Abdominal
Examination
Xue Huiping
Introduction
It is well known that advances in
scientific medicine have occasionally
threatened to displace the history and
physical examination in the evaluation of
the patient,However,we usually discover
that technologic advances serve to make
the physical examination more rational
and provide new understanding or
objective documentation of long-
appreciated physical finding,
New techniques for evaluation of the intra-
abdominal contents include many biochemical,
isotopic,ultrasonic,and angiographic methods,
These advances,although improving our
ability to detect,document,and interpret
physical findings,have not superseded the need
for the skills of the medical interview and
physical examination,An orderly approach to
the examination of the abdomen will make
possible the analysis of the symptoms arising
from the many organs of the digestive and
genitourinary systems found in this region,
Palpation is an important step in
abdominal examination and is difficult to
learn,esp,the palpation of the liver and
spleen,so we must practise more,
We conform to the same basic steps
of inspection,palpation,percussion,and
auscultation used in this area as in other
areas,
2.Topographic anatomy
There have been several systems or
methods devised for dividing the
abdomen into topographic segments,but
two kinds of commonly used systems or
methods will be described here,Other
methods may be found in any standard
textbook of anatomy,
Before you understand these two
methods,at first you should know the
following anatomic landmarks(Figure 1),
— xiphoid (ensiform) process(剑状突
起 ) of sternum(胸骨 )
— costal margin肋弓缘
— umbilicus脐
— anterosuperior iliac spine/ anterior
superior iliac spine髂前上棘
— iliac crest髂骨嵴
— inguinal ligament 腹股沟韧带
— superior margin of os pubis耻骨上
缘
— anterior midline前中线
— lateral border of rectus abdominis
muscle/ lateral border of abdominal
recti muscles腹直肌外缘
— symphysis pubis (耻骨联合 )
Next,I shall introduce the following two
commonly used methods of subdividing
the abdomen,
(1) The abdomen is divided
into four quadrants(四区法 ),
(Figure 2)
The anterior surface of the abdomen
is divided into four quadrants by two
intersecting lines,one extending vertically
from the xiphoid,through the umbilicus,
to the symphysis pubis (耻骨联合 )and
the other extending horizontally across the
abdomen at the level of the umbilicus,
This divides the abdomen into the right
upper,right lower,left upper,and left lower
quadrants,Four areas can be outlined
utilizing the quadrant map i,e,RUQ(right
upper quadrant),LUQ(left upper quadrant),
RLQ(right lower quadrant),LLQ(left lower
quadrant),The content of the abdomen
underlying each of the four quadrants in
both males and females should be known as
follows,
?Right upper quadrant
Liver
Gallbladder胆囊
Duodenum十二指肠
Caput pancreas胰头
Right kidney右肾
Hepatic flexure of colon结肠肝曲
?Left upper quadrant
Stomach
Spleen脾
Left kidney左肾
Cauda pancreas胰尾
Splenic flexure of colon结肠睥曲
?Right lower quadrant
Cecum盲肠
Appendix阑尾
Right ovary and uterine tube右侧卵巢
及输卵管
Right ureter右输尿管
?Left lower quadrant
Sigmoid colon乙状结肠
Left ovary and uterine tube左
侧卵巢及输卵管
Left ureter左输尿管
(2) The abdomen is divided
into nine sections(九区法 ),
This kind of method elaborates more correctly
and clearly,so everyone should learn it by heart,
That method states that at first you should draw
imaginary,parallel,horizontal lines across the
lowest border of the costal margin and the
anterior superior iliac spine,and then you should
draw two vertical lines across the middle of
inguinal ligament,approximating the lateral
borders of the abdominal recti muscles,
Now nine areas can be outlined with these
four lines,The content,or structure,of the
abdomen underlying the nine areas should also
be known as follows,
? Left hypochondrial region
左上腹部；左季肋部
Spleen; stomach; splenic flexure of colon;
cauda pancreas; left kidney; left adrenal
gland(左肾上腺 )
? Left lumber region左侧腹
部；左腰部
Descending colon(降结肠 );
jejunum(空肠 ) or ileum(回肠 ); left kidney
? Left iliac region左下腹部；
左髂部
Sigmoid colon; female left ovary and
uterine tube; male left varicosity(精索 ) and
lymph node
? Right hypochondrial
region右上腹部；右季肋部
Right lobe of liver(肝右叶 ); gallbladder;
hepatic flexure of colon; right kidney; right
adrenal gland
? Right lumber region
右侧腹部；右腰部
Ascending colon; jejunum(空肠 );
right kidney
? Right iliac region右下腹
部；右髂部
Cecum(盲肠 ); appendix; lower part of
ileum(回肠 ); lymph node; female right
ovary and uterine tube; male right
varicosity
? Epigastric region上腹部
Stomach; left lobe of liver;
duodenum(十二指肠 ); caput pancreas and
body of pancreas; transverse colon; aorta
abdominalis(腹主动脉 ); omentum
majus/the greater omentum (大网膜 )
? Umbilical region中腹部；
脐部
Lower part of duodenum; jejunum;
ileum; ptosis(下垂 ) part of the stomach or
transverse colon; ureter(输尿管 ); aorta
abdominalis; mesentery(肠系膜 ) and
lymph nodes; omentum majus
? Hypogastric region下腹部
Ileum; sigmoid colon; ureter; full bladder;
pregnant uterus(子宫 )
Now we will discuss physical examination
of abdomen,conforming to the sequence
from inspection,through palpation and
percussion,to auscultation,Please
remember,before any physical
examination is carried on,you should do
several general preparations as follows,
1,To ask the patient to urinate completely to be sure that
the bladder is empty,
2,Patient should be lying on his back with a pillow under
his head and his knees bent to relax his abdominal
muscles,
Be sure the arms are on either side,not behind his head,A
little conversation or repeating of the patient’s history might
help to relax the patient,
3,To expose abdomen completely from the breasts to
pubis,
For female patients,breasts should be covered with a sheet,
Inspection
The major contents of inspection are
composed of abdominal contour,respiratory
movements,abdominal veins,gastral or
intestinal pattern(胃型或肠型 ),peristalsis(蠕
动波 ),and abdominal rash,hernia(疝 ),
striae(纹 ),etc,Now let’s discuss one by one,
(1) abdominal contour
You should pay attention to whether
the abdomen is symmetrical,whether it is
bulged or retracted,and whether it is
indicative of ascites or enclosed mass(包块 ),
In normal person,you can find
abdominal flatness(腹部平坦 ),abdominal
fullness(腹部饱满 ),and abdominal
lowness(腹部低平 ),
Abdominal flatness means the
abdomen is at the same level or lower
as between costal margin and
symphysis pubis,If you ask the patient
to sit,the lower part of umbilicus can
become more or less protruded or
bulged,
If he or she is very fat or is a child,the
abdomen is a little bit round,and the
level of the abdomen is higher than that
of the surface between costal margin and
symphysis pubis,This phenomenon is
called abdominal fullness,But,If a
patient is very thin or slender,the level of
the abdomen is lower than that of the
surface between costal margin and
symphysis pubis,as a result of little
subcutaneous fat,
This phenomenon is called abdominal
lowness,In a word,abdominal flatness,
abdominal fullness,and abdominal lowness
are all normal cases,But,If the abdomen is
obviously or extremely protruded or bulged,
or it is conspicuously or exceedingly
retracted or depressed,that phenomenon is
abnormal and usually indicates pathological,
Now let’s discuss some important
pathological conditions,
1) Abdominal bulge腹部膨隆
I,Overall/generalized abdominal
bulge全腹膨隆
Overall abdominal bulge can be caused by
several pathological factors except for overly
obesity,It is commonly seen in following
conditions,
i,Peritoneal fluid
If there is a large amount of free
fluid within the abdomen,i,e,ascites,
abdominal wall can be lax in supine
position,fluid can deposit at both
lateral sides,abdominal wall just likes
a frog belly,
If the patient lies on one side or sits,the
lower part of abdominal wall will be bulged,
as from the movement of free fluid,This is
commonly found in ascites complicated by
portal hypertension of liver cirrhosis,At that
case,esp,in long-standing ascites,the
appearance of the umbilicus is protruded or
everted,But in obesity and fat,the umbilicus
is usually deeply inverted,
? Frog belly蛙腹
? Apical belly尖腹
Apical belly is caused by peritonitis and
hence abdominal muscle is tense,usu,
with the apical shape,apical belly is so
called,
ii,Peritoneal air腹腔积气
Peritoneal air is caused by a large amount
of air accumulating in the cavity of stomach,
The general shape of abdomen is globular
and two sides of lumber region is not
obviously protrudent,If you ask the patient
to move or change the position,the shape of
abdomen remains globular,This is commonly
found in intestinal obstruction or
enteroparalysis(肠麻痹 ),
? Pneumoperitoneum气腹
Pneumoperitoneum is caused by air
accumulating in the abdominal cavity,It is
commonly found in perforation of
gastrointestinal diseases or artificial
pneumoperitoneum meant to treat,
iii,Huge abdominal enclosed mass
腹内巨大包块
Huge abdominal enclosed mass is
usually found in full-term pregnancy,huge
ovarian cyst(卵巢囊肿 ),teratoma,etc,
In addition,for any generalized
abdominal bulge,circumference of
abdomen should be measured in
centimeters at the level of the
umbilicus with a soft tape measure
during normal abdominal breathing,
II,Local abdominal bulge局部膨隆
Local abdominal bulge is usually
caused by enlarged viscera,tumor,
inflammatory enclosed mass,
gastrointestinal flatulence(肠胃胀气 ),
hernia,etc,
2) Abdominal retraction腹部凹陷
In supine position,if the abdomen is at
the level much lower than that between
costal margin and symphysis pubis,we call it
abdominal retraction,There are two kinds
of retraction,that is,overall abdominal
retraction and local abdominal retraction,
The former one is of great significance,
I,Overall abdominal retraction
全腹凹陷
Overall abdominal retraction is usually
found in patients severely emaciated or
seriously dehydrated,
? Scaphoid abdomen舟状腹
Scaphoid abdomen is so called
because the contour of abdomen is shaped
like a boat,with the anterior abdomen
almost approximating to spinal column
and arch of rib,crista iliaca/iliac crest (髂
嵴 ),as well as symphysis pubis all
appearing,This sign is commonly seen in
cachexia(恶病质 ),
II,Local abdominal retraction
局部凹陷
Local abdominal retraction is caused
by the contraction of scar after
operation and is less common,
(1) respiratory movements
? Respiration in a female is mainly
costal,and little movement of the
abdominal wall occurs;
? In males and children,the breathing
is quiet with the major respiratory
movement being abdominal,
? Restriction of the abdominal phase of
respiration,especially in the male patient,may
be found in disease and inflammation below
the diaphragm (particularly peritonitis),In
severe case,as in acute peritonitis from
gastrointestinal perforation or
phrenoplegia(膈瘫痪 ),i.e.,diaphragm
paralysis,respiration entirely disappears,
(3) abdominal veins
Normally,abdominal veins do not
appear unless the patient is thinner or is
light-complexioned,or abdominal inner
pressure is elevated,as from ascites,huge
abdominal tumor,pregnancy,etc,
The presence of distended
abdominal veins indicates impairment of
circulation caused by portal hypertension
or obstruction of superior or inferior vena
cava,Prominence of these vessels,called
abdominal wall varicosis(腹壁静脉曲
张 ),indicates increased collateral
circulation as a result of obstruction in the
portal venous system or in the vena cava,
With obvious portal hypertension,the
dilated veins appear to radiate outward
from the umbilicus,like the head of
medusa(水母 ),so these distended veins
are called caput medusae(海蛇神头 ),
(Fig),
It is known that the normal
direction of flow in abdominal vessels
is away from the umbilicus,that is,the
upper abdominal veins carry blood
upward to the superior vena cava and
the lower abdominal veins drain
downward to the inferior vena cava,
If a vein is engorged,the direction of
flow can be demonstrated by a simple
maneuver,that is,placing the index fingers
side by side over the vein,pressing
laterally,separating the fingers one by one,
and observing the time it takes the veins
to refill from each direction; the flow of
venous blood is in the direction that fills
the fastest,The concrete procedure is as
follows,
A segment of vein in the epigastrium
is emptied between two fingers to a
distance of a few centimeters,One then
allows blood to refill the vein from one
direction by removing one compressing
finger and observing the rate of refilling,
The same segment is again emptied
and filling from the opposite direction is
estimated,
Usually the rate of filling is obviously
faster in one direction than in the other,
indicating the direction of flow in that
portion of the collateral venous system,The
process is repeated in the hypogastrium and
the direction of flow in the lower abdominal
veins is observed.In portal hypertension
normal flow direction is maintained,In
contrast,obstruction of the vena cava alters
the flow direction in these veins,
In obstruction of the superior vena
cava,the flow direction in the upper
abdominal venous collaterals is reversed or
downward,
In inferior vena cava obstruction the
direction is reversed in the lower abdominal
veins,and they will drain upward,
(4) gastral or intestinal pattern(胃型
或肠型 ) and peristalsis(蠕动波 )
? In lean individuals,even in the
absence of disease,motility of the stomach
and intestines may be reflected in the
abdominal wall,
? When strong contractions are visible
through an abdominal wall of average
thickness,the possibility of bowel
obstruction should be investigated,
? Reverse peristalsis indicates pyloric
stenosis,duodenal stenosis,or malrotation
of the bowel,
(5) others
A) rash
B) pigment色素
The abdomen is inspected for evidence
of unusual pigmentation,such as jaundice,
Disorders accompanied by
hyperpigmentation also may be more
notable on inspection of the skin of the
abdomen,where changes caused by
exposure of the skin to sunlight are readily
separated from those caused by generalized
increase in pigment,
The tendency of these disorders to manifest
increased pigmentation in areas of minor or
persistent trauma to the skin may be especially
evident at the belt line,Other pigment changes
caused by intra-abdominal hemorrhage may be
found,A bluish discoloration of the umbilicus
occasionally is seen after major intraperitoneal
hemorrhage,A similar discoloration of the flanks,
in the absence of trauma,occasionally is seen
following the extravasation of blood from intra-
abdominal organs into extraperitoneal sites,as in
hemorrhagic pancreatitis,
? Cullen sign
----- A bluish discoloration of the
umbilicus occasionally is seen after major
intraperitoneal hemorrhage,
? Grey-Turner sign
----- A similar discoloration of the flanks,
in the absence of trauma,occasionally is
seen following the extravasation of blood
from intra-abdominal organs into
extraperitoneal sites,as in hemorrhagic
pancreatitis,
C) abdominal striae腹纹
D) scar
E) hernia
F) umbilicus
G) abdominal hair
Finally,hair distribution should be noted,
In the normal female the pubic hair is
roughly triangular with the base above the
symphysis,whereas in the male it is in the
shape of a diamond,often with hair
continuing to the umbilicus,The distribution
and quantity of hair may be altered by
chronic liver disease and various endocrine
abnormalities,
H) abdominal pulsation
Palpation
This procedure is usually the most
important and often the most difficult to
perform accurately,
1,the principle of palpation
a) To relax the patient
? During palpation the patient should continue
to lie supine with arms relaxed on the chest or at
the sides,The examiner should make certain that
his hands are warm,He should assure the patient
that he will make an effort not to cause
discomfort and follow up this assurance by
avoiding at the outset an area already described as
painful,If the patient exhibits ticklishness,the
examiner should disregard it and try to continue,
If this proves unsuccessful,it is useful to have the
patient place his own hand on his abdomen,since
this never tickles,
The examiner may tentatively exert pressure
on the abdomen through the patient’s own hand,
and gradually increase the pressure,while
assuring the patient that the examination will
cause no discomfort,When the patient has
relaxed,the examiner again places his own hand
on the abdomen and allows the patient to
maintain contact with his hand,This usually
completes the relaxation of the ticklish patient,
and the examination proceeds as usual,
? The examination begins with gentle
exploration of the abdominal wall and with no
effort made to palpate deeply,The patient may be
further relaxed by instructing him to breathe
slowly and deeply,As with inspection,the initial
step in palpation may be facilitated by distracting
conversation or questions regarding the history,If
the patient remains tense or if the abdominal wall
is very muscular,better results may be obtained
by having the patient flex the thighs and knees,
It should be emphasized again that during
the preliminary stages muscle relaxation is
the goal,At this time no attempt should
be made either to elicit discomfort or to
palpate for a mass or enlarged viscus,
b) To palpate four quadrants
superficially from LLQ counterclockwise
? To palpate all areas of the abdomen
counterclockwise and superficially from left
lower quadrant screening for tenseness(紧张
度 ),tenderness(压痛 ),masses,etc,
? Examination begins with gentle
maneuvers and then palpation occurs
more deeply,
? Examiner uses the palms of his
hands with fingers together and arm
relaxed and forearm on a horizontal plane,
? The examiner presses with his fingers,
c) To palpate four quadrants deeply
Using the palmer surface of the fingers,
examiner palpates in four quadrants to
identify masses,tenderness,pulsations,etc,
The abdominal wall should be depressed
more than 2 cm,When deep palpation is
difficult,examiner may want to use left
hand placed over right hand to help exert
pressure,
If a mass is suspected,determine its size,
contour,mobility,tenderness,smoothness,
irregularity,the hardness or softness and
listen with stethoscope for a bruit over the
mass,If there is tenderness,determine
the point of maximum tenderness and
distribution,
To check for rebound tenderness,
palpate deeply at the point of tenderness,
pause briefly,then remove the fingers
quickly,Watch the patient’s face to see
whether it hurts,Then check other areas in
the same manner for comparison,
2,the contents of palpation
a) abdominal tenseness腹壁紧张
度
In normal persons,abdominal wall is
somewhat tense,but usually soft when
palpated and easily depressed,and is
called abdominal softness(腹壁柔软 ),
While some pathological conditions can
lead to an abnormal increase or decrease
of abdominal tenseness,
1) The increase of abdominal
tenseness
? Abdominal tenseness increases,not
accompanyed by muscle spasm,is due to
the increase of abdominal contents,as
gastrointestinal flatulence(肠胃胀气 ),
artificial pneumoperitoneum(人工气腹 ),
ascites,etc,
? Board-like rigidity板状腹
If abdominal wall is palpated as obviously
tense,even as rigid as a board,board-like
rigidity is so called,This sign is caused by
the spasm of abdominal muscle due to
peritoneal irritation,as the perforation of
the gastrointeatinal diseases or rupture of
the viscera,
? Dough kneading sensation揉面
感；柔韧感
If abdominal wall is palpated as pliable
and tough,and if it has resistance
and is not easily depressed,then the
examiner feels the sensation of dough
kneading,This sign is usually seen in
tuberculosis peritonitis or cancerous
peritonitis,
2) The decrease of abdominal tenseness
The decrease of abdominal tenseness is
caused by the decrease or
disappearance of abdominal muscle’s
tension(张力 ),the sign usually found in
chronic deeline(消耗性疾病 ) or drainage of
large amount of ascites,
b) tenderness and rebound tenderness
压痛和反跳痛
After relaxation is obtained,the examining
hand is first moved gently over the entire
abdomen,and an estimate of the muscle tone
in the various quadrants is made,Following
general palpation an attempt should be made
to detect and localize any painful area (i,e,
tenderness) within the abdomen,Two types
of pain may be elicited by palpation,
1,Visceral(内脏的 )—This is pain that
arises from an organic lesion or functional
disturbance within an abdominal viscus,
For example,it is the type seen in an
obstructive lesion of the intestine in which
there is a buildup of pressure and
distention of the gut,This type of pain has
sveral characteristics,it is dull,poorly
localized,and difficult for the patient to
characterize,
2,Somatic(躯体的；体壁的 )—This is similar
to the distress noted in painful lesions of the
skin,It is sharp,bright,and well localized,It
is not caused primarily by involvement of the
viscera; rather it indicates involvement of one
of the somatic structures,such as the
parietal peritoneum or the abdominal wall
itself,It should be pointed out that an
inflammatory process originating in a viscus will
produce visceral pain that may extend to
involve the peritoneum,
Inflammation of the peritoneum would then
result in somatic pain,This is best illustuated by
appendicitis(阑尾炎 ) in which the pain is at first
poorly localized,dull,ill defined,and primarily
midiline (when it is entriely visceral in origin),
Later,as the inflammation spreads to the
peritoneum,the pain becomes sharp,bright,and
well localized in the right lower quadrant over
the involved region,
After a painful area is located,the examiner
should determine whether the pain is constant
under the pressure of the examing hand or if it
is transient,tending to disappear even though
pressure is continued over the area,Pain caused
by inflammation usually remains unchanged or
increases as pressure is applied,Visceral pain as
the result of distention or contraction of a
viscus tends to become less severe while
pressure is maintained,
Occasionally the examiner may have difficulty
in distinguishing visceral pain from that arising
in somatic structures,such as the spine and
abdominal wall,An example of abdominal wall
discomfort is seen in patients with fibrositis(纤
维组织炎 ),These types of pain may be
differentiated by having the patient tense his
abdominal muscles,which may be
accomplished by forcefully elevating his head
while keeping his shoulders flat on the table,
Under these conditions increased tension of the
abdominal wall will accentuate the pain if it
originates in somatic structures,On the other
hand,discomfort from intra-abdominal sources
will be less severe with the abdomen tense than
when relaxed,
When pain has been elicited,the examiner
should test for the phenomenon of rebound
tenderness,This is found only when the
peritoneum overlying a diseased viscus becomes
inflamed,Although it may be produced in
different ways,the most common is to press
firmly over a region distant from the tender area
and then suddenly release the pressure,The
patient will feel a sharp stab of pain in the area of
disease if true rebound tenderness is present,
For example,pressure applied in the
right lower quadrant and then suddenly
released will cause a marked increase in
pain over an area of diverticulitis(憩室炎 )
in the left quadrant,Rebound tenderness
may also be elicited by having pressure
over the tender area and having the patient
cough or strain,Marked tenderness to
percussion in the area is usually seen in this
situation,
This type of tenderness indicates
widespread inflammation of the
peritoneum (peritonitis),At times,if the
area involved is small,rebound tenderness
may be elicited only over the most tender
area of the abdomen,
a) Viscera
u To palpate liver at
midclavicular and midsternal
lines
Method,The right hand may be held
either parallel or perpendicular to the long
axis of the patient,In the midclavicular
starting at the anterior superior iliac crest,
examiner presses down firmly and asks
patient to inhale deeply,This allows the
liver to move down to meet your
fingertips,
If you feel nothing,press up a few
centimeters toward the rib cage and repeat
the maneuver,Do this continuously until
you feel the liver or reach the coastal
margin,Ordinarily the liver is not palpable,
although not infrequently the examiner may
feel the edge of the normal liver at or
slightly below the right costal margin,When
the liver is palpated,a firm edge will strike
the fingers upon inspiration,
In the midsternal line,from the level of
the umbilicus,repeat the above maneuvers
to palpate the liver,Most doctors like to
use bimanual maneuvers to palpate the
liver,To do this,place the left hand at right
lower posterior chest wall parallel to,or
supporting patient’s right 11-12th ribs or at
lower sternal area to limit the chest
respiration to make right hand palpation
more effective,(Fig),
Note,（ 1） When felt more that 1cm,below
the costal margin,however,the organ should be
considered abnormally large,An exception is a
congenitally large right lobe of the liver,which
occasionally extends quite far into the right
flank,Another exception is seen in severe,
chronic emphysema(肺气肿 ),in which the
diaphragms are depressed by the overexpanded
lung,displacing the liver below the costal
margin,In both instances the total mass of the
liver is within normal limits,
（ 2） If you feel the liver,detect the edge
(sharp or round),tender or not,hard or soft
and repeat the process laterally and medially to
define the contour,For masses within the liver,
describe the same characteristics as above and
listen for a bruit over the mass,
l Size
Ordinarily the liver is not palpable,or the
liver can not be felt more than 1cm below the
lower coastal margin,and can not be felt more
than upper 1/3 distance of the line from
xiphoid to umbilicus or more than 3cm under
the xiphoid,Failure to feel the liver does not
mean that the liver is normal,Measurement of
the liver is done in the midclavicular line and
midsternal line,
l Texture/quality质地
The quality of liver is classified into three grades,
softness(质软 ),toughness(质韧 ),and
hardness(质硬 ),Normally the quality of liver is
soft and tender,just like the pouted(撅嘴 ) lip,In
acute hepatitis or fatty liver(脂肪肝 ),the quality of
liver is slightly tough,In chronic hepatitis or blood
stasis of liver,liver is more tough and usually as
tough as apex nasi(鼻尖 ),In liver cirrhosis,the
quality of liver is hard,In liver carcinoma,the
quality of liver is extremely hard and as hard as
forehead(前额 ),
l Surface and edge
To observe whether the surface of liver is smooth
or not,whether there is any node(结节 ) or not,
and whether the edge is thin or thick and is regular
or irregular,The character of the surface of the
liver should be described,Not infrequently large
metastatic masses may be present and palpable in
the liver,In some persons with cirrhosis,the
anterior surface of the liver will have a granular
feel,This is easily felt in the thin individual,
l Tenderness
Normally liver cannot be palpated as tenderness
unless the liver is irritated by the liver chitonitis
(that is,inflammation of the diolame包膜 of
the liver) or pulled by the enlargement of itself,
l Pulsation搏动
Normally you cannot palpate any pulsation of
the liver,If you palpate the pulsation of the
liver,you should pay attention to its direction,
that is,whether it is unidirectional(单向性 ) or
expansile(扩张性 ),The former one,
unidirectional pulsation,is usually a conductive
one(传导性搏动 ),That is caused by the the
conduction of the pulsation of aorta
abdominalis(腹主动脉 ),
If you put your hand on the sufface of the liver,
you will feel your hand is pushed upward,The
later one,expansile pulsation,is the pulsation of
the liver per se and usually found in tricuspid
valve insufficiency(三尖瓣关闭不全 ),Because
the contractive pulsation of right ventricle
conducts to liver through right atrium and then
inferior vena cava,If you put your hand on the
sufface of the liver,you will have the opening-
closing sensation,
The positive Hepatojugular reflux sign(肝－
颈静脉回流征 ),If you press the liver,you will
find the dilated jugular vein becomes more
bulged or distended,as from the enlargement of
liver passive congestion resulted from right
failure,
l Liver friction sensation肝区摩擦感
l Liver thrill肝震颤
u To palpate spleen from umbilicus
to left costal margin
In examining for splenic enlargement,
the examiner should stand at the patient’s
right side,His left hand is placed over the
patient’s left costovertebral angle,exerting
pressure to move the spleen anteriorly,At
the same time his right hand is worked
gently under the left anterior costal margin,
With the examiner’s hands stationary in
this position,the patient is instructed to
take a deep breath,
If there is significant enlargement of the
spleen,it will be palpated as a firm mass that
slides out from under the ribs,bumping against
the finger of the examiner’s right hand,The
spleen normally moves down with inspiration,
If splenic enlargement cannot be felt by the
technique just described,the patient should
then be rolled slightly toward the right so that
the spleen may fall anteriorly,
The examining hands are again placed as
described and the procedure is repeated,
Occasionally a spleen that cannot be felt with
the patient in the supine position may be
palpated by this maneuver,When the spleen
can be felt,it must be considered abnormal,
since the normal spleen is not palpable,
Notes,
（ 1） Starting from the level of
the umbilicus (or below the percussed
dullness),
（ 2） The maneuver is similar to
that used to palpate the liver,but is
more subtle because the spleen is more
mobile and deeper than the liver,
（ 3） If the spleen is not palpated,
have the patient roll on his right side
and repeat palpation,
（ 4） Measurement of the spleen
is the same as that of the liver and is
usually expressed as centimeters under
the costal margin in the midclavicular
and under the xiphoid process in the
midsternal lines,
（ 5） A moderately or greatly
enlarged spleen is best described by a
drawing,especially the three lines which are
presented schematically in the following
diagram (Fig),(NOTE,Severe
splenomegaly may cause rupture when
spleen is vigorously palpated,so palpate
gently and carefully),
Line 1,The distance between left costal
border and the lower edge of spleen along
left midclavicular line
Line 2,The distance between the crossing
point of left midclavicular line and left
costal border and the
most remote point of the spleen
Line 3,(when the spleen is extremely large
and exceeds the anterior midline.) The
distance between the right border of the
spleen and the anterior midline,If the
spleen indeed exceeds the anterior midline,
The mark ―+‖ is used to indicate
―exceeding‖,while ― – ― is used to indicate
―not exceeding‖,
In clinical practice,splenomegaly is
classified into three levels,
level 1 (slight enlargement轻度肿大 ),
During deep respiration,the lower edge of
spleen is not more than 2cm below the
costal border
level 2 (moderate enlargement中度肿
大 ),
During deep respiration,the lower edge of
spleen is more than 2cm below the costal
border but above the umbilical horizontal
line
level 3 (severe enlargement高度肿大 ),
During deep respiration,the lower edge of
Spleen is below the umbilical horizontal
line or over anterior midline
u To palpate gall bladder
Method,Put right hand below the costal
margin or lower border of liver at
midclavicular line (grossly equal to the
lateral border of the right rectus
muscles) and palpate deeply to check for
tenderness or bulging,
Under normal circumstances,the gallbladder
cannot be palpated,However,in a jaundiced
patient,the right upper quadrant should always
be carefully palpated for a soft,cystic mass,
approximately 6 to 8 cm in diameter,which
appears to be attached to the liver and moves
with respiration,This is an exceedingly valuable
sign in differentiating jaundice caused by cancer
of the head of the pancreas or the common bile
duct from that caused by gallstones,
In the presence of tumor of the common bile
duct or head of the pancreas,the wall of the
gallbladder is normal,and consequently the
organ is capable of distending to the point that
it is palpable,Such sign is named Courvoisier
sign,On the other hand,if the obstruction is
caused by gallstones,the gallbladder wall is
inflamed,and this diseased organ is not capable
of distention,Therefore,the gallbladder will not
become palpable,
u To check for Murphy’s
sign
If pain is found in the gallbladder area but
gallbladder is not palpated,the examiner
should put his left hand on the lower lateral rib
cage with the 4 fingers stretching superiorly and
the thumb hooked under the costal margin,
Press down to the point of gallbladder
tenderness and ask the patient to breathe deeply
and check to see whether the patient stops
breathing,changes facial expression,or
complains of pain,The sign is indicative of the
inflammation of gallbladder,
u To palpate kidneys bimanually
For palpation of the kidney,examiner puts
his left hand below left rib cage,at the
costospinal angle,and lifts up,Examiner
uses his right hand to palpate deeply from
umbilical level in the left midclavicular line,
and moves progressively upward,The
lower pole of the kidney may be felt as a
smooth,round,and deep structure that
moves relatively little with respiration,
This maneuver is repeated on the right
side to palpate the right kidney,Normally
the kidney is not palpated,Sometimes the
lower pole of the right kidney may be felt
in normal patients,During deep
inspiration,if more than half of the kidney
is palpated,nephroptosis(肾下垂 ) is
considered,Repeat the maneuver with the
patient in sitting and standing positions if
you wish to expose the kidney further,
d) abdominal masses
e) fluidthrill液波震颤
(discussed in auscultation)
f) succussion splash振水音
(discussed in auscultation)
Percussion
1,General percussion
All four quadrants of the abdomen are
evaluated by percussion,Light percussion
is preferable,since it produces a clearer
tone,
Tympany(鼓音 ) is the most common
percussion sound in the abdomen due to
gas collection,It is appreciated over the
stomach,small intestine,and colon,
2,Percussion of the liver
Percussion of the upper border of liver(肝
上界 ) is executed along the right midclavicular
line(右锁骨中线 ),right midaxillary line(右腋中
线 ),and right scapular line(右肩胛线 ),The
level of the shift from resonance downward
into dullness is defined as the upper border of
liver,At this level,the liver is covered by lung
and hence the border is also called the relative
dullness border of liver(肝相对浊音界 ),
Then percussing downward 1-2 intercostal
space,the level of the shift from dullness into
flatness(实音 ) is identified as the absolute
dullness border of liver(肝绝对浊音界 ),
without lung covering,and also called the lower
border of lung(肺下界 ),Normally the the
upper border of liver locates at the 5th
intercostal space along the right midclavicular
line,the 7th intercostal space along the right
midaxillary line,and the 10th intercostal space
along the right scapular line,
Percussion of the lower border of liver(肝下
界 ) is executed along the right midclavicular
line or anterior midline,The level of the shift
from tympany upward into dullness is defined
as the lower border of liver,
u Percussion of liver span (肝上下径 )
Percussion of liver span should be done with
the patient breathing normally,Percussion
should occur through the right midclavicular
line from resonance over the lung field
downward to dullness and from tympany over
abdomen upward to dullness,Measure from
upper to lower border of dullness for liver
span,It is normally about 9-11 cm in the
midclavicular line,
Dullness extending into the normally
tympanitic right upper quadrant indicates
hepatic enlargement,a mass adjacent to
the liver,or downward displacement of
the liver,
There may be an absence of liver dullness
following perforation of a hollow viscus,which
allows free air to enter the abdominal cavity,
This indication of an intra-abdominal
catastrophe must be correlated with the clinical
situation,since on occasion interposition of the
hepatic flexure of the colon between the
diaphragm and the liver (间位结肠 [结肠位于
肝与横膈之间 ]) will produce the same finding
with no clinical consequences,
u Fist percussion(拳击叩诊 ) of liver
To tell the patient what you intend to do before
you start,Examiner places one palm over the
area of liver dullness,Examiner then hits that
hand gently with the fist of his other hand,
Examiner should watch the patient’s facial
expression and withdrawal effort and ask him if
it hurts,If pain occurs,do fist percussion at the
same site on the left side for comparison and
pay attention to the intensity and site of the
pain,(Fig),
3,Percussion of the spleen
n To percuss for splenic dullness
This should be done when splenic enlargement
is suspected,
Normally splenic dullness can be percussed
between 9 intercostal space to 11 intercostal
space along left midaxillary line,the scope that
is 4-7cm,without passing over left anterior
axillary line,
Percuss the lowest intercostal space in the
left midaxillary line,This area is usually
tympanitic,Then ask the patient to take a deep
breath,When size of the spleen is normal,the
percussion note usually remains tympanitic,
n Fist percussion of spleen
As discussed in fist percussion of liver
The remainder of the normal abdomen is more
or less tympanitic to percussion,depending on
the amount of gas in the intestine,After
percussion of the liver and spleen,one may
percuss over any visible masses to determine
whether they are dull (as with tumor or fluid-
filled spaces) or tympanitic (as with distended
bowel),Distention of the urinary bladder may
yield an area of suprapubic dullness,If other
masses are detected by palpation,percussion
may help to characterize them further,
The last thing to be noted on percussion is the
presence or absence of free fluid in the
abdominal cavity (ascites),This may be detected
by several maneuvers(1) shifting dullness,(2)
fluid wave,and (3) elbow-knee position,
5,Percussion for shifting dullness(移动
性浊音 )
When the patient with ascites lies on his back,
the fluid will migrate into the flanks,producing
dullness laterally,At the same time the
midabdomen is tympanitic because of the
underlying bowel,When dullness is found in
the flanks,The line of demarcation between the
dull and tympanitic sounds is marked,The
patient is then rolled onto his right side,and the
percussion is again carried out toward each
flank,All of the ascites will flow to a dependent
portion on the right side of the abdomen,
A new line is marked and the change is
measured in centimeters,Consequently it will
be noted that the level of dullness on the right
has moved toward the midline and that the
bowel,which has been displaced upward by the
fluid,results in a tympanitic note in the upper
flank,This is repeated after rolling the patient
to his left side,By this means,an estimate of
the amount of free fluid can be made,A
volume of free fluid in the peritoneal cavity
greater than 1000ml can be detected with this
method,
To simplify the procedure,the examiner first
determines the point from tympany to dullness
with the patient in the supine position,The
patient is then asked to turn on his side while
the examiner holds his pleximeter on the point
where the change in percussion sound occurred,
The examiner then percusses this same point
again,If the sound changes from dullness to
tympany,it means that the dullness has been
shifted to a more dependent position,This
implies that ascites is present,
6,Testing for a fluid wave
(液波震颤 )
With patient lying on his back,the examiner’s
left hand is placed against the patient’s right
flank,An assistant or the patient places the
ulnar edge of one hand lightly against the
middle of the abdomen to prevent the
transmission of any wave through the tissues of
the abdominal wall,The examiner’s right hand
then lightly taps the left flank of the patient,In
the presence of a siguificant amount of ascites,
a wave will be transmitted through the fluid that
will be felt against the examiner’s left hand as a
sharp impulse,This finding is present only
when there is a reasonably large amount of fluid,
7,Elbow-knee position(肘膝位 )
The presence of small amounts of fluid may be readily
detected by placing the patient in an elbowknee
position and percussing from the flanks toward the
most dependent portion of the abdomen,Free fluid,
if present,will run from the pelvis(骨盆 ) and gutters
of the abdomen into the most dependent area,which,
if the patient is in the proper position,is located in the
periumbilical region,
The finding of dullness in this area indicates the
presence of ascitic fluid,This technique is more
sensitive for detecting small amounts of fluid than are
the previously described methods,
Auscultation
1,Bowel sounds(borhorygmus) 肠鸣音
Auscultate bowel sounds with diaphragmatic head
of stethoscope for at least one minute,
If there are no bowel sounds,listen until you hear
them or for at least 5 minutes,
Normal bowel sounds are a glue-glue,glue-glue-like
sound occurring either separately or together,
approximately 4-5 times per minute,Pay attention to
the frequency,pitch,and intensity,High-pitched
(gurgling) sounds with increased frequency are
regarded as hyperactivety,Lack of bowel sounds
indicate little or no peristalsis,
Two abnormalities of the bowel sounds are
significant,The absence of any sound or
extremely weak and infrequent sounds heard
after several minutes of continuous auscultation
ordinarily represent the immobile bowel of
peritonitis or paralytic ileus,In contrast,
increased sounds with a characteristic loud,
rushing,high-pitched tinkling quality often
occur in mechanical intestinal obstruction and
may be accompanied by waves of pain,The
latter findings are caused by distention of the
bowel and increased peristaltic activity proximal
to the site of the obstruction,
1,Murmurs(杂音 ) or bruits
Murmurs from arteries are called bruits
and are similar to low-pitched heart murmurs,
Murmurs from veins sound like a hum and are
more continuous; they are called venous bruits
or venous hum(静脉“嗡鸣声” ),
To be of significance a bruit must be
heard consistently in the area if the patient is
moved into various positions,and it must be
heard with extremely light pressure on the
diaphragm of the stethoscope or with bell-type
head of stethoscope,
Left upper quadrant to include (L) renal artery
左肾动脉
Right upper quadrant to include (R) renal
artery右肾动脉
Right lower quadrant to include (R) iliac
artery右髂总动脉
Left lower quadrant to include (L) iliac artery
左髂总动脉
Aorta(主动脉 ) along the midsternal line
3,Succession splash(振水声 ) in the
epigastric area
Succession splash is the splash sound over the
upper abdomen,It should be checked by
rocking the upper abdomen to the left and right,
In normal patients this is negative about 6-8
hours after eating food,If positive,it indicates
gastric retention,
4,Friction rubs over the liver and
spleen(肝区或脾区摩擦音 )
Listen with stethoscope over liver and spleen
while patient breathes deeply,
Peptic Ulcer Disease
消化性溃疡病
Question,What’s the
meaning of ―Peptic Ulcer
Disease‖?
Definition
Peptic Ulcer Disease is defined as an
ulcer occurring in a region that touches
gastric acid(胃酸 ) and pepsin(胃蛋白酶 )
and usually refers to gastric ulcer(胃溃疡 )
or duodenal ulcer(十二指肠溃疡 ),
Typical endoscopic appearance of a
benign gastric ulcer,The ulcer is on the
angularis,the most common location for
a gastric ulcer,and is well
circumscribed without any associated
mass effect,The surrounding mucosa is
mildly erythematous红斑的 and without
nodularity结节,
Typical radiographic features of a
benign gastric ulcer,A large well-
circumscribed ulcer is seen on the
angularis,
a posterior duodenal
ulcer
Typical radiographic features of
duodenal ulcer,This duodenal bulb
ulcer is associated with marked
edema,resulting in the appearance
of radiating folds to the ulcer crater,
The bulb is also distored secondary
to previously existing ulceration,
Questions,
What does ulcer 溃疡 mean?
How can we differentiate between ulcer
and erosion 糜烂?
Erosions in the duodenal
bulb and a posterior
duodenal ulcer
Erosion糜烂, a superficial lesion caused
by denudation of the surface epithelium
（上皮细胞）
ulcer 溃疡, a mucosal defect extending
into the muscularis mucosa(粘膜肌层 )
Mucosa can be divided into,
Epithelium 上皮
Lamina propria 固有层
Muscularis mucosae 粘膜肌层
Clinical manifestations of
Peptic Ulcer Diseases
消化性溃疡病的临床表现
symptoms
症状
abdominal pain
腹痛
located in the epigastric(上腹 ) area;
burning in quality(烧灼样 );
occurred on an empty stomach 2 to 4 hours after
meals and/or at night (nocturnal pain夜间疼痛 );
relieved by antacids(抗酸剂 ) and/or meals(进餐 );
tend to wax and wane(加重与缓解 ) over months
,acid dyspepsia酸消化不良,
the majority of patients (approximately
70%) with epigastric distress
(“dyspepsia”) do not have evidence of
active ulcer disease;
conversely up to 40% of patients with
an active ulcer crater deny abdominal
pain;
patients can present with an ulcer-
related complication,particularly
hemorrhage,without antecedent
symptoms
despite being both insensitive
and non-specific,the symptom
of epigastric abdominal pain,
particularly burning after meals
and at night and relieved with
food or antacid,suggests the
possibility of ulcer disease,
Other symptoms
gastroesophageal reflux 胃食管反流
(including upright 直立位 and supine仰
卧位 reflux and non-cardiac chest pain
非心源性胸痛 );
symptoms of indigestion 消化不良
occurring with or shortly after eating
and characterized by epigastric fullness
and discomfort(上腹饱胀与不适 ),
belching(打嗝 ),bloating(胀气 ),
nausea(恶心 ),early satiety(早饱 ),and
specific food intolerances);
signs
体征
Physical examination is of limited value
in patients with uncomplicated ulcer,
For epigastric tenderness 压痛 on deep
palpation深部触诊,the sensitivity and
specificity are all approximately 50% or
less,
Furthermore,many patients with non-
ulcer diseases 非溃疡性消化不良 also have
epigastric tenderness on physical
examination,
In patients with free perforation穿孔 or
ulcer penetration穿透 into the
pancreas,findings of peritonitis腹膜炎
are usually present,
In patients with gastric retention 胃潴
留 who have been fasting禁食 for a few
hours,a succussion splash 振水声
(produced by auscultating 听诊 the
abdomen while rocking the patient
back and forth)
suggests retained gastric contents,
Complications
并发症
Hemorrhage 出血
the most common complication of ulcer
disease (in approximately 15% of
patients)
Perforation穿孔 and Penetration
穿透
(in approximately 7% of patients )
Duodenal ulcers,perforate anteriorly
Gastric ulcers,perforate along the
anterior wall of the lesser curvature of
the stomach
Perforated peptic ulcer,Air is
present under the right
hemidiaphragm in a patient
with acute severe abdominal
pain,
Penetration is similar pathologically
to perforation,except that the ulcer
crater壁龛 burrows打洞 through the
entire wall of the intestine,and
instead of leaking digestive contents
into the peritoneal cavity腹腔,the
crater bores钻孔 into an adjacent
organ附近脏器,
Gastric ulcers most commonly
penetrate into the left lobe of the liver,
while duodenal ulcers penetrate
posteriorly into the adjacent pancreas
胰腺,sometimes leading to
pancreatitis胰腺炎, Rarely,gastric
ulcers may penetrate into the colon结
肠,resulting in a gastrocolic fistula胃
结肠瘘,
Gastric outlet obstruction 梗阻 (gastric
retention or pyloric stenosis胃潴留或 幽门狭窄 )
functional impairment of antral motility 胃
窦动力功能不良 due to the effects of acute
inflammation and edema;
mechanical obstruction 机械性梗阻 due to
scarring near the gastroduodenal junction;
manifest as gastroesophageal reflux,early
satiety,weight loss,abdominal pain,and
vomiting;
As the degree of retention increases,the
quantity of vomitus呕吐物 also increases,
often containing food ingested 12 or more
hours previously,
Barium upper
gastrointestinal study
demonstrates the size of the
stomach,
Endoscopy demonstrates the
pyloric obstruction with an
active ulcer crater seen in the
pyloric channel,
Canceration癌变
(Gastric ulcer )
Questions for summary,
(1) What does Peptic Ulcer Disease
refer to?
(2) What are the symptoms and signs
you can find in the patients with peptic
ulcer disease?
(3) Which kind of complication most
frequently occur?
PORTAL HYPERTENSION
FEATURES OF THE
PORTAL CIRCULATION
AND CLASSIFICATION OF
PROTAL HYPERTENSION
The hepatic vein drains most of the
blood from the liver into the inferior
vena cava,In addition,there is some
direct venous drainage between the
caudate lobe and the inferior vena
cava,The portal vein is formed by the
union of the splenic vein and the
superior mesenteric vein,The splenic
vein receives branches from the
pancreatic veins,short gastric veins,
and inferior mesenteric veins,
The portal circulation is a low-
pressure system (<10mm Hg) formed
by the venous drainage from
intrtraperitoneal viscera,including the
luminas gastrointestinal tract,spleen,
gallbladder,and pancreas,Veins
collecting from these sites form the
splenic vein and superior and inferior
mesenteric veins,which,in turn,
merge to create the portal vein,
Portal hypertension occurs when portal
venous pressure exceeds the pressure in
the non-portal abdominal veins (e.g.,inferior
vena cava) by at least 5mmHg;
portosystemic collateral vessels develop in
an effort to equalize pressures between
these two venous systems,These collateral
vessels,or varices,most commonly develop
in the esophagus and proximal stomach and
can cause clinically significant bleeding,
Altered portal homodynamics can also lead
to the development of ascites and
contribute to hepatic encephalopathy,
In cirrhosis,which is the most
common cause of portal hypertension,
the lesion is intrahepatic and primarily
sinusoidal,Portal hypertension may
also arise from presinusoidal
obstruction,either outside (e.g.,portal
vein thrombosis ) or within (e.g.,
schistosomiasis) the liver,Similarly,
lesions leading to portal hypertension
may be postsinusoidal,either within
the liver(e.g.,veno-occlusive disease )
or distal to it (e.g.,Budd-Chair
syndrome,right -sided heart failure ),
In rare circumstances,portal
hypertension can result in a normal
liver from markedly increased inflow
beyond the capacity of the compliant
portal vessels to absorb,Examples
include arterial -portal fistulas and
massive splenomegaly due to infection
or neoplasm,
CLINICAL PRESENTATION
The cirrhotic with portal hypertension
will often have variceal hemorrhage,ascites,
encephalopathy,or some manifestation of
hepatic dysfunction such as coagulopathy or
infection,Splenomegaly and /or distention of
abdominal wall veins (caput medusae ) may
be initial or associated findings,Other
physical finds include the presence of
clinical jaundice,spider nevi,facial
telangiectasia,gynecomastia,abdominal
distention caused by ascites (with a possible
umbilical or inguinal hernia ),parotid
enlargement,a magenta tongue,palmer
erythema,clubbing,etc,
Patients with non-cirrhotic portal hypertension
generally have well-preserved liver function so
that clinical manifestations primarily reflect
altered hemodynamics,In patients with
presinusoidal lesions such as schistosomiasis or
portal vein thrombosis,variceal hemorrhage and
splenomegaly are prominent,In postsinusoidal
obstruction,such as veno-occlusive disease or
Budd-Chiari syndrome,hepatomegaly and rapid
onset of ascites and weight gain are typical
presenting symptoms,When portal abnormalities
are a manifestation of infection or neoplasm,
there may be specific associated non-hepatic
findings,such as a hypercoagulable state,
anemia,or evidence of heart failure,
l Portal-Systemic Collaterals
The portal system has numerous
collaterals that interconnect with
the systemic circulation (See
table ),
TABLE Portal-Systemic
Collaterals
1,Located at transition zones
between squamous and glandular
epithelium,for example,
gastroesophageal junction,anus,
ileostomies,
2,Obliterated fetal circulation
in the falciform ligament,for
example,umbilical and
periumbilical veins
3,Retroperitoneal channels
originating in the splenic vein and
anastomosing with the adrenal
gland or renal veins,especially
the left renal vein
4,Areas in which the
gastrointestinal tract becomes
retroperitoneal,that is,when a
somatic surface is in contact
with an area not covered by
peritoneum,These areas include
the duodenum; descending,
ascending and sigmoid colon;
spleen; liver
Modified from mclndoe AH,Arch
Pathol 5:23,Copyright 1928,
American Medical Association,
The collaterals that lead to the
greatest clinical problems lie within
the mucosae of the stomach and
esophagus,When dilated,they form
gastric and esophageal varices,which
may appear as abnormalities on upper
gastrointestinal series,or they may be
seem at endoscopy,The umbilical vein
may dilate,as will the veins of the
abdominal wall,with the development
of visible collaterals,
If the inferior cava is also occluded( as
may be seem in the Budd-Chiari syndrome),
the direction of blood flow in the
abdominal wall collaterals will be
cephalad,When the inferior vena cava is
patent,the direction of flow of collaterals
will be cephalad above the umbilicus and
caudad below it,Without markedly dilated
vessels,the direction of flow is usually
difficult to determine,In my experience,
the finding of posterior collaterals has
been the most reliable diagnostic finding
in patients with obstruction of the inferior
vena cava,
If flow in the umbilical and
periumbilical veins becomes great
enough,a caput medusae will form,
and there my be an audible venous
hum( Cruveilhier- Baumgarten murmur)
over the course of the umbilical vein,
The origin of the umbilical vein is the
left portal vein; therefore,if the
umbilical vein is dilated,the cause of
the portal hypertension must be
intrahepatic,Large venous shunts may
also form between the portal vein and
the left renal vein,
On occasion,these shunts may appear
to be as large as surgical portacaval
shunts,They appear,however,to be
ineffective in reducing portal venous
pressure and preventing bleeding from
esophageal varices,In some cirrhotic
patients with chronic encephalopathy,
very large spontaneous portal-systemic
collaterals are present,and they shunt a
large portion of the splanchnic venous
blood into the systemic circulation,
Esophageal varices may never develop
in these patients,
The remaining collaterals listed in
Table usually do not cause symptoms,
However,varices may develop in
adhesions from previous
intraabdominal surgery or in the small
bowel or colon,and the patient may
seek treatment because of
gastrointestinal hemorrhage,
A particularly difficult problem is
bleeding enterostomal varices in
patients who have received
ileostomies or colostomies for
inflammatory bowel disease and in
whom portal hypertension develops
because of liver disease,for example,
sclerosing cholangitis,Bleeding from
rectal varices is infrequent,
Hemorrhoids are different from rectal
varices,and the frequency of
hemorrhoids is not increased in
patients with portal hypertension,
VARICEAL HEMORRHAGE
Hemorrhage from gasirocesophageal
varices is often the initial
complication of portal hypertension,
Less commonly,variceal hemorrhage
occurs from other sites of
portosystemic collateral vessels,
including the duodenum,rectum,or
sites of prior abdominal surgery,
Esophageal variceal hemorrhage
typically occurs as painless,
largevolume hematemesis or melena
with minimal abdominal pain,Signs of
significant volume depletion,including
orthostasis and pallor,are common,
Mortality from variceal hemorrhage is
more a function of underlying liver
disease than severity of hemorrhage
per se,
l Splenomegaly
Although splenomegaly is commonly
associated with portal hypertension,there
is a poor correlation between portal venous
pressure and the size of the spleen,
Splenomegealy may be associated with
hypersplenism,Leukopenia,
thrombocytopnia,and anemia aare common
clinical features of diseases such as
schistosomiasis,The degree of depression
of the formed elements is infrequently of
sufficient severity to cause clinical
problems,that is,bleeding or infection,and
splenectomy is rarely indicated for
hypersplenism resulting from portal
hyertension,
l ASCITES
Ascites is the accumulation of exccss
fluid in the abdomen,Cirrhosis is the
underlying cause in at least 80% of
patients,but other etiologic factors in
addition to liver disease must always
be considered,
PATHOGENESIS
Multiple factors contribule to
ascites formation in chronic liver
injury,
1,Sinusoidal hypertension,which
develops because of increased outflow
resistance from matrix deposition and
possibly stellate cell contraction,Initially,
albumin traverses the porous sinusoidal
endothelium along with fluid; but as
fibrosis progresses,only protein-free fluid
can escape the sinusoid,from where it
enters hepatic lymphatics,Continued
accumulation of lymph overcomes the
capacity for lymphatic drainage,and the
excess fluid ―’weeps‖ from the liver into
the peritoneal cavity,
2,Hypoalbuminemia,which worsens
with advancing liver dysfunction and
decreases oncotic pressure,
3,Fixed capacity to resorb ascites,
despite its increasing accumulation,
4,Increased sodium reabsorption by
the kidneys,possibly due to humoral
factors
5,Splanchnic arteriolar vasodilation,
which may independently stimulate
sodium and free water retention by
increasing sympathetic tone,
The roles of antidiuretic hormone and
atrial natriuretic peptide are not
clearly established despite extensive
study,
Examination
Xue Huiping
Introduction
It is well known that advances in
scientific medicine have occasionally
threatened to displace the history and
physical examination in the evaluation of
the patient,However,we usually discover
that technologic advances serve to make
the physical examination more rational
and provide new understanding or
objective documentation of long-
appreciated physical finding,
New techniques for evaluation of the intra-
abdominal contents include many biochemical,
isotopic,ultrasonic,and angiographic methods,
These advances,although improving our
ability to detect,document,and interpret
physical findings,have not superseded the need
for the skills of the medical interview and
physical examination,An orderly approach to
the examination of the abdomen will make
possible the analysis of the symptoms arising
from the many organs of the digestive and
genitourinary systems found in this region,
Palpation is an important step in
abdominal examination and is difficult to
learn,esp,the palpation of the liver and
spleen,so we must practise more,
We conform to the same basic steps
of inspection,palpation,percussion,and
auscultation used in this area as in other
areas,
2.Topographic anatomy
There have been several systems or
methods devised for dividing the
abdomen into topographic segments,but
two kinds of commonly used systems or
methods will be described here,Other
methods may be found in any standard
textbook of anatomy,
Before you understand these two
methods,at first you should know the
following anatomic landmarks(Figure 1),
— xiphoid (ensiform) process(剑状突
起 ) of sternum(胸骨 )
— costal margin肋弓缘
— umbilicus脐
— anterosuperior iliac spine/ anterior
superior iliac spine髂前上棘
— iliac crest髂骨嵴
— inguinal ligament 腹股沟韧带
— superior margin of os pubis耻骨上
缘
— anterior midline前中线
— lateral border of rectus abdominis
muscle/ lateral border of abdominal
recti muscles腹直肌外缘
— symphysis pubis (耻骨联合 )
Next,I shall introduce the following two
commonly used methods of subdividing
the abdomen,
(1) The abdomen is divided
into four quadrants(四区法 ),
(Figure 2)
The anterior surface of the abdomen
is divided into four quadrants by two
intersecting lines,one extending vertically
from the xiphoid,through the umbilicus,
to the symphysis pubis (耻骨联合 )and
the other extending horizontally across the
abdomen at the level of the umbilicus,
This divides the abdomen into the right
upper,right lower,left upper,and left lower
quadrants,Four areas can be outlined
utilizing the quadrant map i,e,RUQ(right
upper quadrant),LUQ(left upper quadrant),
RLQ(right lower quadrant),LLQ(left lower
quadrant),The content of the abdomen
underlying each of the four quadrants in
both males and females should be known as
follows,
?Right upper quadrant
Liver
Gallbladder胆囊
Duodenum十二指肠
Caput pancreas胰头
Right kidney右肾
Hepatic flexure of colon结肠肝曲
?Left upper quadrant
Stomach
Spleen脾
Left kidney左肾
Cauda pancreas胰尾
Splenic flexure of colon结肠睥曲
?Right lower quadrant
Cecum盲肠
Appendix阑尾
Right ovary and uterine tube右侧卵巢
及输卵管
Right ureter右输尿管
?Left lower quadrant
Sigmoid colon乙状结肠
Left ovary and uterine tube左
侧卵巢及输卵管
Left ureter左输尿管
(2) The abdomen is divided
into nine sections(九区法 ),
This kind of method elaborates more correctly
and clearly,so everyone should learn it by heart,
That method states that at first you should draw
imaginary,parallel,horizontal lines across the
lowest border of the costal margin and the
anterior superior iliac spine,and then you should
draw two vertical lines across the middle of
inguinal ligament,approximating the lateral
borders of the abdominal recti muscles,
Now nine areas can be outlined with these
four lines,The content,or structure,of the
abdomen underlying the nine areas should also
be known as follows,
? Left hypochondrial region
左上腹部；左季肋部
Spleen; stomach; splenic flexure of colon;
cauda pancreas; left kidney; left adrenal
gland(左肾上腺 )
? Left lumber region左侧腹
部；左腰部
Descending colon(降结肠 );
jejunum(空肠 ) or ileum(回肠 ); left kidney
? Left iliac region左下腹部；
左髂部
Sigmoid colon; female left ovary and
uterine tube; male left varicosity(精索 ) and
lymph node
? Right hypochondrial
region右上腹部；右季肋部
Right lobe of liver(肝右叶 ); gallbladder;
hepatic flexure of colon; right kidney; right
adrenal gland
? Right lumber region
右侧腹部；右腰部
Ascending colon; jejunum(空肠 );
right kidney
? Right iliac region右下腹
部；右髂部
Cecum(盲肠 ); appendix; lower part of
ileum(回肠 ); lymph node; female right
ovary and uterine tube; male right
varicosity
? Epigastric region上腹部
Stomach; left lobe of liver;
duodenum(十二指肠 ); caput pancreas and
body of pancreas; transverse colon; aorta
abdominalis(腹主动脉 ); omentum
majus/the greater omentum (大网膜 )
? Umbilical region中腹部；
脐部
Lower part of duodenum; jejunum;
ileum; ptosis(下垂 ) part of the stomach or
transverse colon; ureter(输尿管 ); aorta
abdominalis; mesentery(肠系膜 ) and
lymph nodes; omentum majus
? Hypogastric region下腹部
Ileum; sigmoid colon; ureter; full bladder;
pregnant uterus(子宫 )
Now we will discuss physical examination
of abdomen,conforming to the sequence
from inspection,through palpation and
percussion,to auscultation,Please
remember,before any physical
examination is carried on,you should do
several general preparations as follows,
1,To ask the patient to urinate completely to be sure that
the bladder is empty,
2,Patient should be lying on his back with a pillow under
his head and his knees bent to relax his abdominal
muscles,
Be sure the arms are on either side,not behind his head,A
little conversation or repeating of the patient’s history might
help to relax the patient,
3,To expose abdomen completely from the breasts to
pubis,
For female patients,breasts should be covered with a sheet,
Inspection
The major contents of inspection are
composed of abdominal contour,respiratory
movements,abdominal veins,gastral or
intestinal pattern(胃型或肠型 ),peristalsis(蠕
动波 ),and abdominal rash,hernia(疝 ),
striae(纹 ),etc,Now let’s discuss one by one,
(1) abdominal contour
You should pay attention to whether
the abdomen is symmetrical,whether it is
bulged or retracted,and whether it is
indicative of ascites or enclosed mass(包块 ),
In normal person,you can find
abdominal flatness(腹部平坦 ),abdominal
fullness(腹部饱满 ),and abdominal
lowness(腹部低平 ),
Abdominal flatness means the
abdomen is at the same level or lower
as between costal margin and
symphysis pubis,If you ask the patient
to sit,the lower part of umbilicus can
become more or less protruded or
bulged,
If he or she is very fat or is a child,the
abdomen is a little bit round,and the
level of the abdomen is higher than that
of the surface between costal margin and
symphysis pubis,This phenomenon is
called abdominal fullness,But,If a
patient is very thin or slender,the level of
the abdomen is lower than that of the
surface between costal margin and
symphysis pubis,as a result of little
subcutaneous fat,
This phenomenon is called abdominal
lowness,In a word,abdominal flatness,
abdominal fullness,and abdominal lowness
are all normal cases,But,If the abdomen is
obviously or extremely protruded or bulged,
or it is conspicuously or exceedingly
retracted or depressed,that phenomenon is
abnormal and usually indicates pathological,
Now let’s discuss some important
pathological conditions,
1) Abdominal bulge腹部膨隆
I,Overall/generalized abdominal
bulge全腹膨隆
Overall abdominal bulge can be caused by
several pathological factors except for overly
obesity,It is commonly seen in following
conditions,
i,Peritoneal fluid
If there is a large amount of free
fluid within the abdomen,i,e,ascites,
abdominal wall can be lax in supine
position,fluid can deposit at both
lateral sides,abdominal wall just likes
a frog belly,
If the patient lies on one side or sits,the
lower part of abdominal wall will be bulged,
as from the movement of free fluid,This is
commonly found in ascites complicated by
portal hypertension of liver cirrhosis,At that
case,esp,in long-standing ascites,the
appearance of the umbilicus is protruded or
everted,But in obesity and fat,the umbilicus
is usually deeply inverted,
? Frog belly蛙腹
? Apical belly尖腹
Apical belly is caused by peritonitis and
hence abdominal muscle is tense,usu,
with the apical shape,apical belly is so
called,
ii,Peritoneal air腹腔积气
Peritoneal air is caused by a large amount
of air accumulating in the cavity of stomach,
The general shape of abdomen is globular
and two sides of lumber region is not
obviously protrudent,If you ask the patient
to move or change the position,the shape of
abdomen remains globular,This is commonly
found in intestinal obstruction or
enteroparalysis(肠麻痹 ),
? Pneumoperitoneum气腹
Pneumoperitoneum is caused by air
accumulating in the abdominal cavity,It is
commonly found in perforation of
gastrointestinal diseases or artificial
pneumoperitoneum meant to treat,
iii,Huge abdominal enclosed mass
腹内巨大包块
Huge abdominal enclosed mass is
usually found in full-term pregnancy,huge
ovarian cyst(卵巢囊肿 ),teratoma,etc,
In addition,for any generalized
abdominal bulge,circumference of
abdomen should be measured in
centimeters at the level of the
umbilicus with a soft tape measure
during normal abdominal breathing,
II,Local abdominal bulge局部膨隆
Local abdominal bulge is usually
caused by enlarged viscera,tumor,
inflammatory enclosed mass,
gastrointestinal flatulence(肠胃胀气 ),
hernia,etc,
2) Abdominal retraction腹部凹陷
In supine position,if the abdomen is at
the level much lower than that between
costal margin and symphysis pubis,we call it
abdominal retraction,There are two kinds
of retraction,that is,overall abdominal
retraction and local abdominal retraction,
The former one is of great significance,
I,Overall abdominal retraction
全腹凹陷
Overall abdominal retraction is usually
found in patients severely emaciated or
seriously dehydrated,
? Scaphoid abdomen舟状腹
Scaphoid abdomen is so called
because the contour of abdomen is shaped
like a boat,with the anterior abdomen
almost approximating to spinal column
and arch of rib,crista iliaca/iliac crest (髂
嵴 ),as well as symphysis pubis all
appearing,This sign is commonly seen in
cachexia(恶病质 ),
II,Local abdominal retraction
局部凹陷
Local abdominal retraction is caused
by the contraction of scar after
operation and is less common,
(1) respiratory movements
? Respiration in a female is mainly
costal,and little movement of the
abdominal wall occurs;
? In males and children,the breathing
is quiet with the major respiratory
movement being abdominal,
? Restriction of the abdominal phase of
respiration,especially in the male patient,may
be found in disease and inflammation below
the diaphragm (particularly peritonitis),In
severe case,as in acute peritonitis from
gastrointestinal perforation or
phrenoplegia(膈瘫痪 ),i.e.,diaphragm
paralysis,respiration entirely disappears,
(3) abdominal veins
Normally,abdominal veins do not
appear unless the patient is thinner or is
light-complexioned,or abdominal inner
pressure is elevated,as from ascites,huge
abdominal tumor,pregnancy,etc,
The presence of distended
abdominal veins indicates impairment of
circulation caused by portal hypertension
or obstruction of superior or inferior vena
cava,Prominence of these vessels,called
abdominal wall varicosis(腹壁静脉曲
张 ),indicates increased collateral
circulation as a result of obstruction in the
portal venous system or in the vena cava,
With obvious portal hypertension,the
dilated veins appear to radiate outward
from the umbilicus,like the head of
medusa(水母 ),so these distended veins
are called caput medusae(海蛇神头 ),
(Fig),
It is known that the normal
direction of flow in abdominal vessels
is away from the umbilicus,that is,the
upper abdominal veins carry blood
upward to the superior vena cava and
the lower abdominal veins drain
downward to the inferior vena cava,
If a vein is engorged,the direction of
flow can be demonstrated by a simple
maneuver,that is,placing the index fingers
side by side over the vein,pressing
laterally,separating the fingers one by one,
and observing the time it takes the veins
to refill from each direction; the flow of
venous blood is in the direction that fills
the fastest,The concrete procedure is as
follows,
A segment of vein in the epigastrium
is emptied between two fingers to a
distance of a few centimeters,One then
allows blood to refill the vein from one
direction by removing one compressing
finger and observing the rate of refilling,
The same segment is again emptied
and filling from the opposite direction is
estimated,
Usually the rate of filling is obviously
faster in one direction than in the other,
indicating the direction of flow in that
portion of the collateral venous system,The
process is repeated in the hypogastrium and
the direction of flow in the lower abdominal
veins is observed.In portal hypertension
normal flow direction is maintained,In
contrast,obstruction of the vena cava alters
the flow direction in these veins,
In obstruction of the superior vena
cava,the flow direction in the upper
abdominal venous collaterals is reversed or
downward,
In inferior vena cava obstruction the
direction is reversed in the lower abdominal
veins,and they will drain upward,
(4) gastral or intestinal pattern(胃型
或肠型 ) and peristalsis(蠕动波 )
? In lean individuals,even in the
absence of disease,motility of the stomach
and intestines may be reflected in the
abdominal wall,
? When strong contractions are visible
through an abdominal wall of average
thickness,the possibility of bowel
obstruction should be investigated,
? Reverse peristalsis indicates pyloric
stenosis,duodenal stenosis,or malrotation
of the bowel,
(5) others
A) rash
B) pigment色素
The abdomen is inspected for evidence
of unusual pigmentation,such as jaundice,
Disorders accompanied by
hyperpigmentation also may be more
notable on inspection of the skin of the
abdomen,where changes caused by
exposure of the skin to sunlight are readily
separated from those caused by generalized
increase in pigment,
The tendency of these disorders to manifest
increased pigmentation in areas of minor or
persistent trauma to the skin may be especially
evident at the belt line,Other pigment changes
caused by intra-abdominal hemorrhage may be
found,A bluish discoloration of the umbilicus
occasionally is seen after major intraperitoneal
hemorrhage,A similar discoloration of the flanks,
in the absence of trauma,occasionally is seen
following the extravasation of blood from intra-
abdominal organs into extraperitoneal sites,as in
hemorrhagic pancreatitis,
? Cullen sign
----- A bluish discoloration of the
umbilicus occasionally is seen after major
intraperitoneal hemorrhage,
? Grey-Turner sign
----- A similar discoloration of the flanks,
in the absence of trauma,occasionally is
seen following the extravasation of blood
from intra-abdominal organs into
extraperitoneal sites,as in hemorrhagic
pancreatitis,
C) abdominal striae腹纹
D) scar
E) hernia
F) umbilicus
G) abdominal hair
Finally,hair distribution should be noted,
In the normal female the pubic hair is
roughly triangular with the base above the
symphysis,whereas in the male it is in the
shape of a diamond,often with hair
continuing to the umbilicus,The distribution
and quantity of hair may be altered by
chronic liver disease and various endocrine
abnormalities,
H) abdominal pulsation
Palpation
This procedure is usually the most
important and often the most difficult to
perform accurately,
1,the principle of palpation
a) To relax the patient
? During palpation the patient should continue
to lie supine with arms relaxed on the chest or at
the sides,The examiner should make certain that
his hands are warm,He should assure the patient
that he will make an effort not to cause
discomfort and follow up this assurance by
avoiding at the outset an area already described as
painful,If the patient exhibits ticklishness,the
examiner should disregard it and try to continue,
If this proves unsuccessful,it is useful to have the
patient place his own hand on his abdomen,since
this never tickles,
The examiner may tentatively exert pressure
on the abdomen through the patient’s own hand,
and gradually increase the pressure,while
assuring the patient that the examination will
cause no discomfort,When the patient has
relaxed,the examiner again places his own hand
on the abdomen and allows the patient to
maintain contact with his hand,This usually
completes the relaxation of the ticklish patient,
and the examination proceeds as usual,
? The examination begins with gentle
exploration of the abdominal wall and with no
effort made to palpate deeply,The patient may be
further relaxed by instructing him to breathe
slowly and deeply,As with inspection,the initial
step in palpation may be facilitated by distracting
conversation or questions regarding the history,If
the patient remains tense or if the abdominal wall
is very muscular,better results may be obtained
by having the patient flex the thighs and knees,
It should be emphasized again that during
the preliminary stages muscle relaxation is
the goal,At this time no attempt should
be made either to elicit discomfort or to
palpate for a mass or enlarged viscus,
b) To palpate four quadrants
superficially from LLQ counterclockwise
? To palpate all areas of the abdomen
counterclockwise and superficially from left
lower quadrant screening for tenseness(紧张
度 ),tenderness(压痛 ),masses,etc,
? Examination begins with gentle
maneuvers and then palpation occurs
more deeply,
? Examiner uses the palms of his
hands with fingers together and arm
relaxed and forearm on a horizontal plane,
? The examiner presses with his fingers,
c) To palpate four quadrants deeply
Using the palmer surface of the fingers,
examiner palpates in four quadrants to
identify masses,tenderness,pulsations,etc,
The abdominal wall should be depressed
more than 2 cm,When deep palpation is
difficult,examiner may want to use left
hand placed over right hand to help exert
pressure,
If a mass is suspected,determine its size,
contour,mobility,tenderness,smoothness,
irregularity,the hardness or softness and
listen with stethoscope for a bruit over the
mass,If there is tenderness,determine
the point of maximum tenderness and
distribution,
To check for rebound tenderness,
palpate deeply at the point of tenderness,
pause briefly,then remove the fingers
quickly,Watch the patient’s face to see
whether it hurts,Then check other areas in
the same manner for comparison,
2,the contents of palpation
a) abdominal tenseness腹壁紧张
度
In normal persons,abdominal wall is
somewhat tense,but usually soft when
palpated and easily depressed,and is
called abdominal softness(腹壁柔软 ),
While some pathological conditions can
lead to an abnormal increase or decrease
of abdominal tenseness,
1) The increase of abdominal
tenseness
? Abdominal tenseness increases,not
accompanyed by muscle spasm,is due to
the increase of abdominal contents,as
gastrointestinal flatulence(肠胃胀气 ),
artificial pneumoperitoneum(人工气腹 ),
ascites,etc,
? Board-like rigidity板状腹
If abdominal wall is palpated as obviously
tense,even as rigid as a board,board-like
rigidity is so called,This sign is caused by
the spasm of abdominal muscle due to
peritoneal irritation,as the perforation of
the gastrointeatinal diseases or rupture of
the viscera,
? Dough kneading sensation揉面
感；柔韧感
If abdominal wall is palpated as pliable
and tough,and if it has resistance
and is not easily depressed,then the
examiner feels the sensation of dough
kneading,This sign is usually seen in
tuberculosis peritonitis or cancerous
peritonitis,
2) The decrease of abdominal tenseness
The decrease of abdominal tenseness is
caused by the decrease or
disappearance of abdominal muscle’s
tension(张力 ),the sign usually found in
chronic deeline(消耗性疾病 ) or drainage of
large amount of ascites,
b) tenderness and rebound tenderness
压痛和反跳痛
After relaxation is obtained,the examining
hand is first moved gently over the entire
abdomen,and an estimate of the muscle tone
in the various quadrants is made,Following
general palpation an attempt should be made
to detect and localize any painful area (i,e,
tenderness) within the abdomen,Two types
of pain may be elicited by palpation,
1,Visceral(内脏的 )—This is pain that
arises from an organic lesion or functional
disturbance within an abdominal viscus,
For example,it is the type seen in an
obstructive lesion of the intestine in which
there is a buildup of pressure and
distention of the gut,This type of pain has
sveral characteristics,it is dull,poorly
localized,and difficult for the patient to
characterize,
2,Somatic(躯体的；体壁的 )—This is similar
to the distress noted in painful lesions of the
skin,It is sharp,bright,and well localized,It
is not caused primarily by involvement of the
viscera; rather it indicates involvement of one
of the somatic structures,such as the
parietal peritoneum or the abdominal wall
itself,It should be pointed out that an
inflammatory process originating in a viscus will
produce visceral pain that may extend to
involve the peritoneum,
Inflammation of the peritoneum would then
result in somatic pain,This is best illustuated by
appendicitis(阑尾炎 ) in which the pain is at first
poorly localized,dull,ill defined,and primarily
midiline (when it is entriely visceral in origin),
Later,as the inflammation spreads to the
peritoneum,the pain becomes sharp,bright,and
well localized in the right lower quadrant over
the involved region,
After a painful area is located,the examiner
should determine whether the pain is constant
under the pressure of the examing hand or if it
is transient,tending to disappear even though
pressure is continued over the area,Pain caused
by inflammation usually remains unchanged or
increases as pressure is applied,Visceral pain as
the result of distention or contraction of a
viscus tends to become less severe while
pressure is maintained,
Occasionally the examiner may have difficulty
in distinguishing visceral pain from that arising
in somatic structures,such as the spine and
abdominal wall,An example of abdominal wall
discomfort is seen in patients with fibrositis(纤
维组织炎 ),These types of pain may be
differentiated by having the patient tense his
abdominal muscles,which may be
accomplished by forcefully elevating his head
while keeping his shoulders flat on the table,
Under these conditions increased tension of the
abdominal wall will accentuate the pain if it
originates in somatic structures,On the other
hand,discomfort from intra-abdominal sources
will be less severe with the abdomen tense than
when relaxed,
When pain has been elicited,the examiner
should test for the phenomenon of rebound
tenderness,This is found only when the
peritoneum overlying a diseased viscus becomes
inflamed,Although it may be produced in
different ways,the most common is to press
firmly over a region distant from the tender area
and then suddenly release the pressure,The
patient will feel a sharp stab of pain in the area of
disease if true rebound tenderness is present,
For example,pressure applied in the
right lower quadrant and then suddenly
released will cause a marked increase in
pain over an area of diverticulitis(憩室炎 )
in the left quadrant,Rebound tenderness
may also be elicited by having pressure
over the tender area and having the patient
cough or strain,Marked tenderness to
percussion in the area is usually seen in this
situation,
This type of tenderness indicates
widespread inflammation of the
peritoneum (peritonitis),At times,if the
area involved is small,rebound tenderness
may be elicited only over the most tender
area of the abdomen,
a) Viscera
u To palpate liver at
midclavicular and midsternal
lines
Method,The right hand may be held
either parallel or perpendicular to the long
axis of the patient,In the midclavicular
starting at the anterior superior iliac crest,
examiner presses down firmly and asks
patient to inhale deeply,This allows the
liver to move down to meet your
fingertips,
If you feel nothing,press up a few
centimeters toward the rib cage and repeat
the maneuver,Do this continuously until
you feel the liver or reach the coastal
margin,Ordinarily the liver is not palpable,
although not infrequently the examiner may
feel the edge of the normal liver at or
slightly below the right costal margin,When
the liver is palpated,a firm edge will strike
the fingers upon inspiration,
In the midsternal line,from the level of
the umbilicus,repeat the above maneuvers
to palpate the liver,Most doctors like to
use bimanual maneuvers to palpate the
liver,To do this,place the left hand at right
lower posterior chest wall parallel to,or
supporting patient’s right 11-12th ribs or at
lower sternal area to limit the chest
respiration to make right hand palpation
more effective,(Fig),
Note,（ 1） When felt more that 1cm,below
the costal margin,however,the organ should be
considered abnormally large,An exception is a
congenitally large right lobe of the liver,which
occasionally extends quite far into the right
flank,Another exception is seen in severe,
chronic emphysema(肺气肿 ),in which the
diaphragms are depressed by the overexpanded
lung,displacing the liver below the costal
margin,In both instances the total mass of the
liver is within normal limits,
（ 2） If you feel the liver,detect the edge
(sharp or round),tender or not,hard or soft
and repeat the process laterally and medially to
define the contour,For masses within the liver,
describe the same characteristics as above and
listen for a bruit over the mass,
l Size
Ordinarily the liver is not palpable,or the
liver can not be felt more than 1cm below the
lower coastal margin,and can not be felt more
than upper 1/3 distance of the line from
xiphoid to umbilicus or more than 3cm under
the xiphoid,Failure to feel the liver does not
mean that the liver is normal,Measurement of
the liver is done in the midclavicular line and
midsternal line,
l Texture/quality质地
The quality of liver is classified into three grades,
softness(质软 ),toughness(质韧 ),and
hardness(质硬 ),Normally the quality of liver is
soft and tender,just like the pouted(撅嘴 ) lip,In
acute hepatitis or fatty liver(脂肪肝 ),the quality of
liver is slightly tough,In chronic hepatitis or blood
stasis of liver,liver is more tough and usually as
tough as apex nasi(鼻尖 ),In liver cirrhosis,the
quality of liver is hard,In liver carcinoma,the
quality of liver is extremely hard and as hard as
forehead(前额 ),
l Surface and edge
To observe whether the surface of liver is smooth
or not,whether there is any node(结节 ) or not,
and whether the edge is thin or thick and is regular
or irregular,The character of the surface of the
liver should be described,Not infrequently large
metastatic masses may be present and palpable in
the liver,In some persons with cirrhosis,the
anterior surface of the liver will have a granular
feel,This is easily felt in the thin individual,
l Tenderness
Normally liver cannot be palpated as tenderness
unless the liver is irritated by the liver chitonitis
(that is,inflammation of the diolame包膜 of
the liver) or pulled by the enlargement of itself,
l Pulsation搏动
Normally you cannot palpate any pulsation of
the liver,If you palpate the pulsation of the
liver,you should pay attention to its direction,
that is,whether it is unidirectional(单向性 ) or
expansile(扩张性 ),The former one,
unidirectional pulsation,is usually a conductive
one(传导性搏动 ),That is caused by the the
conduction of the pulsation of aorta
abdominalis(腹主动脉 ),
If you put your hand on the sufface of the liver,
you will feel your hand is pushed upward,The
later one,expansile pulsation,is the pulsation of
the liver per se and usually found in tricuspid
valve insufficiency(三尖瓣关闭不全 ),Because
the contractive pulsation of right ventricle
conducts to liver through right atrium and then
inferior vena cava,If you put your hand on the
sufface of the liver,you will have the opening-
closing sensation,
The positive Hepatojugular reflux sign(肝－
颈静脉回流征 ),If you press the liver,you will
find the dilated jugular vein becomes more
bulged or distended,as from the enlargement of
liver passive congestion resulted from right
failure,
l Liver friction sensation肝区摩擦感
l Liver thrill肝震颤
u To palpate spleen from umbilicus
to left costal margin
In examining for splenic enlargement,
the examiner should stand at the patient’s
right side,His left hand is placed over the
patient’s left costovertebral angle,exerting
pressure to move the spleen anteriorly,At
the same time his right hand is worked
gently under the left anterior costal margin,
With the examiner’s hands stationary in
this position,the patient is instructed to
take a deep breath,
If there is significant enlargement of the
spleen,it will be palpated as a firm mass that
slides out from under the ribs,bumping against
the finger of the examiner’s right hand,The
spleen normally moves down with inspiration,
If splenic enlargement cannot be felt by the
technique just described,the patient should
then be rolled slightly toward the right so that
the spleen may fall anteriorly,
The examining hands are again placed as
described and the procedure is repeated,
Occasionally a spleen that cannot be felt with
the patient in the supine position may be
palpated by this maneuver,When the spleen
can be felt,it must be considered abnormal,
since the normal spleen is not palpable,
Notes,
（ 1） Starting from the level of
the umbilicus (or below the percussed
dullness),
（ 2） The maneuver is similar to
that used to palpate the liver,but is
more subtle because the spleen is more
mobile and deeper than the liver,
（ 3） If the spleen is not palpated,
have the patient roll on his right side
and repeat palpation,
（ 4） Measurement of the spleen
is the same as that of the liver and is
usually expressed as centimeters under
the costal margin in the midclavicular
and under the xiphoid process in the
midsternal lines,
（ 5） A moderately or greatly
enlarged spleen is best described by a
drawing,especially the three lines which are
presented schematically in the following
diagram (Fig),(NOTE,Severe
splenomegaly may cause rupture when
spleen is vigorously palpated,so palpate
gently and carefully),
Line 1,The distance between left costal
border and the lower edge of spleen along
left midclavicular line
Line 2,The distance between the crossing
point of left midclavicular line and left
costal border and the
most remote point of the spleen
Line 3,(when the spleen is extremely large
and exceeds the anterior midline.) The
distance between the right border of the
spleen and the anterior midline,If the
spleen indeed exceeds the anterior midline,
The mark ―+‖ is used to indicate
―exceeding‖,while ― – ― is used to indicate
―not exceeding‖,
In clinical practice,splenomegaly is
classified into three levels,
level 1 (slight enlargement轻度肿大 ),
During deep respiration,the lower edge of
spleen is not more than 2cm below the
costal border
level 2 (moderate enlargement中度肿
大 ),
During deep respiration,the lower edge of
spleen is more than 2cm below the costal
border but above the umbilical horizontal
line
level 3 (severe enlargement高度肿大 ),
During deep respiration,the lower edge of
Spleen is below the umbilical horizontal
line or over anterior midline
u To palpate gall bladder
Method,Put right hand below the costal
margin or lower border of liver at
midclavicular line (grossly equal to the
lateral border of the right rectus
muscles) and palpate deeply to check for
tenderness or bulging,
Under normal circumstances,the gallbladder
cannot be palpated,However,in a jaundiced
patient,the right upper quadrant should always
be carefully palpated for a soft,cystic mass,
approximately 6 to 8 cm in diameter,which
appears to be attached to the liver and moves
with respiration,This is an exceedingly valuable
sign in differentiating jaundice caused by cancer
of the head of the pancreas or the common bile
duct from that caused by gallstones,
In the presence of tumor of the common bile
duct or head of the pancreas,the wall of the
gallbladder is normal,and consequently the
organ is capable of distending to the point that
it is palpable,Such sign is named Courvoisier
sign,On the other hand,if the obstruction is
caused by gallstones,the gallbladder wall is
inflamed,and this diseased organ is not capable
of distention,Therefore,the gallbladder will not
become palpable,
u To check for Murphy’s
sign
If pain is found in the gallbladder area but
gallbladder is not palpated,the examiner
should put his left hand on the lower lateral rib
cage with the 4 fingers stretching superiorly and
the thumb hooked under the costal margin,
Press down to the point of gallbladder
tenderness and ask the patient to breathe deeply
and check to see whether the patient stops
breathing,changes facial expression,or
complains of pain,The sign is indicative of the
inflammation of gallbladder,
u To palpate kidneys bimanually
For palpation of the kidney,examiner puts
his left hand below left rib cage,at the
costospinal angle,and lifts up,Examiner
uses his right hand to palpate deeply from
umbilical level in the left midclavicular line,
and moves progressively upward,The
lower pole of the kidney may be felt as a
smooth,round,and deep structure that
moves relatively little with respiration,
This maneuver is repeated on the right
side to palpate the right kidney,Normally
the kidney is not palpated,Sometimes the
lower pole of the right kidney may be felt
in normal patients,During deep
inspiration,if more than half of the kidney
is palpated,nephroptosis(肾下垂 ) is
considered,Repeat the maneuver with the
patient in sitting and standing positions if
you wish to expose the kidney further,
d) abdominal masses
e) fluidthrill液波震颤
(discussed in auscultation)
f) succussion splash振水音
(discussed in auscultation)
Percussion
1,General percussion
All four quadrants of the abdomen are
evaluated by percussion,Light percussion
is preferable,since it produces a clearer
tone,
Tympany(鼓音 ) is the most common
percussion sound in the abdomen due to
gas collection,It is appreciated over the
stomach,small intestine,and colon,
2,Percussion of the liver
Percussion of the upper border of liver(肝
上界 ) is executed along the right midclavicular
line(右锁骨中线 ),right midaxillary line(右腋中
线 ),and right scapular line(右肩胛线 ),The
level of the shift from resonance downward
into dullness is defined as the upper border of
liver,At this level,the liver is covered by lung
and hence the border is also called the relative
dullness border of liver(肝相对浊音界 ),
Then percussing downward 1-2 intercostal
space,the level of the shift from dullness into
flatness(实音 ) is identified as the absolute
dullness border of liver(肝绝对浊音界 ),
without lung covering,and also called the lower
border of lung(肺下界 ),Normally the the
upper border of liver locates at the 5th
intercostal space along the right midclavicular
line,the 7th intercostal space along the right
midaxillary line,and the 10th intercostal space
along the right scapular line,
Percussion of the lower border of liver(肝下
界 ) is executed along the right midclavicular
line or anterior midline,The level of the shift
from tympany upward into dullness is defined
as the lower border of liver,
u Percussion of liver span (肝上下径 )
Percussion of liver span should be done with
the patient breathing normally,Percussion
should occur through the right midclavicular
line from resonance over the lung field
downward to dullness and from tympany over
abdomen upward to dullness,Measure from
upper to lower border of dullness for liver
span,It is normally about 9-11 cm in the
midclavicular line,
Dullness extending into the normally
tympanitic right upper quadrant indicates
hepatic enlargement,a mass adjacent to
the liver,or downward displacement of
the liver,
There may be an absence of liver dullness
following perforation of a hollow viscus,which
allows free air to enter the abdominal cavity,
This indication of an intra-abdominal
catastrophe must be correlated with the clinical
situation,since on occasion interposition of the
hepatic flexure of the colon between the
diaphragm and the liver (间位结肠 [结肠位于
肝与横膈之间 ]) will produce the same finding
with no clinical consequences,
u Fist percussion(拳击叩诊 ) of liver
To tell the patient what you intend to do before
you start,Examiner places one palm over the
area of liver dullness,Examiner then hits that
hand gently with the fist of his other hand,
Examiner should watch the patient’s facial
expression and withdrawal effort and ask him if
it hurts,If pain occurs,do fist percussion at the
same site on the left side for comparison and
pay attention to the intensity and site of the
pain,(Fig),
3,Percussion of the spleen
n To percuss for splenic dullness
This should be done when splenic enlargement
is suspected,
Normally splenic dullness can be percussed
between 9 intercostal space to 11 intercostal
space along left midaxillary line,the scope that
is 4-7cm,without passing over left anterior
axillary line,
Percuss the lowest intercostal space in the
left midaxillary line,This area is usually
tympanitic,Then ask the patient to take a deep
breath,When size of the spleen is normal,the
percussion note usually remains tympanitic,
n Fist percussion of spleen
As discussed in fist percussion of liver
The remainder of the normal abdomen is more
or less tympanitic to percussion,depending on
the amount of gas in the intestine,After
percussion of the liver and spleen,one may
percuss over any visible masses to determine
whether they are dull (as with tumor or fluid-
filled spaces) or tympanitic (as with distended
bowel),Distention of the urinary bladder may
yield an area of suprapubic dullness,If other
masses are detected by palpation,percussion
may help to characterize them further,
The last thing to be noted on percussion is the
presence or absence of free fluid in the
abdominal cavity (ascites),This may be detected
by several maneuvers(1) shifting dullness,(2)
fluid wave,and (3) elbow-knee position,
5,Percussion for shifting dullness(移动
性浊音 )
When the patient with ascites lies on his back,
the fluid will migrate into the flanks,producing
dullness laterally,At the same time the
midabdomen is tympanitic because of the
underlying bowel,When dullness is found in
the flanks,The line of demarcation between the
dull and tympanitic sounds is marked,The
patient is then rolled onto his right side,and the
percussion is again carried out toward each
flank,All of the ascites will flow to a dependent
portion on the right side of the abdomen,
A new line is marked and the change is
measured in centimeters,Consequently it will
be noted that the level of dullness on the right
has moved toward the midline and that the
bowel,which has been displaced upward by the
fluid,results in a tympanitic note in the upper
flank,This is repeated after rolling the patient
to his left side,By this means,an estimate of
the amount of free fluid can be made,A
volume of free fluid in the peritoneal cavity
greater than 1000ml can be detected with this
method,
To simplify the procedure,the examiner first
determines the point from tympany to dullness
with the patient in the supine position,The
patient is then asked to turn on his side while
the examiner holds his pleximeter on the point
where the change in percussion sound occurred,
The examiner then percusses this same point
again,If the sound changes from dullness to
tympany,it means that the dullness has been
shifted to a more dependent position,This
implies that ascites is present,
6,Testing for a fluid wave
(液波震颤 )
With patient lying on his back,the examiner’s
left hand is placed against the patient’s right
flank,An assistant or the patient places the
ulnar edge of one hand lightly against the
middle of the abdomen to prevent the
transmission of any wave through the tissues of
the abdominal wall,The examiner’s right hand
then lightly taps the left flank of the patient,In
the presence of a siguificant amount of ascites,
a wave will be transmitted through the fluid that
will be felt against the examiner’s left hand as a
sharp impulse,This finding is present only
when there is a reasonably large amount of fluid,
7,Elbow-knee position(肘膝位 )
The presence of small amounts of fluid may be readily
detected by placing the patient in an elbowknee
position and percussing from the flanks toward the
most dependent portion of the abdomen,Free fluid,
if present,will run from the pelvis(骨盆 ) and gutters
of the abdomen into the most dependent area,which,
if the patient is in the proper position,is located in the
periumbilical region,
The finding of dullness in this area indicates the
presence of ascitic fluid,This technique is more
sensitive for detecting small amounts of fluid than are
the previously described methods,
Auscultation
1,Bowel sounds(borhorygmus) 肠鸣音
Auscultate bowel sounds with diaphragmatic head
of stethoscope for at least one minute,
If there are no bowel sounds,listen until you hear
them or for at least 5 minutes,
Normal bowel sounds are a glue-glue,glue-glue-like
sound occurring either separately or together,
approximately 4-5 times per minute,Pay attention to
the frequency,pitch,and intensity,High-pitched
(gurgling) sounds with increased frequency are
regarded as hyperactivety,Lack of bowel sounds
indicate little or no peristalsis,
Two abnormalities of the bowel sounds are
significant,The absence of any sound or
extremely weak and infrequent sounds heard
after several minutes of continuous auscultation
ordinarily represent the immobile bowel of
peritonitis or paralytic ileus,In contrast,
increased sounds with a characteristic loud,
rushing,high-pitched tinkling quality often
occur in mechanical intestinal obstruction and
may be accompanied by waves of pain,The
latter findings are caused by distention of the
bowel and increased peristaltic activity proximal
to the site of the obstruction,
1,Murmurs(杂音 ) or bruits
Murmurs from arteries are called bruits
and are similar to low-pitched heart murmurs,
Murmurs from veins sound like a hum and are
more continuous; they are called venous bruits
or venous hum(静脉“嗡鸣声” ),
To be of significance a bruit must be
heard consistently in the area if the patient is
moved into various positions,and it must be
heard with extremely light pressure on the
diaphragm of the stethoscope or with bell-type
head of stethoscope,
Left upper quadrant to include (L) renal artery
左肾动脉
Right upper quadrant to include (R) renal
artery右肾动脉
Right lower quadrant to include (R) iliac
artery右髂总动脉
Left lower quadrant to include (L) iliac artery
左髂总动脉
Aorta(主动脉 ) along the midsternal line
3,Succession splash(振水声 ) in the
epigastric area
Succession splash is the splash sound over the
upper abdomen,It should be checked by
rocking the upper abdomen to the left and right,
In normal patients this is negative about 6-8
hours after eating food,If positive,it indicates
gastric retention,
4,Friction rubs over the liver and
spleen(肝区或脾区摩擦音 )
Listen with stethoscope over liver and spleen
while patient breathes deeply,
Peptic Ulcer Disease
消化性溃疡病
Question,What’s the
meaning of ―Peptic Ulcer
Disease‖?
Definition
Peptic Ulcer Disease is defined as an
ulcer occurring in a region that touches
gastric acid(胃酸 ) and pepsin(胃蛋白酶 )
and usually refers to gastric ulcer(胃溃疡 )
or duodenal ulcer(十二指肠溃疡 ),
Typical endoscopic appearance of a
benign gastric ulcer,The ulcer is on the
angularis,the most common location for
a gastric ulcer,and is well
circumscribed without any associated
mass effect,The surrounding mucosa is
mildly erythematous红斑的 and without
nodularity结节,
Typical radiographic features of a
benign gastric ulcer,A large well-
circumscribed ulcer is seen on the
angularis,
a posterior duodenal
ulcer
Typical radiographic features of
duodenal ulcer,This duodenal bulb
ulcer is associated with marked
edema,resulting in the appearance
of radiating folds to the ulcer crater,
The bulb is also distored secondary
to previously existing ulceration,
Questions,
What does ulcer 溃疡 mean?
How can we differentiate between ulcer
and erosion 糜烂?
Erosions in the duodenal
bulb and a posterior
duodenal ulcer
Erosion糜烂, a superficial lesion caused
by denudation of the surface epithelium
（上皮细胞）
ulcer 溃疡, a mucosal defect extending
into the muscularis mucosa(粘膜肌层 )
Mucosa can be divided into,
Epithelium 上皮
Lamina propria 固有层
Muscularis mucosae 粘膜肌层
Clinical manifestations of
Peptic Ulcer Diseases
消化性溃疡病的临床表现
symptoms
症状
abdominal pain
腹痛
located in the epigastric(上腹 ) area;
burning in quality(烧灼样 );
occurred on an empty stomach 2 to 4 hours after
meals and/or at night (nocturnal pain夜间疼痛 );
relieved by antacids(抗酸剂 ) and/or meals(进餐 );
tend to wax and wane(加重与缓解 ) over months
,acid dyspepsia酸消化不良,
the majority of patients (approximately
70%) with epigastric distress
(“dyspepsia”) do not have evidence of
active ulcer disease;
conversely up to 40% of patients with
an active ulcer crater deny abdominal
pain;
patients can present with an ulcer-
related complication,particularly
hemorrhage,without antecedent
symptoms
despite being both insensitive
and non-specific,the symptom
of epigastric abdominal pain,
particularly burning after meals
and at night and relieved with
food or antacid,suggests the
possibility of ulcer disease,
Other symptoms
gastroesophageal reflux 胃食管反流
(including upright 直立位 and supine仰
卧位 reflux and non-cardiac chest pain
非心源性胸痛 );
symptoms of indigestion 消化不良
occurring with or shortly after eating
and characterized by epigastric fullness
and discomfort(上腹饱胀与不适 ),
belching(打嗝 ),bloating(胀气 ),
nausea(恶心 ),early satiety(早饱 ),and
specific food intolerances);
signs
体征
Physical examination is of limited value
in patients with uncomplicated ulcer,
For epigastric tenderness 压痛 on deep
palpation深部触诊,the sensitivity and
specificity are all approximately 50% or
less,
Furthermore,many patients with non-
ulcer diseases 非溃疡性消化不良 also have
epigastric tenderness on physical
examination,
In patients with free perforation穿孔 or
ulcer penetration穿透 into the
pancreas,findings of peritonitis腹膜炎
are usually present,
In patients with gastric retention 胃潴
留 who have been fasting禁食 for a few
hours,a succussion splash 振水声
(produced by auscultating 听诊 the
abdomen while rocking the patient
back and forth)
suggests retained gastric contents,
Complications
并发症
Hemorrhage 出血
the most common complication of ulcer
disease (in approximately 15% of
patients)
Perforation穿孔 and Penetration
穿透
(in approximately 7% of patients )
Duodenal ulcers,perforate anteriorly
Gastric ulcers,perforate along the
anterior wall of the lesser curvature of
the stomach
Perforated peptic ulcer,Air is
present under the right
hemidiaphragm in a patient
with acute severe abdominal
pain,
Penetration is similar pathologically
to perforation,except that the ulcer
crater壁龛 burrows打洞 through the
entire wall of the intestine,and
instead of leaking digestive contents
into the peritoneal cavity腹腔,the
crater bores钻孔 into an adjacent
organ附近脏器,
Gastric ulcers most commonly
penetrate into the left lobe of the liver,
while duodenal ulcers penetrate
posteriorly into the adjacent pancreas
胰腺,sometimes leading to
pancreatitis胰腺炎, Rarely,gastric
ulcers may penetrate into the colon结
肠,resulting in a gastrocolic fistula胃
结肠瘘,
Gastric outlet obstruction 梗阻 (gastric
retention or pyloric stenosis胃潴留或 幽门狭窄 )
functional impairment of antral motility 胃
窦动力功能不良 due to the effects of acute
inflammation and edema;
mechanical obstruction 机械性梗阻 due to
scarring near the gastroduodenal junction;
manifest as gastroesophageal reflux,early
satiety,weight loss,abdominal pain,and
vomiting;
As the degree of retention increases,the
quantity of vomitus呕吐物 also increases,
often containing food ingested 12 or more
hours previously,
Barium upper
gastrointestinal study
demonstrates the size of the
stomach,
Endoscopy demonstrates the
pyloric obstruction with an
active ulcer crater seen in the
pyloric channel,
Canceration癌变
(Gastric ulcer )
Questions for summary,
(1) What does Peptic Ulcer Disease
refer to?
(2) What are the symptoms and signs
you can find in the patients with peptic
ulcer disease?
(3) Which kind of complication most
frequently occur?
PORTAL HYPERTENSION
FEATURES OF THE
PORTAL CIRCULATION
AND CLASSIFICATION OF
PROTAL HYPERTENSION
The hepatic vein drains most of the
blood from the liver into the inferior
vena cava,In addition,there is some
direct venous drainage between the
caudate lobe and the inferior vena
cava,The portal vein is formed by the
union of the splenic vein and the
superior mesenteric vein,The splenic
vein receives branches from the
pancreatic veins,short gastric veins,
and inferior mesenteric veins,
The portal circulation is a low-
pressure system (<10mm Hg) formed
by the venous drainage from
intrtraperitoneal viscera,including the
luminas gastrointestinal tract,spleen,
gallbladder,and pancreas,Veins
collecting from these sites form the
splenic vein and superior and inferior
mesenteric veins,which,in turn,
merge to create the portal vein,
Portal hypertension occurs when portal
venous pressure exceeds the pressure in
the non-portal abdominal veins (e.g.,inferior
vena cava) by at least 5mmHg;
portosystemic collateral vessels develop in
an effort to equalize pressures between
these two venous systems,These collateral
vessels,or varices,most commonly develop
in the esophagus and proximal stomach and
can cause clinically significant bleeding,
Altered portal homodynamics can also lead
to the development of ascites and
contribute to hepatic encephalopathy,
In cirrhosis,which is the most
common cause of portal hypertension,
the lesion is intrahepatic and primarily
sinusoidal,Portal hypertension may
also arise from presinusoidal
obstruction,either outside (e.g.,portal
vein thrombosis ) or within (e.g.,
schistosomiasis) the liver,Similarly,
lesions leading to portal hypertension
may be postsinusoidal,either within
the liver(e.g.,veno-occlusive disease )
or distal to it (e.g.,Budd-Chair
syndrome,right -sided heart failure ),
In rare circumstances,portal
hypertension can result in a normal
liver from markedly increased inflow
beyond the capacity of the compliant
portal vessels to absorb,Examples
include arterial -portal fistulas and
massive splenomegaly due to infection
or neoplasm,
CLINICAL PRESENTATION
The cirrhotic with portal hypertension
will often have variceal hemorrhage,ascites,
encephalopathy,or some manifestation of
hepatic dysfunction such as coagulopathy or
infection,Splenomegaly and /or distention of
abdominal wall veins (caput medusae ) may
be initial or associated findings,Other
physical finds include the presence of
clinical jaundice,spider nevi,facial
telangiectasia,gynecomastia,abdominal
distention caused by ascites (with a possible
umbilical or inguinal hernia ),parotid
enlargement,a magenta tongue,palmer
erythema,clubbing,etc,
Patients with non-cirrhotic portal hypertension
generally have well-preserved liver function so
that clinical manifestations primarily reflect
altered hemodynamics,In patients with
presinusoidal lesions such as schistosomiasis or
portal vein thrombosis,variceal hemorrhage and
splenomegaly are prominent,In postsinusoidal
obstruction,such as veno-occlusive disease or
Budd-Chiari syndrome,hepatomegaly and rapid
onset of ascites and weight gain are typical
presenting symptoms,When portal abnormalities
are a manifestation of infection or neoplasm,
there may be specific associated non-hepatic
findings,such as a hypercoagulable state,
anemia,or evidence of heart failure,
l Portal-Systemic Collaterals
The portal system has numerous
collaterals that interconnect with
the systemic circulation (See
table ),
TABLE Portal-Systemic
Collaterals
1,Located at transition zones
between squamous and glandular
epithelium,for example,
gastroesophageal junction,anus,
ileostomies,
2,Obliterated fetal circulation
in the falciform ligament,for
example,umbilical and
periumbilical veins
3,Retroperitoneal channels
originating in the splenic vein and
anastomosing with the adrenal
gland or renal veins,especially
the left renal vein
4,Areas in which the
gastrointestinal tract becomes
retroperitoneal,that is,when a
somatic surface is in contact
with an area not covered by
peritoneum,These areas include
the duodenum; descending,
ascending and sigmoid colon;
spleen; liver
Modified from mclndoe AH,Arch
Pathol 5:23,Copyright 1928,
American Medical Association,
The collaterals that lead to the
greatest clinical problems lie within
the mucosae of the stomach and
esophagus,When dilated,they form
gastric and esophageal varices,which
may appear as abnormalities on upper
gastrointestinal series,or they may be
seem at endoscopy,The umbilical vein
may dilate,as will the veins of the
abdominal wall,with the development
of visible collaterals,
If the inferior cava is also occluded( as
may be seem in the Budd-Chiari syndrome),
the direction of blood flow in the
abdominal wall collaterals will be
cephalad,When the inferior vena cava is
patent,the direction of flow of collaterals
will be cephalad above the umbilicus and
caudad below it,Without markedly dilated
vessels,the direction of flow is usually
difficult to determine,In my experience,
the finding of posterior collaterals has
been the most reliable diagnostic finding
in patients with obstruction of the inferior
vena cava,
If flow in the umbilical and
periumbilical veins becomes great
enough,a caput medusae will form,
and there my be an audible venous
hum( Cruveilhier- Baumgarten murmur)
over the course of the umbilical vein,
The origin of the umbilical vein is the
left portal vein; therefore,if the
umbilical vein is dilated,the cause of
the portal hypertension must be
intrahepatic,Large venous shunts may
also form between the portal vein and
the left renal vein,
On occasion,these shunts may appear
to be as large as surgical portacaval
shunts,They appear,however,to be
ineffective in reducing portal venous
pressure and preventing bleeding from
esophageal varices,In some cirrhotic
patients with chronic encephalopathy,
very large spontaneous portal-systemic
collaterals are present,and they shunt a
large portion of the splanchnic venous
blood into the systemic circulation,
Esophageal varices may never develop
in these patients,
The remaining collaterals listed in
Table usually do not cause symptoms,
However,varices may develop in
adhesions from previous
intraabdominal surgery or in the small
bowel or colon,and the patient may
seek treatment because of
gastrointestinal hemorrhage,
A particularly difficult problem is
bleeding enterostomal varices in
patients who have received
ileostomies or colostomies for
inflammatory bowel disease and in
whom portal hypertension develops
because of liver disease,for example,
sclerosing cholangitis,Bleeding from
rectal varices is infrequent,
Hemorrhoids are different from rectal
varices,and the frequency of
hemorrhoids is not increased in
patients with portal hypertension,
VARICEAL HEMORRHAGE
Hemorrhage from gasirocesophageal
varices is often the initial
complication of portal hypertension,
Less commonly,variceal hemorrhage
occurs from other sites of
portosystemic collateral vessels,
including the duodenum,rectum,or
sites of prior abdominal surgery,
Esophageal variceal hemorrhage
typically occurs as painless,
largevolume hematemesis or melena
with minimal abdominal pain,Signs of
significant volume depletion,including
orthostasis and pallor,are common,
Mortality from variceal hemorrhage is
more a function of underlying liver
disease than severity of hemorrhage
per se,
l Splenomegaly
Although splenomegaly is commonly
associated with portal hypertension,there
is a poor correlation between portal venous
pressure and the size of the spleen,
Splenomegealy may be associated with
hypersplenism,Leukopenia,
thrombocytopnia,and anemia aare common
clinical features of diseases such as
schistosomiasis,The degree of depression
of the formed elements is infrequently of
sufficient severity to cause clinical
problems,that is,bleeding or infection,and
splenectomy is rarely indicated for
hypersplenism resulting from portal
hyertension,
l ASCITES
Ascites is the accumulation of exccss
fluid in the abdomen,Cirrhosis is the
underlying cause in at least 80% of
patients,but other etiologic factors in
addition to liver disease must always
be considered,
PATHOGENESIS
Multiple factors contribule to
ascites formation in chronic liver
injury,
1,Sinusoidal hypertension,which
develops because of increased outflow
resistance from matrix deposition and
possibly stellate cell contraction,Initially,
albumin traverses the porous sinusoidal
endothelium along with fluid; but as
fibrosis progresses,only protein-free fluid
can escape the sinusoid,from where it
enters hepatic lymphatics,Continued
accumulation of lymph overcomes the
capacity for lymphatic drainage,and the
excess fluid ―’weeps‖ from the liver into
the peritoneal cavity,
2,Hypoalbuminemia,which worsens
with advancing liver dysfunction and
decreases oncotic pressure,
3,Fixed capacity to resorb ascites,
despite its increasing accumulation,
4,Increased sodium reabsorption by
the kidneys,possibly due to humoral
factors
5,Splanchnic arteriolar vasodilation,
which may independently stimulate
sodium and free water retention by
increasing sympathetic tone,
The roles of antidiuretic hormone and
atrial natriuretic peptide are not
clearly established despite extensive
study,
