the ileum is felt thickened, dense, overflowing with contents, giving a sharp splashing noise and vigorously peristalting.
Palpation of the appendix is possible only in cases where it lies medially to the cecum and is not covered by the intestine or mesentery. To feel it, you must first find the part of the ileum that flows into the colon. Having felt the cecum and found the pars coecalis ilei, they palpate the area below and above the latter, mainly along the musculus psoas, which is easily determined when the patient lifts his outstretched right leg.
The palpable normal process, according to Strazhesko’s description, appears “in the form of a thin, goose feather thick, movable with passive displacement, absolutely painless, smooth, non-rumbling cylinder, the length of which varies in different subjects.”
Changed processes, fixed in a certain position due to inflammatory adhesions or inflammatory-thickened and painful, are palpable much easier than normal ones.
Palpation of the transverse colon with its two curvatures - flexura colica dextra (hepatica) and flexura collca sinistra (lienalis) - should be preceded by percussion-palpation determination of the position lower limit stomach. The transverse colon in most cases lies 3-4 cm below the greater curvature of the stomach. If it is not found in this area, then they try to find it below or above, gradually examining the entire area of the rectus abdominis muscles from the xiphoid process to the pubis. If in this way it is possible to find the transverse colon; you should look for it in the lateral sections of the abdomen.
To palpate the transverse colon, use either one right or both hands - “bilateral palpation”. When palpating with one hand, the fingers of the right hand, slightly apart and slightly bent at the phalangeal joints, are gradually immersed into the abdominal cavity on both sides of the white line 2-3 cm below the found border of the stomach. Having reached the back wall of the abdominal cavity, they slide downwards along it, trying to palpate the intestine under their fingers (Strazhesko). “Bilateral” palpation is performed in the same way, but only simultaneously with both hands located on either side of the navel.
The transverse colon in most cases is palpable in the form of a slightly downwardly curved transverse cylinder, which can be traced in both directions to the hypochondrium. With significant splanchnoptosis, it has the shape of the letter V.
When palpating the colon, its consistency, volume, mobility and sensitivity are determined. The thinner the contents and the more gases in the intestine, the softer it seems to the touch. The thicker and denser the contents, the more dense it appears when palpated. On the other hand, an absolutely empty intestine with spastic contraction gives the impression of a dense, thin and smooth cord. On the contrary, with intestinal atony, it is palpable in the form of a tube with flaccid, relaxed walls. With colitis, it is palpated dense, contracted and painful. When developing in it malignant neoplasm it is thickened and lumpy. With narrowings located below the transverse intestine, it appears increased in volume, elastic, smooth, periodically peristaltic and sometimes loudly rumbling.
It is also necessary to mention palpation using a finger inserted per rectum. Forefinger lubricated with some fat and with slow rotational movements moves as far as possible into the rectum. This method of palpation of the rectum, in addition to the condition and diseases of the rectum itself (stool, condition of the mucous membrane, tumors, ulcers, varicose veins veins), often allows one to judge the condition of more distant parts of the intestine that are not in direct contact with the rectum, such as the appendix and cecum when they are inflamed (perityphlitis, appendicular infiltrates).
When palpating tumors, it is sometimes useful to fill the colon with air after an enema (using an enema tip connected to a pressure rubber balloon). Air, like water, does not pass through the Bauhinian valve, and the entire colon is outlined in the shape of the letter P. In this case, the topographic relationships of palpable tumors are determined much more clearly. It is extremely important to find out whether the palpable tumor after inflating the colon becomes clearer or, on the contrary, less clear and less accessible to palpation. In the latter case, one can think that the tumor belongs to the organs lying behind the intestine.
Among the properties of the tumor ascertained by palpation (size, consistency, shape, pain, surface properties), one of most important places occupies displacement. Tumors belonging to the intestines usually have very slight turnover with breathing movements, since for this they are located too far from the diaphragm, the excursions of which affect mainly the organs closest to it - the liver, spleen, stomach. The passive turnover of intestinal tumors during palpation, on the contrary, is quite large, especially for tumors of the small intestines with a long mesentery. The mobility of intestinal tumors also depends on whether they are fused with surrounding organs or not.
When researching pain sensitivity First of all, you need to eliminate pain in the skin of the abdomen and abdominal muscles. In the depths of the abdominal cavity, to the left and up from the navel, there is the solar plexus, which is very sensitive to pressure in neurotics. Outward and slightly downward from the navel are the mesenteric plexuses - upper to the right and lower to the left of the navel; they can also be painful. With inflammation the blind and sigmoid colon pain is noted upon palpation of the corresponding areas; the same pain can be observed with colitis along the transverse colon. In case of appendicitis, the Mac Burney pain point is determined, corresponding to the location of the vermiform appendix of the cecum; it lies in the middle of the line connecting the umbilicus and the superior anterior spine of the right ilium. However, it must be borne in mind that the position of the appendix is extremely often deviated, both upward and downward.
The splashing noise that appears in the abdomen, which can be obtained by a rough jerky shaking of the abdominal wall with the ends of the fingers, is important. Intestinal splashing sounds are often observed in the area of distended areas of the intestine, as a sign of abnormal stagnation of liquid contents. In the area of the cecum, palpation often causes the sound of splashing or rumbling, giving at the same time a tactile sensation of iridescent liquid. This phenomenon is observed in various types of enterocolitis, especially in typhoid fever, but also occurs in healthy people.
Percussion
Percussion plays a very small role in the diagnosis of intestinal diseases. It is not possible to distinguish between separate segments of the intestines (large and thin) by percussion, since they are closely adjacent to each other, partially covering each other. An increase in tympanic sound in the abdominal cavity is observed during flatulence. Percussion of the intestines can detect dullness over tumors or over intestinal loops filled with dense contents only if there are no parts of the gastrointestinal tract swollen with gases between them and the abdominal wall.
