Abdomen (a concept encompassing the representation of)

ABDOMEN, a concept encompassing the representation of the abdominal cavity (see) and the abdominal walls (see Abdominal Wall) that limit it in front. Objective changes in the abdomen, as well as its cavity, and the diverse subjective symptoms from the abdomen have exceptional differential diagnostic value and have created a whole doctrine on methods of abdominal examination, on differentiation of pains in it, etc. Examination of the abdomen must be performed both in the recumbent and standing positions of the patient, and in the recumbent position not only on the back, but also on the side, or rather, in the semi-lateral position. When examining the abdomen in various positions (both by palpation and inspection), one must take into account those changes in the configuration of the abdomen and its volume that are caused by the changing direction of gravity on the abdominal organs depending on the position of the trunk, as well as the position of the diaphragm and the tone of the abdominal wall. Finally, the respiratory phase must also be taken into account. In the standing position, the diaphragm stands lower than in the recumbent position, hence the difference in the configuration of the abdomen in these two positions: in the standing position, the protrusion and volume of the abdomen are greater than in the recumbent position. In the standing position, especially when the tone of the abdominal press is lowered, the organs descend, which causes protrusion of the lower part of the abdomen. In the recumbent position, in such cases, the lateral parts protrude. In the lateral position, the diaphragm on the side where the patient lies stands higher than on the other side - therefore, on this side the organs also lie higher. Additionally, with lowered tone of the coverings, the organs, due to gravity, move toward the side where the patient lies, which is why protrusion occurs on this side, while the opposite side sinks. The lower the diaphragm stands, the more the organs adjacent to or near the diaphragm protrude from under the costal arch and the more accessible they become for examination. The tone of the abdominal coverings is influenced by the Magnus reflex tone, which depends on the position of the labyrinth in space. In the standing position, the tone of the abdominal press increases, in the recumbent position it decreases. Finally, the configuration of the abdomen and the tone of the abdominal coverings also depend on the respiratory phase. During diaphragmatic breathing during inspiration, the diaphragm descends, and the organs of the abdominal cavity also descend, and the more so the closer they lie to the diaphragm (Holzknecht). Contrary to the view expressed in many manuals that the stomach and transverse colon are immobile during breathing, it should be especially emphasized that both organs are very mobile during breathing. During inspiration, i.e., during contraction of the diaphragm, the abdominal muscles reflexively relax as antagonists of the diaphragm, as a result of which the abdominal coverings protrude and the intra-abdominal pressure increases relatively little (Kelling). During expiration, the coverings approach the posterior abdominal wall. This approach is used during deep palpation of parts of the gastrointestinal tract (Obraztsov, Gaussman), while for superficial palpation of organs adjacent to the abdominal wall (liver and spleen), the inspiratory phase of breathing is used, during which these organs descend and become accessible for palpation. Normal abdominal coverings during diaphragmatic breathing and in the absence of conditions causing active contraction of the muscles (uncomfortable position of the patient) relax sufficiently to allow both superficial palpation during inspiration and deep palpation during expiration. However, there are individuals in whom the abdominal muscles are constantly in a state of increased tension. In these individuals, not only deep but also superficial palpation of the abdomen is difficult. The configuration of the abdominal coverings in these individuals changes little depending on the position of the patient or the phase of breathing, as it is determined by the tone of the coverings. On the other hand, in individuals of asthenic constitution, the lowered tone of the abdominal coverings, together with the low position of the diaphragm, elongated relaxed ligaments, and fat-poor intra-abdominal organs, cause splanchnoptosis. For this condition, therefore, the configuration of the abdomen with a protruding lower part and retraction of the epigastric region is characteristic in the standing position. In contrast to this type, with good tone of the coverings, high position of the diaphragm, and abundant fat deposition in the intra-abdominal organs, the upper part of the abdomen protrudes even in the standing position (picnic or hypersthenic type). To a high degree, the configuration of the abdomen and the degree of protrusion of its walls depend on the accumulation of gases in the digestive tract, with particularly strong general protrusion occurring with general flatulence of the small intestine, and local - with flatulence of the large intestine or stomach. Ascites also causes protrusion of the abdomen, and the configuration of the abdomen in ascites depends not only on the amount of fluid in the abdominal cavity but also on the tone of the abdominal wall. The following methods are used in the examination of the abdomen: ventrometry, inspection, percussion, palpation, abdominal puncture, auscultation. Ventrometry aims to determine the distance between certain points (Gaussman), in particular: 1. The distance from the base of the xiphoid process to the pubis; at the same height, it is the greater the more the type approaches the asthenic, resp. the higher the diaphragm stands. 2. The distance from the navel to the pubis and to the base of the xiphoid process. The lower the navel lies, resp. the closer it is to the pubis, the more usually the asthenic type is expressed in this individual. 3. The transverse diameter of the lower border of the chest. 4. The transverse diameter of the pelvic bone. 5. The volume of the abdomen at the level of the navel. These ventrometric data give an idea of the shape of the abdomen and clarify the constitutional character of the individual. Practically, ventrometry and especially the measurement of the abdominal circumference are usually used to determine changes in the size of pathologically enlarged organs, resp. tumors, or the amount of fluid accumulated in the abdominal cavity. Inspection of the abdomen, performed in different positions of the patient, determines the configuration and profile of the abdomen. Inspection of the abdomen is of great importance in terms of the possibility of determining the presence of pathological deviations in the movements of the stomach and intestines (see Stomach-examination, Intestine-examination). To some extent, edema of the abdominal coverings is also determined by inspection, which is usually most strongly expressed in the suprapubic part of the abdomen. Even during inspection, one sees thickened skin with deepened pores and uneven surface, shiny skin, which cannot be folded. The navel also requires inspection. In obesity, the navel is drawn in, in flatulence it is smoothed out, and in ascites it often protrudes like an umbilical hernia. When inspecting the abdomen, attention must also be paid to the veins of the abdomen, which are clearly visible 1) when outflow of blood through the portal vein system is impaired, 2) when there is stagnation in the system of the inferior vena cava (when the latter is compressed by ascites, tumor, etc.). In the first case, the blood flow in the veins of the abdominal coverages is directed from the navel in different directions (caput Medusae), in the second - from the femoral vein upward. To determine the direction of blood flow in the vein, the vein is compressed with two fingers placed side by side, blood is squeezed out of the vein segment by moving the fingers apart, and when removing one or the other finger, the filling of the vein is observed. A boat-like drawn-in abdomen is a sign of various ailments: saturnism, morphine poisoning, tuberculous meningitis. It is also observed after prolonged vomiting, in cancer of the esophagus (and generally with prolonged fasting), in prolonged diarrhea. Percussion of the abdomen does not have the same significance as in the examination of the chest cavity, since the percussion sound in the same place of the gastrointestinal tract changes depending on the degree of its contraction and mainly on the degree of its filling with gaseous, liquid, or solid contents. Thus, in the same place, there may be a clear tympanic sound, a dull tympanic sound, or a dull sound. In addition, the location of individual segments of the gastrointestinal tract not only differs in different subjects but changes in the same subject (spontaneous displacement, Gaussman). Generally, the left side of the abdomen gives a duller sound than the right, and often on the left side there is a completely dull sound, which cannot be considered a pathological sign. It is hardly possible to delineate individual segments of the intestines, for example, the large intestine, by percussion, despite attempts made by authors in this direction, since loops of the small intestine and segments of the large intestine are closely adjacent to each other and partially cover each other. Often, however, it is possible to percussively determine the lower border of the stomach, since the intestines approach the space occupied by the stomach only from one (lower) side. Percussion of individual segments of the intestines is only possible with their pathological expansion (e.g., above acute or chronic narrowing). Under normal conditions, the area of the liver gives a dull sound, and usually the lower edge of the liver can be easily determined by percussion, but ¹ the edge of the liver determined by percussion, as a rule, lies somewhat higher than the edge determined by palpation, to which Frerichs already drew attention. But sometimes in flatulence, in the place of even a markedly hardened, enlarged, and palpable liver, instead of the expected dull sound, a tympanic sound is obtained.

Just as the liver, large tumors of the Abdomen also produce a dull sound, but only in cases where they do not belong to a hollow segment of the digestive tract and if there are no parts of the digestive tract between the tumor and the abdominal wall, as for example with retroperitoneal tumors. Dullness is also observed with the accumulation of fluid in the abdominal cavity (see Ascites). In the recumbent position, depending on the amount of fluid, either the entire Abdomen gives a dull sound or only the sloping parts, mainly the lateral ones. In such cases, when lying on one side, dullness on that side increases, while on the other side it is replaced by tympany. However, in peritonitis, if the exudate is loculated, displacement of fluid may not occur, as a result of which the dullness caused by it will not substantially change its position. In the standing position, even relatively small amounts of fluid (less than 1 liter) can be easily determined by percussion. Percussing from top to bottom, in the presence of fluid in the abdominal cavity, a zone of dullness is detected above the pubis with a horizontal upper border. A full bladder, pregnancy, tumors of the uterus, ovary, etc., also produce dullness above the pubis, but in such cases the upper border of dullness is not horizontal but more or less convex and does not change with a change in position; dullness from a full bladder decreases or disappears after urination or catheterization. The technique for percussing the Abdomen is the same as for percussing the chest (see Percussion). The Abdomen should always be percussed as gently as possible. Palpation of the abdomen should begin with general palpation (palpation generale G16nard's), which aims to determine: 1) the general properties of the abdominal coverings and their properties in individual areas, i.e., the degree of tension, protrusion, depressibility, resistance (defense); 2) sensitivity of the abdomen in various areas and 3) areas differing in their consistency (for detecting resistance, tumors, fluctuation). For this purpose, the hand is placed flat on the Abdomen and simple depressions, sliding movements, rotational movements, or finally thrusts are performed. After completing the general palpation, a detailed examination of the abdominal coverings is undertaken. This includes determining the degree of mobility of the skin over the muscular layer of the abdominal wall; it is greater the less developed the fatty tissue and the more flaccid the skin, as is the case, for example, in women who have given birth and in individuals who were previously obese and have become emaciated due to disease, etc. Then, using sliding movements without pressure, the properties of the muscular layer are determined. To ensure that hardening or protrusion does not belong to an intra-abdominal organ, the following maneuver (Gausmann) is used: the lying patient crosses their hands on their chest and then raises their head and shoulders themselves, as a result of which the abdominal press actively contracts. If the hardening (or protrusion) belongs to an intra-abdominal organ, it disappears or becomes less distinct when the abdominal press is tensed; if it belongs to the abdominal walls, it either remains the same as it was or becomes even more distinct. The presence of passive and respiratory mobility of the palpable hardening also speaks against the tumor belonging to the abdominal coverings. Special attention should be paid to the white line when examining the abdominal wall. Here, divergence of the rectus muscles (diastasis m. recti) of smaller or larger sizes is often found. In the absence of noticeable divergence, examining the white line in the epigastric region, small hernias invisible to the eye, the size of a cherry, pea, or millet grain, are sometimes found. In other cases, small hernias are found at the outer edge of the rectus muscle along the so-called linea Spigelii. When examining the abdomen, the places where femoral and inguinal hernias occur, as well as the spermatic cord and testicles, should always be inspected and palpated. Two methods of abdominal palpation are distinguished: superficial, with the hand placed flat on the Abdomen, and deep palpation, in which palpation should be done with bent fingers, as the hand must be immersed more or less deeply. Superficial palpation is necessary for palpating the edges of the liver and spleen, which are palpated when they have descended downward under the edge of the costal arch after a deep inspiration during diaphragmatic breathing. Deep palpation according to Gausmann is performed for palpating parts of the digestive tract. For this, the moment of approximation of the coverings to the posterior wall during expiration after a deep inspiration is used. During expiration, both depression of the fingers into the depth and those movements of the hand that are needed for palpating individual segments of the digestive tract are performed, namely sliding movements in the direction transverse to the long axis of the palpated segment (according to Gleanar and Obraztsov). Since loops of the small intestine, except for the terminal segment (pars caecalis ilei), are not palpated, but only parts of the stomach and large intestine are palpated, this makes it possible to recognize the particular palpated segment and to perform topographic palpation. Topographic palpation (Gausmann) localizes the palpated body not so much by its location and properties as by its topographic relationship to other palpated parts. The palpated segments of the stomach and large intestines, representing cords or cylindrical bodies, are garland-like segments (Gausmann); the following segments are distinguished: 1) the gastric segment (curvatura major, antrum pylori), 2) the transverse colon segment, 3) the ileocecal segment (pars caecalis ilei, caecum, colon ascendens), 4) the sigmoid segment (flexura sigmoidea, colon ascendens). These segments divide the abdominal cavity into several areas: 1) the area above the gastric segment, between the latter and the edge of the liver, 2) the area between the gastric and transverse colon segments, 3) the area between the transverse colon segment and the pubis, bordered by the sigmoid and ileocecal segments, 4) the area lateral to the sigmoid segment, 5) the area lateral to the ileocecal segment. Additionally, the properties of the tumor must be studied. In this regard, mobility of tumors comes first: 1) passive, i.e., mobility under the examining hand, 2) respiratory, depending on respiration, 3) spontaneous, depending on the degree of contraction of the stomach and intestinal muscles. The absence of all types of mobility is characteristic of retroperitoneal tumors, for example, tumors of the pancreas. The liver and spleen, with rare exceptions, are only respiratory mobile. The stomach and transverse colon possess all types of mobility, but the latter is lost with extensive adhesions (walled-in). Tumors of the stomach and transverse colon can be held in place by the hand during expiration; tumors of the liver cannot be held. For localizing tumors, in the past, inflation of the stomach was widely used, which has now to a large extent been replaced by X-ray examination. The task of palpation is to determine the position of the organs of the abdominal cavity and to localize the tumor within the aforementioned possibilities. After determining the location of the tumor in a particular place, the question of which organ or tissue (to the pancreas, lymph glands, retroperitoneal tissue, mesentery, loops of the small intestine) of this area the given tumor belongs is then left to other methods of investigation to decide. Puncture. Puncture in the abdominal area is undertaken 1) to detect free fluid in the cavity of the Abdomen, 2) to detect closed cavities containing liquid masses, 3) to obtain material for histological research from parenchymal organs, mainly from the spleen. Puncture of the abdomen should not be performed with a needle fitted to a syringe. This very common method, especially among surgeons, deprives the physician's hand of the ability to fully obtain the tactile sensations that are so important for determining the nature of the medium into which the tip of the needle passes. Moreover, with this method, a mechanical rupture of internal tissues can easily occur when the patient, contrary to the physician's instructions, makes a sudden movement or a deep respiratory movement during puncture. Therefore, it is necessary first to make a puncture with the needle, and only then connect the needle to the syringe. With this method, it is immediately visible when the needle has entered a larger vessel (which, however, is extremely rare). When the needle is inserted sufficiently deeply, it is connected to the syringe; first the syringe is removed, and only then is the needle withdrawn. With a small amount of fluid, with this method, it sometimes turns out that no fluid is visible in the syringe, but 1-2 drops of fluid are blown out of the needle, which can be examined microscopically. In case of ascites, puncture is best performed not along the midline, but a few fingers to the side and down from the navel, along the middle of the line connecting the navel and the upper anterior iliac spine (spina ilii ant. sup.). There is no need to fear injuring vessels. Only injury to an enlarged vein or sclerosed artery can cause bleeding, but an enlarged vein is visible on the coverings, and the artery gives a distinct pulsation.

If ascites is large, puncture can be performed in the area of dullness in the recumbent position. If ascites is small, in the recumbent position all the fluid flows to the lateral parts of the abdomen, and therefore puncture should be performed in the vertical position, determining the upper level of fluid by percussion. In such cases, puncture sometimes has to be made close to the Poupart's ligament. Thus, it is possible to prove that a low band of dullness in the lower part of the Abdomen, giving rise to doubt about the cause of dullness, is due to a small accumulation of fluid, which of course has great diagnostic significance (minimal ascites). Of the parenchymatous organs, the enlarged spleen, directly adjacent to the abdominal wall, is punctured. Punctures are made with a thin needle and with strict adherence to all rules to avoid rupture of the spleen capsule. Microscopic examination of the splenic pulp obtained in this way can provide valuable diagnostic services to an experienced researcher (see Spleen - examination). However, it must be borne in mind that punctures of the spleen undertaken for diagnostic purposes have repeatedly caused fatal hemorrhages due to rupture of the spleen. It is also necessary to emphasize that during puncture, loops of intestine are never pierced, as they easily move away from the needle if there are no adhesions. If a puncture is made in the area of a solid body, that body may be injured. Therefore, before making a puncture, one must be sure that the dullness at the puncture site is due to ascites, i.e., that it disappears after a change of position. However, encapsulated peritoneal ascites may not disappear in this case. Puncture of the Abdomen is used when there is no ascites a) for laparoscopy, proposed 15 years ago by Jacobaeus, b) for obtaining pneumoperitoneum (see Aeroperitoneum). Acoustic phenomena. Sound phenomena in the abdominal cavity are perceived 1) during palpation, 2) during auscultation. During palpation, sound phenomena in the form of noise, splashing, rumbling, crepitation occur where there is air and gas, and therefore the appearance of such phenomena during palpation indicates that the palpated body belongs to the gastro-intestinal tract and not to a solid organ. The complete absence of acoustic phenomena in the palpated body on re-examination with great probability speaks against the palpated body belonging to the gastro-intestinal tract. But it must be remembered that normal Abdomen 87v loops of small intestine, with the exception of the pars caecalis ilei, do not give any sound phenomena, and only in the presence of stenosis can sound phenomena arise in the loops dilated above the stenosis (Mathieu). The character of sound phenomena depends both on the amount of gas and on the consistency of the stomach or intestinal contents and on the tone of the walls. With a large amount of liquid and gas and with a flaccid tone of the walls, a splashing noise is produced when the corresponding area is shaken by hand; with semi-liquid content, rumbling is sometimes obtained on palpation, and with denser content mixed with gas, crepitation. Splashing noise can be produced by shaking only in the recumbent position of the patient, but the patient himself can produce it both in the recumbent and in the standing position by a sudden contraction of the diaphragm. Splashing noise is observed both in the stomach and in the large intestine. From the splashing noise in the stomach, the so-called clapotement (splashing) should be distinguished, which also occurs in the absence of liquid in the stomach when the stomach is filled with gas. This phenomenon is produced in the recumbent patient by sudden thrusts made by the doctor's hand, placed flat on the Abdomen. In percussive palpation of the recumbent patient on the height of a deep diaphragmatic inspiration, rapid thrusts are made with the fingertips, during which the anterior wall of the stomach strikes against the layer of liquid covering the posterior wall. The necessary condition for the occurrence of this sound phenomenon is the presence in the stomach of a certain amount of liquid and gas. By Gausmann, who proposed for determining the position of the stomach instead of percussive palpation the direct palpation of the greater curvature by deep sliding palpation, attention has been drawn to the acoustic phenomenon, the so-called expiratory rumbling, which is observed at the moment when the fingers, during expiration, make sliding movements from top to bottom, slide past the greater curvature. With a complete absence of liquid, expiratory rumbling is not obtained. Acoustic phenomena are sometimes also perceived during palpation of the pylorus, at the moments of relaxation of the contracted pylorus, in the form of the so-called mouse squeak (Obraztsov, Cohnheim). Sound phenomena in the parts of the large intestine are very diverse depending on the above-mentioned reasons. From their character, one can to some extent judge the tone and contents of the intestine. Acoustic phenomena determined by auscultation have only relative significance, since sounds occurring in one place are heard in any other place of the abdomen. In this respect, a significant difference should be noted between the Abdomen and the lungs. Only the complete disappearance of auscultatory phenomena in acute diseases of the abdominal cavity serves as an ominous sign indicating the onset of intestinal paralysis. Of particular importance is the appearance during auscultation of large-bubble metallic sounds, which indicate the formation of a cavity due to dilatation of the intestine above its stenosis. Research of painful phenomena. Palpation indicates places sensitive to pressure. But if it is known in which area there is a place sensitive to pressure, this still says nothing about the source of the pains. Before attributing pain to an intra-abdominal organ, it is necessary to exclude the occurrence of pain in the abdominal coverings. For this, pressure is applied with actively contracted abdominal press (see above). If the pain increases or does not decrease with this, it can be attributed to the abdominal coverings, but if it decreases or disappears with this, it should be attributed to an intra-abdominal organ (Gausmann). Tenderness of the coverings may be due to tenderness of the skin or subcutaneous layer. By taking the skin in a fold and squeezing it with two fingers, one determines whether it is tender or not. Tenderness of the skin may be due either to neuralgia or an inflammatory condition or to a viscerosensory reflex to the skin. If the subcutaneous layer of the abdominal walls is tender, it is most often a matter of muscles, and it may be either neuralgia or myositis or a viscerosensory reflex similar to Ged's skin zones. If the pain does not belong to the abdominal wall, it is necessary to localize the pain, i.e., determine in which organ it arises. This is done in the same way as a tumor is localized, i.e., by determining the location of the organs of the abdominal cavity by topographic palpation and clarifying the topographic relationship of the painful spot to the palpated organs (see above - palpation). Thus, it can be determined, for example, whether pain in the so-called "stomach area" really belongs to the stomach or lies outside it. During palpation, it is not always possible to decide whether a particular organ or the posterior abdominal wall, for example, nerve plexuses on the spine, is painful on pressure. This question is solved more reliably by percussion (proposed at one time by Mendel and Plonies). Pain from percussion in the absence of pain originating from the abdominal coverings indicates that some diseased organ lies at the site of the percussive pain. Percussive pain in the area of the cecum and in the subcostal area is particularly valuable. Percussive pain in the area of the cecum with certainty indicates an inflammatory condition in this area. Percussion in the epigastric region and in the costal margins is valuable for differentiating cholecystopathy and hepatopathy on the one hand and ulcer on the other. In an ulcer of the lesser curvature, the zone of percussive pain lies below the hepatic dullness along the median line or somewhat to the side of it and does not reach the costal arch. In an ulcer of the pylorus or duodenum30H, the percussive pain is located to the right of the median line and also does not reach the costal arch itself. Percussive pain in ulcers decreases or disappears during deep inspiration, i.e., during protrusion of the Abdomen, which is a valuable diagnostic sign. Percussive pain in cholecystopathy is present right at the costal arch and, unlike ulcer, increases during inspiration, because the liver becomes more accessible during this phase of respiration. In hepatitis, percussive pain, increasing on inspiration, is present in the area of the entire hepatic dullness; outside this area there is no pain. As for tenderness from pressure during deep palpation of the posterior abdominal wall, tenderness of the vertebra or aorta is a very frequent phenomenon indicating neuropathy. Of much greater diagnostic significance is tenderness of the m. psoas (Gausmann), but not bilateral (indicating neuropathy), but unilateral, which indicates an inflammatory condition of some organ of the same side: vermiform appendix, cecum, appendages, gallbladder, renal pelvis. In all these diseases, there is therefore a McBurney's tender point.

In diseases of the renal pelvis and gallbladder, the upper part of the m. psoas is more painful than the lower part, and sometimes only the upper part is painful; conversely, in appendicitis and diseases of the appendages, the lower part is more painful or only this part is painful. If the pain of the m. psoas is caused by cholecystopathy, then in addition to percussion pain at the site of the gallbladder, a blow to the costal arch or a push in the area of the gallbladder causes pain, whereas simple pressure during inspiration (Ker's symptom) in cases of definite cholecystitis often causes no pain at all. Also, Boas's symptom (pain on pressure from behind about the X-XI vertebrae) and Skvirsky's symptom (pain in the right hypochondrium when shaking the same area from behind) are often absent where direct impact (blow, push, percussion) causes pain. Sometimes a blow to the costal arch causes pain in ulcers when the pylorus or duodenum are drawn to the liver and fused with it. In such cases, pressure on the back also causes pain. In such cases, only careful percussion and palpation examination and other clinical research methods make it possible to make the correct diagnosis.