Methods for diagnosing intestinal diseases
When questioning, it is necessary to clarify in detail questions about the presence, nature and localization of pain and changes in stool. So, for example, cramping pains, or colic, ending with the escape of gases or stools, are forced to suspect disruption of intestinal permeability. When perforating an ulcer of the duodenum, immediately an extremely strong pain( "dagger blow") appears, leading sometimes even to loss of consciousness.
It is very important to establish the possible localization of pain. The pain in the right upper quadrant of the abdomen is characteristic of duodenal ulcers. Pain in the right iliac fossa is observed with appendicitis, cancer, tuberculosis of the cecum. In the lower lower abdomen, acute pain often occurs with intestinal obstruction, with inflammation of the sigmoid colon. Pain in the navel is observed with narrowing of the intestine, lead colic, colorectal cancer, with fermentation dyspepsia and inflammation of the small intestine( enteritis).
Chair changes are of great diagnostic value. Stool retention occurs with habitual constipation, tumors in the intestine, and central nervous diseases. Complete constipation, i.e., not only the absence of feces, but also the cessation of the escape of gases, is characteristic of intestinal obstruction. Diarrhea occurs with catarrh of the intestines, with fermentative and putrefactive dyspepsia, dysentery, etc. It is important to find out the presence of so-called false diarrhea, in which the bowel movements mostly consist of mucus, blood and pus, while the actual stool is retained;The chair appears with painful tenesmus 10-20 times a day;false diarrhea is mainly due to severe changes in sigmoid and rectum( rectal cancer, sigmoiditis, proctitis).It should also be asked about the appearance of the bowel movements and the departure of the worm.
From the transferred diseases it is important to clarify the issue of diseases with localization in the intestine( dysentery), diseases of other organs that often lead to reflex disorders of the intestine( cholecystitis), the possibility of occupational poisoning( lead, arsenic, etc.), in women about diseasessexual apparatus( inflammation of the ovaries, parametrite, etc.), since they can cause changes in the intestine.
Data on the nature of diet, habits, time of meals, working conditions, alcohol abuse, tobacco, etc. are also important.
A study of the abdomen in bowel disease can yield very valuable results for the diagnosis. Especially characteristic is a change in the shape of the abdomen when the abdominal entrails in general and the intestines in particular are lowered( with enteroptosis).The upper part of the abdomen thus falls, the lower part, on the contrary, protrudes.
The embroidered stomach of is observed in the empty intestine due to, for example, stenosis of the pylorus, with prolonged diarrhea. Scaphoid retraction of the abdomen is characteristic of reflex spasm of the intestines during meningitis.
Uniform bloating of the abdomen is observed with bowel flatulence( swelling of the intestines with gases).Stenosis of the rectus or sigmoid colon can also cause a uniform bloating. Acute peritonitis after abdominal operations, acute flatulence in hysterical and paralysis of intestines due to poisons poisoning or infectious diseases can cause balloon protrusion of the abdomen.
Asymmetric local protrusions of the abdomen depend on the limited flatulence in some loop of the intestines if they are impaired due to strangulation, curvature, or with strangulated hernias.
enhanced peristaltic movements of intestines are of great importance;they give the most bizarre changes in the relief of the abdomen. They are always connected with the sensation of pain and stop often with the rumbling and escaping of gases. They are an expression of chronic narrowing of the intestine, and with acute blockages may be absent. Often one has to wait a fairly long time until such a strong peristalsis of the intestines can be seen;but if it is available, then the diagnosis of impaired intestinal permeability becomes unquestionable. It is often impossible to locate the obstruction by simply observing the increased peristalsis of the intestinal loops, since the caliber of the distended intestinal loops can be so large that it is easy to confuse them with the prolate large intestine.
Palpation is the most important method for finding out pathological processes in the intestine.
Initially, an approximate palpation of the abdomen is made, which aims to determine the general properties of the abdominal walls, the degree of their tension and sensitivity in different areas. Then proceed to a more detailed study, resorting to superficial and deep palpation.
With deep sliding palpation of the abdomen, place the hand flat and with slightly bent fingers tend to penetrate to the posterior abdominal wall of the organ being examined or a tumor during exhalation. Having reached the posterior abdominal wall or the organ under examination, glide with the tips of the fingers in a direction transverse to the axis of the organ being examined or to its edge. When you feel your intestines, your fingers roll across your intestine, pushing it against the back abdominal wall. Depending on the position of the various parts of the colon, they feel the stomach in different directions. The sliding movements of the touching fingers should not occur along the skin of the abdomen, but with it, that is, shifting the skin;in most cases, put your fingers on one side of the intestinal loop and then slide your fingers across it, lightly pressing it against the back abdominal wall.
Gut feeling begins with the sigmoid colon as a more accessible area for palpation and most commonly palpable( in 90% of all cases);then, according to Strazhesko, go to the caecum, to the final segment of the ileum and appendix, after which the transverse intestine is examined.
Usually the sigmoid colon is probed in the left ileal region. Since it has a direction on the left from above and from the outside to the right down and to the inside, then it is probed right from top to bottom and to the left or, conversely, from the left below and to the right to the top. The sigmoid colon in the normal state is palpated in the form of a smooth, dense cylinder with the thickness of the thumb of the hand, is painless, rarely peristals and has passive mobility of 3-5 cm.
In various pathological conditions, these properties of the gut change, and it can become bumpy( with the development of neoplasmor deposition of dense fibrinous exudate around it), painful( with inflammatory process in the intestine or mesentery), strongly and often peristaltic( with inflammation of the intestine or with syExistence of any obstacle below it) and lose their normal mobility( with adhesions or atrophy and the development of scarring in her mesentery).On the other hand, the mobility of the sigmoid colon can also be increased( with the lengthening of the intestine and its mesentery with congenital anomalies), and finally, rumbling can occur in the gut( when liquid contents and gases accumulate in it).
The cecum is normally probed in the right ileal cavity. Palpation should be conducted, as always, perpendicular to the axis of the intestine, ie, left and top to the right and down. In most cases, the cecum is easily palpated with the usual deep palpation of four slightly bent fingers. However, with the tension of the abdominal press, it is useful to transfer the resistance of the abdominal wall to another place in order to reduce counteraction in the place of examination of the cecum. For this purpose, according to Obraztsov, a free left hand should be pressed around the navel during the examination. With a high location of the cecum, place the left hand flat under the right lumbar region, in order to create an emphasis instead of the ilium( bimanual palpation).Together with the cecum, the lower part of the ascending gut is also palpated. Under normal conditions, the cecum is usually palpated "in the shape of a smooth, two-finger width, rumbling, painless on palpation to a moderately movable cylinder with a small pear-shaped blind extension downwards, with moderately elastic walls"( Strazhesko).
In various pathological conditions, the cecum changes its palpation properties. If it is not fixed to the back wall of the abdominal cavity or if the mesentery is lengthened or enlarged, it appears to be excessively mobile( coecum mobile), and, conversely, after the former inflammatory process around the intestine( local peritonitis), it becomes fixed and loses its mobility. With inflammation of the caecum, it acquires a dense texture and becomes painful. With tuberculosis and cancer of the cecum, it is probed as a hard, tuberous tumor. When there is a liquid content in the cecum and a large amount of gases( with enteritis), loud rumbling is determined.
As for the probing of the small intestine, only the terminal segment of the ileum( pars coecalis ilei) lends itself to it. This segment rises from the small pelvis in the large in the direction to the left and from the bottom to the right and upwards and flows from the inside into the cecum somewhat higher than its blind end. The palpation is performed according to general rules in the perpendicular direction to the axis of the bowel, ie, from above and from the left to the bottom 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 caecum, the indicated iliac segment is usually palpated for 10-12 cm in the depth of the right ileal cavity in the form of a soft thin-walled tube giving a loud rumbling, or in the form of a thick strand thick in the little finger. He is moderately mobile, often shortens and completely insensitive.
With various pathological conditions( in severe cases of typhoid fever, with tuberculous ulcers), this part of the intestine is probed with tuberous and painful. In cases of stenosis in the cecal region, the ileum is palpated with a thickened, dense, crowded content, giving a sharp splash and splashing vigorously.
The palpation of the appendix is possible only when it lies inside 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 thick intestine. Feeling the cecum and finding the pars coecalis ilei, feel the area lower and higher than the latter, mainly by the musculus psoas, which is easily determined when the patient is lifted by an elongated right leg.
A palpable normal process, as described by Strazhesko, is represented "in the form of a thin, with a goose feather thick, mobile with passive displacement, an absolutely painless, smooth, unruly cylinder, the length of which varies from subject to subject."
Modified processes, fixed in a certain position due to inflammatory adhesions or inflammatory-thickened and painful probes are much easier than normal.
Palpation of the transverse colon with its two curvatures - flexura colica dextra( hepatica) and flexura collca sinistra( lienalis) - must be preceded by percussion and palpation determination of the position of the lower border of the stomach. The transverse colon in most cases lies 3-4 cm below the large curvature of the stomach. If it is not found in this area, then try to find it lower or higher, gradually examining the entire area of the rectus abdominal muscles from the xiphoid process to the pubis. If in this way she manages to find the transverse colon;you should look for it in the lateral parts of the abdomen.
For probing the transverse colon use either one right, or both hands - "bilateral palpation."When palpating with one hand, slightly diluted and slightly bent in phalangeal joints, the fingers of the right hand are gradually immersed in the abdominal cavity on both sides of the white line 2-3 cm below the found border of the stomach. Reaching the back wall of the abdominal cavity, they slide down it, trying to feel the gut under the 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 is in most cases probed as a slightly curved transverse cylinder, which can be traced in both directions to the sub-stems. With significant splanchnoptosis, it has the form of the letter V.
When palpating the colon, its consistence, volume, mobility and sensitivity are determined. The more liquefied the contents and the more gasses in the gut, the smoother it feels. The thicker and denser the contents, the more it appears to be when it feels denser. On the other hand, an absolutely empty bowel, with its spastic reduction, gives the impression of a dense, thin and smooth strand. On the contrary, with atony of the intestines, it is probed as a tube with sluggish, relaxed walls. In colitis, it is palpated with a dense, shortened and painful. When developing a malignant neoplasm in it, it is thickened and bumpy. With narrowings located below the transverse colon, it appears enlarged in volume, elastic, smooth, periodically peristaltic and sometimes loudly rumbling.
It is necessary to mention also about palpation with the help of a finger inserted per rectum. The index finger is smeared with any fat and slow rotational movements move as far as possible deeper into the rectum. This method of palpation of the rectum, in addition to the condition and diseases of the rectum itself( fecal masses, mucosal conditions, tumors, ulcers, varicose veins), often allows you to judge the state of more distant parts of the intestine that do not come into contact directly with the rectum, such as, for example,vverobrazny process and the caecum with their inflammation( peritiflit, appendicular infiltrates).
When feeling the tumors, it is sometimes useful after filling the enema to fill the large intestine with air( by means of a clitoral tip connected to a pumping rubber bottle).Air, like water, passes through the Bauginievian damper, and the entire colon is depicted in the form of the letter P. At the same time, the topographical relations of the palpable tumors are much more clearly defined. It is extremely important in this case to find out whether the palpable tumor becomes clearer after bloating the colon, or, on the contrary, is less clear and less accessible to the feeling. In the latter case, one can think that the tumor belongs to the organs lying behind the intestine.
Among the properties of the tumor, established by palpation( size, consistency, shape, tenderness, surface properties), one of the most important places is displaced. Tumors belonging to the intestine usually have very little replaceability during respiratory movements, since they are located too far from the diaphragm for this purpose, the excursions of which mainly affect the organs nearest to it - the liver, spleen, stomach. Passive same turnover of intestinal tumors in palpation, on the contrary, is quite large, especially small intestine tumors that have a long mesentery. The mobility of intestinal tumors depends on whether they are fused with surrounding organs or not.
In the study of pain sensitivity, it is first of all necessary to exclude the soreness of the skin of the abdomen and the muscles of the abdominal press. In the depth of the abdominal cavity to the left and upwards from the navel is a solar plexus, very sensitive to pressure in neurotics. Outside and slightly down from the navel are the mesenteric plexus - the upper right and the lower to the left of the navel;they can also be painful. With inflammation of the blind and sigmoid colon, tenderness is noted when palpation of the corresponding sites;the same soreness can be observed in colitis along the course of the transverse intestine. With appendicitis, the pain point of Mek-Burni( Mac Burney), corresponding to the location of the appendix of the cecum, is determined;it lies in the middle of the line connecting the navel and the superior anterior islet of the right ilium. However, it must be borne in mind that the position of the appendix is extremely often deflected, both upward and downward.
The splash noise that appears in the abdomen is important, which can be obtained by rough jerking of the abdominal wall with the ends of the fingers. The intestinal noises of splashing are often observed "in the region of the stretched areas of the intestine, as a sign of abnormal stagnation of the liquid contents. In the region of the cecum, palpation often causes the sound of splashing or rumbling, giving at the same time a tactile sensation of the iridescent liquid. This phenomenon is observed in all kinds of enterocolitis, especially in typhoid fever, but it is also found in healthy people.
Percussion in the diagnosis of bowel disease plays a very small role. Separate percussion separate segments of the intestine( thick and thin) is not possible, because they closely adjoin each other, partly covering each other. Amplification of tympanic sound in the abdominal cavity is observed with flatulence. Percussion of the intestine can detect dullness over tumors or over crowded intestinal loops only if parts of the gastrointestinal tract, inflated with gases, do not lie between them and the abdominal wall.