The liver is the largest digestive gland. She is in abdominal cavity, occupies the right hypochondrium, partially the epigastric and left hypochondrium.

Its weight ranges from 1500-2000 g, depending on gender and blood supply; the shape is wedge-shaped.

Counts a lot of clicks, thanks to the organs that come into contact with it:

• Heart;
• gastric;
• esophageal;
• duodenum;
• colon;
• renal;
• adrenal glands

Contains 2 surfaces - diaphragmatic, visceral, they converge in front and form a sharp lower edge; 2 edges (bottom, back); the right and left lobes, which are separated by the falciform ligament.

Structure of the liver

Performs important functions for the functioning of the body, such as:

1. Production of bile (a necessary enzyme for the digestion of fats).
2. Neutralization of harmful substances.
3. Neutralization of alien formations.
4. Metabolism (proteins, fats, carbohydrates, vitamins).
5. The liver is a glycogen “depot” (energy reserve).

Thanks to palpation, percussion, and ultrasound, its size can be determined. This will allow us to establish a diagnosis in the future and correctly prescribe treatment.

The method for determining the size of the liver according to Kurlov is as follows:

The dimensions and boundaries can be determined through percussion (which involves tapping a section of the organ and analyzing sound phenomena). When percussing the liver, it is normal to hear a dull sound because it is dense and does not contain air.

M. Kurlov proposed the most informative method for recognizing the boundaries of the liver: 5 points are determined during percussion, which indicate its true ones.

Borders according to Kurlov (norm)

• I point (upper limit of hepatic dullness) - lower edge of the 5th rib;
• Point II (lower limit of hepatic dullness) - at the level or 1 cm above the edge of the costal arch along the midclavicular line.
• III point - at the level of I point on the anterior midline.
• IV point (lower border of the liver) - on the border of the upper and middle third between the xiphoid process and the navel.

Having determined the boundaries of five points, three sizes are measured.

Norms for liver size in children and adults

For adults normal sizes according to Kurlov:

The size of the right lobe of the liver is indicated by the first size, the left - by the second and third.

Percussion dimensions in children (according to M. G. Kurlov), in centimeters.

Sizes vary significantly depending on individual accessories.

In newborn children, the liver is functionally immature and large. In newborns, the left lobe large sizes, which decreases at the age of one and a half years; The segmentation of the liver is not clearly expressed and is formed by the end of the first year of life.

Determining boundaries according to Kurlov in children under 3 years of age is not effective enough; preference is given to palpation. Normally, the lower edge protrudes 1.5-2 centimeters below the right costal arch, and subsequently does not protrude from under the costal arch.

In a child, the histological structure of the liver corresponds to that of an adult at 8 years of age, and by that time it has poor development of connective tissue, manifested by large vascularization and inadequate differentiation of parenchymal tissue.

What diseases does a change in the borders of the liver indicate?

An upward shift of the upper limit is observed in the following diseases:

Moving the upper limit down (low aperture).

36. Percussion of the liver. Determination of liver size. Borders and dimensions of the liver according to Kurlov (on average, in cm) in normal and pathological conditions. Clinical significance of detected changes.

Using percussion, you can assess the size of the liver, the enlargement of which is primarily manifested by its displacement lower limit and only in rare cases (abscess, large cyst, large tumor node) - the upper limit. The upper border of the liver usually coincides with the lower border of the right lung; percussion determination of the location of the lower border of the liver helps in further palpation.

The lower border of the liver is determined using quiet percussion. It begins from the area of ​​the tympanic sound at the level of the navel or below, gradually moving the pessimeter finger upward until a dull sound appears, which will correspond to the lower border of the liver. Normally, the liver does not protrude from under the costal arch. With a deep breath and in a vertical position of the body, the lower border of the liver moves downward by 1-1.5 cm.

In clinical practice, percussion determination of the liver boundaries according to Kurlov is widespread. Three percussion sizes of the liver are determined:

Percussion is carried out along the right midclavicular line from the navel to the lower border of the liver and from a clear pulmonary sound down the intercostal spaces until hepatic dullness appears (it should be recalled that the border of the transition of a clear or tympanic sound into a dull sound is marked along the outer edge of the finger - plessimeter, i.e. sides of clear or tympanic sound). By connecting two points, the first size of the liver is measured according to Kurlov. It is usually 9 cm. The upper limit of hepatic dullness is used to determine the other two sizes.

The midline of the abdomen is percussed upward until hepatic dullness appears. The upper border along the midline is difficult to determine due to the location of the dense sternum under the skin, which dampens percussion sounds, therefore, the upper point of this size is conventionally taken to be the point lying on the same level as the upper border of the first size of hepatic dullness (a horizontal line is drawn through this point until it intersects with midline). By connecting these points, the second Kurlov liver size is measured, usually 8 cm.

The third size of the liver according to Kurlov is determined by percussion near the left costal arch parallel to it, starting percussion approximately from the anterior axillary line. The upper point corresponds to the upper point of the second liver size according to Kurlov. The third size is usually 7 cm. If the liver is enlarged, then the first large size is indicated by a fraction, the numerator of which is the total size along the right midclavicular line, and the denominator is its part corresponding to the size extending downwards beyond the costal arch.

37. Examination of the spleen. Examination of the spleen area. Methodology for determining the percussion boundaries of the spleen. Percussion boundaries and sizes of the spleen are normal. Palpation of the spleen. The sequence of actions of the doctor during palpation. Changes in the spleen in pathology (physically determined). Clinical significance of detected changes.

There are many methods for percussion of the spleen, which can be explained by the difficulty of choosing optimal anatomical and topographic landmarks. One of the most traditional methods includes topographic percussion of the spleen according to Kurlov. It is carried out with the patient lying down with an incomplete turn on the right side.

Percussion is carried out along the tenth intercostal space, starting from the spine; The longitudinal size (dinnik) of the spleen is determined by the boundaries of the dullness - in healthy individuals, as a rule, it does not exceed 8-9 cm. If the spleen protrudes from under the edge of the costal arch (which can be observed either when it increases or when it subsides), the length of the protruding part is taken into account separately. The width (diameter) of the spleen (normally up to 5 cm) is determined by percussing from above from the anterior axillary line (perpendicular to the middle of the identified length of the spleen). The results obtained are expressed as a fraction, the numerators of which indicate the length, and the denominator the width of the spleen. Normally, the spleen is most often located between the 9th and 11th ribs. The accuracy of percussion determination of the size of the spleen is low; this is due to the peculiarities of its anatomical location, the proximity of hollow organs (stomach, colon), which can significantly distort the results of the study.

Palpation of the spleen is carried out according to the general rules of deep sliding palpation. The patient should lie on the right side with the right side straight and slightly bent at the hip and knee joints left foot. Similar to palpation of the liver, with a deep breath, the enlarged spleen descends and “rolls” over the fingers of the examiner. With a significant enlargement of the spleen, its lower edge descends into the left hypochondrium, and in this case it is possible to palpate the surface of the spleen, its characteristic notch, and determine its consistency and soreness. Normally, the spleen cannot be palpated. In some cases, it is advisable to palpate the spleen in a position both on the right side and on the back.

In the left upper quadrant of the abdomen, in addition to the spleen, other organs are sometimes identified (kidney, left lobe of the liver, enlarged pancreas, splenic flexure of the colon). Sometimes it can be difficult to distinguish them from the spleen; in these cases, ultrasound and other methods should be used to identify the palpable formation. 38. Examination of the kidney area. Method of palpation of the kidneys (lying and standing). Pasternatsky's symptom. Clinical significance of detected changes. Kidney examination begins with inspection. When examining the anterior wall of the abdomen, a protrusion in the hypochondrium area is sometimes determined due to an enlarged kidney (hydronephrosis, tumor, etc.). With large kidney tumors, the saphenous veins of the corresponding half of the abdomen are sometimes dilated. With paranephritis, swelling is sometimes observed in the corresponding half of the lumbar region. Upon examination, you can see a pear-shaped protrusion above the pubis or in the lower abdomen, which is related to overcrowding. bladder with urinary retention.

Palpation kidneys are performed bimanually with the patient in the supine, lateral and standing position. The patient relaxes his abdominal muscles, breathes evenly and deeply. When examining the right kidney left hand placed under the lumbar region of the patient with the palm up, between the spine and the 12th rib, and the right hand on the front wall of the abdomen under the costal edge. During exhalation, bring the fingers of both hands together: the fingers of the right hand lying on top are held as deep as possible into the hypochondrium, and with the left hand the kidney area is slightly pushed forward. In healthy people, the kidneys, as a rule, cannot be palpated. In thin people, especially women, it is sometimes possible to feel the lower edge of the right kidney, located lower than the left. The left kidney is examined in the same way, but the right hand is placed under the lumbar region, and the left hand is placed on the anterior abdominal wall. Palpation of the kidneys on the side is especially indicated in patients with a significantly developed subcutaneous fat layer of the anterior abdominal wall. The patient lies on the right side when examining the left kidney and on the left side when examining the right kidney. On the side being examined, the leg is slightly bent at the knee and hip joints. The position of the doctor's hands is the same as during the examination on the back. When examining a patient in a standing position, he leans slightly forward to relax the abdominal muscles. Pain caused by tapping the lumbar region in the angle between the 12th rib and the outer edge of the long back muscles (Pasternatsky's symptom) indicates a disease of the kidney or renal pelvis.

39. Complaints of patients with diseases of the respiratory system, their pathogenesis. Shortness of breath (dyspnea) is a feeling of difficulty breathing, objectively accompanied by a change in its frequency, depth and rhythm, duration of inhalation or exhalation. Subjective sensations of shortness of breath do not always coincide with its objective signs. Thus, with constant shortness of breath, the patient gets used to it and ceases to feel it, although the external manifestations of shortness of breath do not disappear (the patient suffocates, often takes a breath when talking) and significant disturbances in the function of external respiration are noted. On the other hand, in some cases, patients complain of a feeling of lack of air in the absence of objective signs of shortness of breath, i.e. they have a false sensation of shortness of breath. In relation to the individual phases of external respiration, shortness of breath can be inspiratory (inhalation is difficult), expiratory (exhalation is difficult) and mixed (inhalation and exhalation are difficult). The extreme degree of shortness of breath is suffocation. Regarding this symptom, it is imperative to find out what is associated with its paroxysmal nature, duration, connection with cough and sputum discharge, how the patient relieves the attack, etc. Cough as a protective reaction in the vast majority of cases is caused by irritation of the receptors of the respiratory tract and pleura. The most sensitive reflexogenic zones are located in the areas of branching of the bronchi, in the area of ​​tracheal bifurcation and in the interarytenoid space of the larynx. Less commonly, cough is associated with stimulation of the central nervous system, with the mucous membrane of the nasal cavity and pharynx, etc. Accordingly, a cough of central origin is distinguished (including a cough as a manifestation of neurosis, or neurotic) and a reflex cough caused by irritation of receptors outside the respiratory tract (auditory canal, esophagus, etc.). In diagnostic terms, cough in itself is not a specific symptom of any lung disease, but its significance as a symptom increases significantly when assessing the nature and characteristics of the manifestation. Cough has its own specific characteristics: character (constant or paroxysmal), duration, time of occurrence (morning, afternoon, night), volume and timbre. Cough can be frequent and infrequent, weak and strong, painful and painless, constant and periodic. Depending on productivity, i.e. the presence or absence of secretion, a distinction is made between dry and wet cough - with sputum production. In the latter case, it is necessary to clarify the amount and nature of sputum (mucous, purulent, etc.) ), color, smell, some features of its separation (for example, by spitting or “mouth full”, in a drainage position, etc.). A productive cough, in which sputum is released, differs from a dry cough in its timbre. The special timbre of a wet cough depends on the fact that noise from the movement of secretions is mixed with the cough noise. It is necessary to determine the timbre of a cough because not all patients expel mucus; some swallow it (weak patients, children). In this regard, the cough may mistakenly appear dry. When questioning, you should find out the factors that cause or intensify the cough (smell, physical activity, etc.), what is accompanied by it (suffocation, nausea, vomiting, fainting, loss of consciousness, epileptiform seizure, etc.), what causes it to decrease or disappear (clean air , taking some medications, etc.). Hemoptysis and pulmonary hemorrhage These are serious complications of diseases of the bronchi, lungs and heart. Hemoptysis is the release (coughing up) of sputum with blood in the form of streaks and pinpoint inclusions due to diapedesis of red blood cells with increased permeability of the vascular walls or rupture of capillaries. Sometimes the sputum is pink-red in color. Pulmonary hemorrhage is the release (coughing) as a result of rupture of the vascular walls of clean, scarlet, foamy blood in the amount of 5 - 50 ml or more. There are small (up to 100 ml), medium (up to 500 ml) and large, profuse (more than 500 ml) pulmonary hemorrhages. Blood released when coughing with sputum may be fresh (scarlet) or altered if red blood cells have broken down and hemosiderin pigment has formed (for example, “rusty sputum” in patients with lobar pneumonia). Hemoptysis and pulmonary hemorrhage must be differentiated from bleeding from oral cavity, nasal, esophageal, gastric bleeding.

Chest pain Chest pain varies in location, nature, intensity, duration, radiation, and in connection with the act of breathing and the position of the body. Chest pain can be both superficial and deep. Superficial pain - thoracalgia- usually associated with skin lesions of the chest muscles, ribs, cartilage, joints, intercostal nerves, tendons, and spine. According to localization they are divided into front(sternal, clavicular, pectoral, etc.) and rear Posterior thoracalgia that occurs in the area of ​​the scapula is called scapalgia (or scapulalgia), and that occurs in the thoracic spine region is called dorsalgia. Such pain is recognized by careful examination and palpation of the chest, which reveals local soreness and muscle tension. These pains are often aching or stabbing in nature, often intense and prolonged, intensifying when lying on the sore side, with sudden movements of the body. Superficial pain can be caused by secondary reflex and neurodystrophic damage to the structures of the chest as a result of diseases of nearby internal organs- lungs and pleura, heart, esophagus, stomach, liver, gall bladder, etc. Secondary neurovascular and neurodystrophic changes in the muscles, tendons, ligaments, ribs, cartilage and joints of the chest are sometimes mistaken by the doctor for primary ones, and the underlying visceral pathology is not diagnosed. Deep pain in the chest associated with damage to the lungs, pleura, and mediastinal organs. These pains intensify when breathing, coughing, and are precisely localized by the patient. Irritation of the mucous membrane of the small bronchi and pulmonary parenchyma by any process does not cause pain in the patient. Inflammation of the pulmonary parenchyma is accompanied by pain only in cases where the parietal pleura is involved in the pathological process. Additional, or general, complaints of patients with respiratory diseases include increased body temperature, sweating, general weakness, increased fatigue, irritability, decreased appetite, etc. These complaints do not allow localizing the pathological process (that’s why they are general), but they significantly complement the picture of the lung disease (that’s why they are called additional) and characterize the severity of the patient’s condition. Patients with respiratory diseases usually attach much greater importance to these additional complaints, since they significantly limit their work and ability to work. General, or additional, complaints most often reflect infectious-inflammatory and intoxication processes. Therefore, an increase in body temperature in pulmonary patients is usually observed in the evening; it reaches febrile levels (i.e. above 38 ° C) and is accompanied by chills. Sweating, as a rule, occurs at rest, during sleep and forces the patient to change underwear several times during the night. The feeling of general weakness in pulmonary patients is combined with their sufficient physical strength.

40. Complaints of patients with diseases of the cardiovascular system, their pathogenesis. Main complaints - pain in the left half of the chest (area of ​​the heart), difficulty breathing (shortness of breath), a feeling of palpitations and interruptions in heart function, swelling, fainting and sudden loss of consciousness. Pain in the heart area can be long-term, chronic and acute, very strong, and sudden onset. Chronic pain is usually of low or moderate intensity, appears in the left front half of the chest or behind the sternum, radiates to the left arm, left shoulder blade. The pain can be dull, aching, squeezing, grasping, pressing; constant, periodic and paroxysmal. Most often they arise in connection with physical or psycho-emotional stress. Pain is relieved with nitroglycerin, validol or “heart drops” - valerian, motherwort, valocordin, corvalol. The “heart” nature of the pain is supported by its combination with other complaints characteristic of diseases of the cardiovascular system - shortness of breath, palpitations, a feeling of interruptions, autonomic disorders. Sensitive endings - receptors - are excited in the heart, the signal from them goes first to spinal cord, then to the cerebral cortex and there the feeling of pain appears. Firstly, pain occurs due to ischemia - a decrease in blood flow to certain areas of the myocardium. The need to increase blood flow occurs during physical activity and emotional stress. Because of this, such pain is characterized by the occurrence of attacks when walking, emotional disorders, cessation of pain at rest, quick withdrawal their nitroglycerin.

The second mechanism of pain is due to the accumulation of products of impaired metabolism in the myocardium due to inflammatory and degenerative changes under medicinal influences. The pain in these situations is prolonged, covers a wide area, and nitroglycerin usually does not relieve it.

The third mechanism of pain in heart disease is inflammatory changes in the outer lining of the heart - the pericardium. In this case, the pain is usually long-lasting, occurs behind the sternum, and intensifies with breathing and coughing. They are not relieved by nitroglycerin and may weaken after the prescription of painkillers.

The fourth mechanism of pain is due to a decrease in the “threshold of pain sensitivity” in central departments nervous system system when "normal" impulses from the heart cause pain. It can be dull, aching, prolonged pain, or short “second” stabbing pain, not associated with physical activity, sometimes the pain subsides after exercise. The pain is accompanied by increased fatigue, insomnia, and sometimes a slight increase in temperature.

For the patient and the doctor, pain associated with cardiac malnutrition should be especially alarming; here there is no need to hesitate in seeing a doctor, examination and treatment.

Dyspnea- one of the most common symptoms of heart damage. The patient complains of difficulty breathing, a feeling of lack of air. Shortness of breath increases with physical activity and lying down. It weakens at rest and when moving to a sitting position. Shortness of breath in the vast majority of cases is the result of stagnation of blood in the lungs, increased pressure in the pulmonary capillaries.

Heartbeat is felt by the patient as a frequent contraction of the heart; Sometimes patients describe it as a “pounding”, “quivering” heart, often interruptions in the activity of the heart. Healthy people can experience palpitations during physical work or emotional stress, but it quickly goes away with rest when the person calms down. In all other situations, this is a symptom indicating the presence of cardiac dysfunction.

Edema in heart disease are a sign of heart failure. First they appear on the ankles, then the legs, intensify in the evening (shoes become tight), and disappear or decrease in the morning.

41. Complaints of patients with diseases of the gastrointestinal tract, their pathogenesis. The main complaints of patients with diseases of the digestive system:

Impaired passage of food through the esophagus

Stomach ache

Belching

Nausea and vomiting

Bloating

Blood in the stool

Jaundice

Disturbances in the passage of food through the esophagus

In diseases of the esophagus, the main complaints will be difficulty passing food through the esophagus (dysphagia) and pain along the esophagus (behind the sternum). Stomach ache- one of the most common complaints. This is a signal of trouble in the digestive system. Pain appears when spasms, strong spastic contractions occur in organs such as the stomach, intestines, and gall bladder, or, conversely, when these organs are stretched by food, gases, or when their muscle tone is reduced. Sometimes the organ is stretched from the outside by adhesions that form after operations on the abdominal organs. During spasms, the pain is strong, sharp, and when stretched, pulling, aching. Diseases of the liver and pancreas - solid organs, without a cavity, usually lead to an enlargement of these organs, stretching of the capsules covering their surface, this also causes pain like a sprain. Belching- one of the common manifestations of impaired motor function of the stomach. At the junction of the esophagus and the stomach there is a kind of muscular valve - the cardiac sphincter. The same valve is located at the exit from the stomach, at the point where it passes into the duodenum. Under normal conditions, both of them are closed, which ensures that food remains in the stomach for a sufficiently long time for it to be digested. The valves open as food passes into and out of the stomach. Belching is like the return of a very small release from the stomach, most often of air, which a person swallows along with food and, less often, the food itself. It can be physiological, i.e. normal, occurs after eating, especially a large meal, or drinking carbonated drinks. In these situations, due to the opening of the cardiac sphincter, intragastric pressure is equalized. Physiological belching is usually one-time. Repeated belching bothers the patient. It is caused by a decrease in the tone of the cardiac sphincter. It can occur in diseases of the stomach and other organs of the digestive system, which have a reflex effect on the cardiac sphincter. Belching rotten (hydrogen sulfide) indicates retention of food masses in the stomach. Sour belching occurs when the acidity of gastric juice increases. Bitter belching is caused by the reflux of bile from the duodenum into the stomach and further into the esophagus. Belching rancid oil may indicate decreased secretion of hydrochloric acid and delayed gastric emptying. Heartburn- this is an unpleasant peculiar burning sensation in the projection of the lower third of the esophagus behind the sternum. You can make sure that a person really feels heartburn if you carry out a simple test. You need to drink half a teaspoon of soda dissolved in 100 ml of water, heartburn goes away very quickly. Heartburn is caused by the backflow of stomach contents into the esophagus due to weakening of the tone of the cardiac sphincter of the stomach. This condition is called cardia failure. It may be a manifestation of a functional disorder or organic damage to the stomach. Heartburn can occur at any level of gastric acidity, but it occurs relatively more often with increased acidity. Persistent repeated heartburn, worsening in a horizontal position of the patient, when working with the torso tilted forward, is characteristic of an inflammatory disease of the esophagus. With a peptic ulcer, heartburn can be the equivalent of rhythmic pain. Nausea and vomiting- closely related phenomena, both occur when the vomiting center, which is located in the medulla oblongata, is excited. Signals that activate the vomiting center can come from the stomach when poor quality food, acids, and alkalis enter it. They can occur in other organs of the digestive or other systems during severe diseases. Damage to the brain itself, for example, a concussion due to injury, also leads to activation of the vomiting center. Finally, if poisonous, toxic substances enter the blood, the vomiting center is washed with blood and is also activated. From the vomiting center a signal goes to the stomach, its muscles contract strongly, but as if in the opposite direction, and the contents of the stomach are thrown out. Usually a person feels nauseous before vomiting. Vomiting should cause particular concern if the vomit is dark in color (“coffee grounds”) or has streaks of blood, or just scarlet blood. This happens when there is bleeding from the esophagus or stomach. In these situations, an urgent examination by a doctor is necessary.

Bloating Bloating and, along with it, rumbling in the stomach are called intestinal dyspepsia. Their long-term existence indicates violations of the basic functions of the intestine. These signs intensify in the afternoon, after eating milk and foods rich in plant fiber. After the gases pass, they temporarily decrease. In a number of people, rumbling and bloating are clearly associated with negative emotions and do not have any organic causes. The appearance of rumbling and bloating in the form of attacks for a relatively short time - alarming symptom, since it can be assumed that there is a mechanical obstacle to the release of gases. Diarrhea - This is an increase in bowel movements (defecations) during the day and at the same time a change in the consistency of stool, it becomes liquid and mushy. U healthy person the intestines are emptied 1-2 times a day, the stool is of a dense consistency. This happens due to the fact that there is a balance between the amount of fluid entering the intestinal cavity from its wall and the amount of fluid absorbed into the intestinal wall. In addition, there are normal contractions (peristalsis) of the intestine. These peristaltic movements seem to delay movement through the intestines, promoting the formation of feces. With diarrhea, these conditions are violated - the secretion of fluid increases, its entry into the intestinal cavity, absorption decreases and peristalsis weakens (see diagram). As a result, feces become liquid and are excreted more often - 4-5 or even more times a day. With diarrhea caused by diseases of the colon, stool is usually very frequent, there is little feces, mucus and sometimes streaks of blood are often found in it. The causes of diarrhea are numerous. These are intestinal viral and bacterial infectious diseases, food poisoning, chronic diseases of the small and large intestines. Constipation - This is a decrease in bowel movements (bowel movements), stool retention for more than 48 hours. The feces are hard and dry, after stool there is no feeling of complete emptying of the bowel. Constipation, therefore, should include not only stool retention, but also those situations where stool is daily, but in an extremely small volume. With constipation, the flow of fluid into the intestinal cavity decreases, absorption (exit from the intestinal cavity into the intestinal wall) increases, the motor activity of the intestine also increases and the time of movement of feces through the intestine increases. Constipation is relatively more common in diseases of the colon; their causes can be functional or organic. Blood in the stool The appearance of blood in the stool is one of the most serious and alarming signs of intestinal diseases. Blood in the stool is a signal of a violation of the integrity of the intestinal mucosa and vessels.

Scarlet blood, not mixed with feces. Characteristic of internal hemorrhoids, anal fissures. Scarlet blood on toilet paper. Characteristic of internal hemorrhoids, anal fissures, rectal cancer. Blood and mucus on laundry. Characteristic of late stages of hemorrhoids and rectal prolapse. Blood on underwear without mucus. Characteristic for rectal cancer. Blood and mucus mixed with stool. Characteristic of ulcerative colitis, proctitis, polyps and tumors of the rectum. Massive bleeding. May be due to diverticulosis of the colon, ischemic colitis. Black stool (melena). Characteristic of bleeding from dilated veins of the esophagus with cirrhosis of the liver, ulcers and stomach cancer. In most cases, the causes of blood in the stool are relatively benign - hemorrhoids, anal fissures. But this can also be a manifestation of very serious diseases - polyps, intestinal tumors.

Jaundice Complaint on appearance yellow color skin - one of the few characteristic of liver damage. At first, patients or their loved ones may notice yellowness of the sclera, then the skin. At the same time, there may be indications of changes in the color of urine (“beer color”) and discoloration of feces. Along with jaundice, there may be itchy skin.

The liver is the largest gland in the human body, the functions of which cannot be replaced. It participates in the metabolic, digestive, hormonal, hematopoietic processes of the body, neutralizes and removes foreign substances. The size of the liver varies depending on the constitution of the person, his age, and weight. One of the methods for studying the organ is percussion according to Kurlov.

Liver and its size

The gland is located with right side abdominal cavity under the diaphragm. A small part of it in an adult extends to left side from the midline. The liver consists of two lobes: right and left, which are separated from each other by the falciform ligament. Normally, the length of a healthy organ reaches 30 cm, the height of the right lobe is 20–22 cm, the left lobe is 15–16 cm.

In newborns, the liver has no lobes and weighs about 150 grams, while in an adult its weight is almost 1.5 kg. The gland grows until the age of 15 and by this age reaches its final size and weight.

A decrease or increase in the size of an organ indicates the presence of diseases. The most common sign of liver disease is hepatohemalgia (pathological enlargement).

The main reasons for the growth of the gland:

Reduction in size is diagnosed in the last (terminal) stage of cirrhosis, which occurs due to alcohol addiction, disorders of bile secretion and blood supply, liver failure.

Technique for determining the boundaries of the liver using the Kurlov method

To diagnose liver diseases, the Kurlov percussion method is used.

The edges of the liver are established along three lines relative to the costal arches:

• midclavicular;
• parasternal;
• anterior axillary.

Using the tapping technique, the highest border of the liver is determined along the right midclavicular line. It is determined once, since the edge goes straight horizontally. The finger is placed parallel to the supposed superior line of the gland and calm tapping (percussion) is performed until a quiet sound appears.

The lower edge of the liver has an oblique cut, descending from left to right. Measured several times. The border is marked from bottom to top. To do this, a finger is placed near the navel, and percussion is performed until a dull sound appears.

To identify the edge along the left costal curve, place the finger perpendicularly at the attachment point of the 8th rib and gently tap, moving towards the sternum.

Exist additional methods liver examinations: palpation, ultrasound, magnetic resonance imaging, computed tomography.

Video: Percussion according to Kurlov

Normal gland size

In a person of average constitution who does not have pathologies of internal organs, the midclavicular line runs from bottom side right costal arch. The right parasternal line descends 2 cm lower. On the left side of the body, along the parasternal line, the edge of the liver is at the level of the left costal arch; along the anterior middle horizontal line, it does not reach the edge of the urinary branch of the sternum by 3–4 cm.

With an asthenic physique, the size of the organ may be slightly smaller than normal. When processing percussion results, the patient’s age must be taken into account. In an adult, the mass of the gland is 2–3% of the total body weight, in infants – up to 6%.

In an adult

The percussion technique determines three sizes of the liver:

• I - horizontally from the middle of the collarbone. Two boundaries are identified - upper and lower, the distance between which is up to 10 cm;
• II – along the midline. Diagnosis is based on differences in percussion sounds. The norm is from 7 to 8 cm;
• III – oblique line from the upper border to the lower. The distance is checked from the midline to the left costal bend. Normally it should be about 7 cm.

In children

In children, the outline of the liver is shifted downwards. Moreover, than smaller child, the more space in the abdominal cavity is required for the lobes of the gland.

Svetlana Sharaeva

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Liver dimensions according to Kurlov: the simplest and fastest method of preliminary diagnosis

Dimensions are determined by palpation. This diagnostic method helps the doctor decide on therapeutic tactics. In this article we will look at the main dimensions of the liver according to Kurlov, which make preliminary diagnosis more accurate.

On initial stage liver diseases, there may be no specific signs or changes in the structure of hepatocytes. When an organ increases in size, a pain syndrome appears, caused by stretching of its membrane. The nature of the pain varies from aching to acute.

Identify liver pathology early stage possible using palpation and percussion. These are accessible diagnostic techniques that do not require time.

With their help you can:

• determine the boundaries of the liver;
• detect changes in the structure of the organ;
• identify liver dysfunction.

Normal parameters

It is not considered a deviation from the norm if the edge of the liver protrudes 2 cm along the midclavicular side and 6 cm along the median border.

Note! Due to lung resection, the liver may be located higher than it should be.

The soreness of the organ is determined during palpation. To determine the size of the liver, the Kurlov method is used.

Method proposed by M. Kurlov

The famous Russian and Soviet therapist M.G. Kurlov proposed his own method for determining the boundaries of the liver. This method is considered the most informative.

The calculation technique involves identifying 5 points using percussion.

Table 1. How to identify Kurlov ordinates?

What are the sizes of the liver?

The tablet provides information about the size of the liver proposed by M. Kurlov.

Table 2. Three liver sizes.

Child factor

In infants at 1 month of life, liver function is poorly developed. The size of the organ is increased. The right lobe of the liver is smaller than the left. These parameters are reduced to one and a half years.

The segmentation of the liver in newborns is not clearly expressed. It is fully formed by 12 months. The lower edge of the liver does not protrude.

The histological structure of the liver is finally formed only when the child reaches the age of eight. Until this time, the connective tissues of the organ are poorly developed, the parenchyma is not completely differentiated.

Note! The Kurlov method is not effective for children under three years of age. The optimal age for such diagnosis is 7 years. Before this, the boundaries of the liver are determined by palpation.

The norms for liver size in children are presented in the table.

Table 3. Liver sizes in children according to M. Kurlov.

Possible pathologies

One of primary symptoms development of the pathological process is a shift in boundaries.

Table 4. Diseases that develop when the upper limit is shifted.

Reducing the upper limit

This condition is called low diaphragm. The occurrence rate is 36%.

Table 5. Probable diseases.

Raising the lower bound

Occurrence possible pathologies presented on the plate.

Table 6. Diseases accompanying an increase in the lower limit.

Reducing the lower limit

This deviation occurs in 42% of cases. Information about possible diseases presented on the plate.

Table 7. Pathologies accompanying a decrease in the lower limit.

Palpation method

By moving the fingers, the doctor can determine by touch the boundaries of the liver and clarify the level of pain. The presence of pain, which intensifies during palpation, signals a violation of the liver. This criterion is used in differential diagnosis.

Note! Palpation is performed according to the method proposed by Strazhesko and Obraztsov.

Technique

The instructions look like this:

1. The patient assumes a horizontal position. This helps make diagnosis easier.
2. The abdominal muscles relax. This is quite difficult due to the pain that accompanies inflammation.
3. When you take a deep breath, the free edge of the liver is shifted downward by the lungs. Then it descends from under the arch of the ribs. If you place your fingers on the wall of the peritoneum, you can easily feel it.

What can you find out?

Palpation reveals the parameters of the following lines:

• midclavicular;
• axillary;
• right parasternal.

A healthy person's liver is round, soft and smooth.

Percussion method

This method was discovered in Austria in the 60s of the 18th century, but gained popularity only 100 years later. The definition of absolute dullness is of clinical importance - parts of the hepatic lobes not covered by lung tissue.

The criterion for determining the boundary is the change in percussion sound. The range can range from clear pulmonary to dull.

When deciphering the obtained data, the age of the patient is taken into account. In adult patients, the weight of the organ under study is 2-3% of the total weight. In infants, the liver weight is 6%.

How younger child, the larger the volume of the abdominal cavity is occupied by the hepatic lobes.

Modern diagnostic methods

Data about modern methods diagnostics are presented in the table.

Table 8. Other methods for studying the liver.

Conclusion

In order to prevent the development dangerous diseases The liver must undergo a medical examination once every six months. You also need to adhere to preventive recommendations.

More detailed information about the Kurlov method, palpation and percussion can be found in the video in this article.

The liver is the largest digestive gland. It is located in the abdominal cavity, in the area of ​​the right hypochondrium. Its dimensions are determined by palpation. Thanks to this method, it is possible to more accurately establish a diagnosis and prescribe appropriate therapy. The method for determining the size of the liver according to Kurlov is considered one of the most effective and informative.

The liver has two surfaces - visceral and diaphragmatic, which form the lower edge of the organ. And the upper border is determined by three vertical lines passing under the parasternal, anterior axillary and midclavicular arches of the ribs. But the main changes in the structure of the organ are still determined by changes in the lower border.

The liver performs many vital functions:

At the initial stage of liver diseases, there may be no visible symptoms or changes in the structure of hepatocytes. But as the size of the organ increases, pain appears due to stretching of its membrane.

For example, when infected viral hepatitis the incubation stage can last up to 6 months. In this case, there are no unpleasant signs of the disease, but a change in the structure of the tissue is already occurring.

By palpation and percussion, the presence of liver diseases can be detected at an early stage. These methods are available to everyone and do not require much time. .

These two diagnostic techniques make it possible to identify the boundaries of an organ, changes in its structure and functioning. When the liver expands or is displaced, we can talk about the development of a pathological process. Domestic scientists have developed several palpation and percussion methods for diagnosing liver diseases. Among them is the method of M.G. Kurlova.

Kurlov method

M. Kurlov proposed a technique for calculating the size of an organ, which consists in determining five points by percussion. Their parameters are also influenced individual characteristics of people. This method is relevant because it allows you to differentiate the disease in just a few minutes, and a correctly established diagnosis is the first step towards recovery.

This technique allows us to identify Kurlov ordinates, which are then used to determine the size of the liver:

• 1 point – the upper border of the blunt edge of the liver, which should be located next to the lower edge of the 5th rib.
• 2 point – the lower border of the obtuse edge of the organ. Normally, it should be located at or 1 cm above the lower edge of the costal arch.
• 3 point – at the level of 1 point, but at the level of the anterior midline.
• 4 point – the lower border of the organ, which should be located at the junction of the middle and upper third of the area from the xiphoid segment to the navel.
• 5 point – the lower sharp edge of the liver, which should be at the level of the 7th-8th rib.

The liver has a high density, and there is no air in its cells, so dull sounds are considered normal when tapping. However, these sounds are significantly shortened when part of the organ covered by the lungs is percussed.

But since the structure of the liver can change, it is recommended to be checked by a specialist once every six months, and also to constantly adhere to preventive recommendations.

After determining five points of the organ using the Kurlov method, 3 sizes can be determined:

• 1 size – along the line on the right side of the body, passing in the middle of the collarbone, the upper and lower boundaries are determined. The normal parameters for this distance are no more than 10 cm in adults and no more than 7 cm in children.
• size 2 calculated using the midline. This takes into account the percussion sound when tapping. In children under 7 years old it should be 6 cm, and in older adults – 7-8 cm.
• Size 3 determined by an oblique running diagonally between the boundaries of the upper and lower edges. For children, the norm is 5 cm, and for adults – 7 cm.

In children

In newborn children, the functionality of the liver is not yet fully developed, and its size is increased. Moreover, the left lobe differs in greater parameters than the right. Up to 1.5 years they will decrease. Also, in infants the segmentation of the organ is unclear, but by the age of one year it should be fully formed.

Determining the boundaries of the liver using the Kurlov method in children under 3 years of age is ineffective. In this case, palpation is better.

The lower edge of the organ should normally protrude beyond the edge of the right lower rib by no more than 2 cm. In children older than this age, liver parameters decrease, so it should not protrude. That is why this diagnosis is usually used for children over 7 years old.

The table below shows the normal liver size in children:

The histological structure of the organ in children becomes similar to that of an adult only at 8 years of age. Before this age, the connective tissues of the liver are poorly developed and the parenchyma is not fully differentiated.

Percussion

The boundaries and dimensions of the liver are determined by tapping and sound analysis. This technique is called percussion. It is considered normal to hear a dull sound during this procedure, since this organ is dense and there is no air in it.

Since the density of the internal organs is different, when they are tapped, various sound effects arise, by analyzing which one can identify their condition and problems in functioning. This technique was proposed back in the 18th century, but for quite a long period of time it was not recognized by doctors. Only in the 19th century did it begin to be used as one of the main methods of primary diagnosis of patients.

Percussion can be mediocre and spontaneous. When performing direct percussion, tapping rib cage and abdominal cavity. And for mediocre percussion, a plessimeter is used in the form of the fingers of the left hand and a special plate. In this way, it is possible to determine the location and structure of internal organs located no deeper than 7 cm from the surface of the body.

But test results may be inaccurate due to gas or fluid in the abdominal cavity, as well as the thickness of the abdominal wall.

When analyzing the results of this technique, the age of the subject is also taken into account. The definition of boundaries differs between children and adults. The mass of the liver in infants is 6% of the total volume of all internal organs, and in adults it is only 2-3%, so the boundaries of the organ in children are somewhat different.

Palpation

After percussion, palpation of the liver is often used. It can be used to determine the sharp or dull lower edge of the liver, as well as the consistency and presence of pain or lumps.

This procedure is usually performed as follows: the patient takes a deep breath, during which the free edge of the liver moves down and falls. This makes it possible to palpate the boundaries of the organ through the wall of the abdominal cavity.

You can palpate the lower edge along the midclavicular line, but only on the right side, since the abdominal muscles are located on the left, which can interfere with palpation. Normally, the free edge of the liver should be sharp and soft. When inhaling, it should protrude beyond the edge of the ribs by 1-2 cm in adults and 3-4 cm in children.

Before you begin palpating, some preparation is required, especially if the patient is a child younger age. To obtain the most accurate palpation parameters, you should relax the abdominal muscles, but this can be difficult to do, since inflamed organs are always painful.

You can palpate the liver with the patient positioned both vertically and horizontally. But it will be more convenient to do this in a lying position.

Palpation allows you to determine the degree of organ enlargement and its compliance with the norm. In healthy adults, the liver should be smooth, soft and round. With this diagnostic, you can find out the parameters of 3 lines; right parasternal, axillary and midclavicular.

Diseases with changes in liver size

The upper border of the liver may shift with the development of certain diseases:

Lowering the upper diaphragm is possible in the following cases:

• with visceroptosis;
• with emphysema;
• with pneumothorax.

Raising the lower border of the liver may also occur with the development of an acute form of dystrophy or atrophy, ascites and flatulence, as well as with late-stage cirrhosis. A lowering of the lower limit is associated with the development of hepatitis, heart failure and cancer.

Judging by the fact that you are reading these lines now, victory in the fight against liver diseases is not yet on your side...

And have you already thought about surgical intervention? This is understandable, because the liver is a very important organ, and its proper functioning is the key to health and wellness. Nausea and vomiting, yellowish tint to the skin, bitterness in the mouth and bad smell, dark urine and diarrhea... All these symptoms are familiar to you firsthand.

But perhaps it would be more correct to treat not the effect, but the cause? We recommend reading the story of Olga Krichevskaya, how she cured her liver...