Palpation of the liver and gallbladder

Palpation of the liver plays a major role in the physical examination of this organ. The palpation of the liver is performed according to all the rules of deep sliding palpation according to Obraztsov. The doctor is located on the right side of the patient lying on his back with his hands stretched along the body. A prerequisite is the maximum relaxation of the muscles of the abdominal wall of the patient with his deep breathing. It is recommended for a larger liver excursion to use the pressure of the palm of the left hand of the doctor located on the front chest wall on the lower right. The palpable right hand lies flat on the anterior abdominal wall below the liver edge, defined percutaneously, with the fingertips located along the supposed lower edge, plunging in sync with the patient's breathing and with another deep inspiration meet the descending edge of the liver from which they slip.

At a palpation of a liver first of all it is estimated its lower edge - the form, density, presence of roughnesses, sensitivity. These properties can be extended to the entire mass of the liver. Edge of normal liver with palpation of soft consistency, smooth, thin, painless.

The displacement of the lower edge of the liver can be associated with the lowering of the organ without increasing it: in this case, the upper border of the hepatic dullness will also be omitted. Of great importance is, of course, the statement of the increase in the liver (hepatomegaly), which is most often observed with congestive heart failure, with acute and chronic hepatitis, liver cirrhosis. Usually the edge of the stagnant liver is more rounded and painful on palpation, the edge of the cirrhotic organ is more dense, uneven. Pressing on the enlarged stagnant liver causes swelling of the right jugular vein - a simple but very important sign of the detection of blood stagnation over a large range (reflux symptom, or hepatouhygular reflux).

It should be noted that with large ascites, conventional percussion and palpation of the liver are difficult, therefore, a ballot palpation method is used (a symptom of a "floating ice floe"), with which one can get an idea of the features of the edge of the liver and its surface.

The dynamics of changes in liver size is very important. A rapid increase is usually observed with liver cancer, a rapid decrease - with cirrhosis of the liver and acute hepatitis of the fulminant course, and also with the successful treatment of congestive heart failure.

Hepatomegaly (enlargement of the liver) is an important sign of liver damage (hepatitis, liver cirrhosis, as well as primary cancer or cirrhosis - liver cancer). Other causes of hepatomegaly are congestive heart failure, metastases of various tumors, polycystosis, lymphomas (primarily lymphogranulomatosis ).

Causes of hepatomegaly

Venous congestion in the liver:

1. Congestive heart failure.
2. Constrictive pericarditis.
3. Insufficient tricuspid valve.
4. Obstruction of hepatic veins (Badd-Chiari syndrome).

Infection:

1. Viral hepatitis (A, B, C, D, E) and liver cirrhosis (B, C, D).
2. Leptospirosis.
3. Liver abscess:
   1. amebic;
   2. pyogenic.
4. Other infections (tuberculosis, brucellosis schistosomiasis, syphilis, echinococcosis, actinomycosis, etc.).

Hepatomegaly not associated with infection:

1. Hepatitis and cirrhosis of the liver of non-viral etiology:
   • alcohol;
   • medications:
   • toxins;
   • autoimmune disorders;
   • nonspecific reactive hepatitis.
2. Infiltrative processes:
   • fatty liver, lipoids (Gaucher disease);
   • amyloidosis;
   • hemochromatosis;
   • Wilson-Konovalov's disease;
   • deficiency of a1-antitrypsin;
   • glycogenoses;
   • granulomatosis (sarcoidosis).

Obstruction of the bile ducts:

1. Stones.
2. Strictures of the common bile duct.
3. Tumors of the pancreas, ampules of the fater's nipple, bile ducts of pancreatitis.
4. Stretch of ducts with enlarged lymph nodes.
5. Sclerosing cholangitis (primary, secondary).

Tumors:

1. Hepatocellular carcinoma, cholangiocarcinoma.
2. Metastasis of tumors in the liver.
3. Leukemia, lymphomas.

Cysts (polycystosis).

In addition to these reasons, liver enlargement is observed with fatty degeneration (more often alcoholic or diabetic genesis), amyloidosis (especially secondary), liver alveococcosis, with large cysts and abscess located close to the anterior surface of the organ.

Since simultaneously with hepatomegaly, there is often an increase in the spleen (splenomegaly), it is advisable to use the term " hepatolyenal syndrome ".

[1], [2]

Causes of hepatolyenal syndrome

Diseases	Causes
Cirrhosis of the liver.	Viral infection; autoimmune disorders; primary sclerosing cholangitis, impaired metabolism of copper, iron; less often - alcoholic, primary biliary cirrhosis.
Granulomatosis.	Sarcoidosis; berylliosis; histoplasmosis; schistosomiasis.
Hemoblastosis:
Myeloproliferative diseases.	True polycythemia (erythremia); myelofibrosis; chronic myelogenous leukemia;
Lymphoproliferative diseases.	Chronic lymphocytic leukemia; lymphoma; lymphogranulomatosis;
Amyloidosis.	Waldenstrom's macroglobulinemia.
Gaucher's disease.

The gallbladder becomes accessible for palpation with its significant increase: with empyema (purulent inflammation), dropsy, chronic cholecystitis, cancer. In these cases, it can be probed in the form of a saccate body of a dense or elastic consistency in the region between the lower edge of the liver and the edge of the right rectus abdominis muscle. Isolate symptom Courvoisier - a gallbladder dilated with normal elastic walls (with a blockage of the common bile duct with a tumor of the head of the pancreas). Very rarely it is possible, with the help of palpation, to get a sense of vibration, which is transmitted to the adjacent spaced fingers of the left hand when one of them is taped.

[3], [4], [5], [6], [7]