Transcript Abdominal Examination

Abdominal
Examination
Xue Huiping
Introduction
Question1 :
What do you think is the
better or more
appropriate sequence of
abdominal examination
compared with that in
other areas? And why?
Normal sequence:
inspection, palpation, percussion, and
auscultation
Abdominal examination: inspection,
auscultation, percussion, and palpation
It’s convenient to perform the auscultation of
abdomen after the auscultation of the heart.
To avoid the negative impacts of a series of
palpations on auscultation of bowel sounds due to
the alteration of peristalsis.
Question 2: Can we say that
abdominal examination will
be outmoded and superseded
because of remarkable
advances in supplementary
examination methods such as
X-ray, ultrasound, endoscopy,
isotope, angiography, CT, MRI,
etc. ?
Definitely Not.
Because the abdominal examination is
a fundamental method of detecting
abnormal signs of abdomen.
Palpation is the most difficult step of
abdominal examination, requiring more
practice.
Anatomic Landmarks
— xiphoid (ensiform) process(剑状突起) of
sternum(胸骨)
— costal margin肋弓缘
— umbilicus脐
— anterior superior iliac spine髂前上棘
— inguinal ligament 腹股沟韧带
— superior margin of os pubis耻骨上缘
— anterior midline/midabdominal line前中线/
腹中线
— lateral border of rectus muscles 腹直肌外缘
— symphysis pubis (耻骨联合)
xiphoid process
腹中线
midabdominal line
costal margin
Lateral border of rectus muscle
umbilicus
Anterior superior iliac
spine
腹股沟韧带
耻骨上缘
superior margin of os pubis
inguinal ligament
Zones used
of abdomen
Commonly
methods of
subdividing
腹 部 the
分abdomen
区
Four quadrants
Nine sections
right upper quadrant
left upper quadrant
right lower quadrant
left lower quadrant
√ 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 RUQ
(right upper quadrant), RLQ (right lower
quadrant), LUQ (left upper quadrant), and
LLQ (left lower quadrant.
√ The content of the abdomen underlying
each of the four quadrants 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
right hypochondrial
epigastric region
right lumber region
left hypochondrial
left lumber region
umbilical region
right iliac region
hypogastric region
left iliac region
Two imaginary, parallel, horizontal lines
√across the lowest border of the costal
margin
√across the anterior superior iliac spine
Two imaginary, parallel, vertical lines
√ across the middle of linking line formed by left
anterior superior iliac and midabdominal line
√ across the middle of linking line formed by
right anterior superior iliac and midabdominal
line
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)
Question 3: What are
the distinct benefits
and disadvantages in
Four-quadrant and Ninesection methods?
Four-quadrant
√ simple, practical,
√ rough, imprecise
(tenderness of epigastric regin)
Nine-section
√ elaborates more clearly and more
exactly
√ inconvenient
√ limited scope of left or right
hypochondrial region, left or right iliac
region
Inspection
notes
position (supine)
scope of exposure (adequate, xiphoid
process -- symphysis pubis, others
covered )
sequence
angle (side, tangent)
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.
The major contents of inspection
abdominal contour
respiratory movements
abdominal veins
gastral or intestinal pattern(胃型或肠型)
peristalsis(蠕动波)
abdominal rash, hernia(疝), striae(纹), etc.
Pay attention to
√ whether the abdomen is
symmetrical
√ whether it is bulged or retracted
√ whether it is indicative of ascites
or enclosed mass(包块)
Normal
√abdominal flatness(腹部平坦)
√ abdominal fullness(腹部饱满)
√ abdominal lowness(腹部低平)
Abdominal flatness
√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.
abdominal fullness
If he or she is very fat or is a
child, the abdomen is a little bit
round.
The level of the abdomen is
higher than that of the surface
between costal margin and
symphysis pubis.
abdominal lowness
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.
√Abdominal flatness, abdominal
fullness, and abdominal lowness are all
normal cases.
√ 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.
some important
pathological conditions
Abdominal protuberance/bulge
腹部膨隆
I.
Overall/generalized abdominal
protuberance/bulge全腹膨隆
√Overall abdominal bulge can be caused
by several pathological factors besides
overly obesity or physiological pregnancy.
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, the contour just like 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.
√ In obesity and fat, the umbilicus is usually
deeply inverted.
Apical belly尖腹
Apical belly is caused by peritonitis
or infiltration of cancers, and hence
abdominal muscle is tense, usu. with
the apical shape.
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.
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.
Abdominal concavity/
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 concavity/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
concavity/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, 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.
abdominal contour
abdominal protuberance (腹部膨隆)
Overall/generalized abdominal protuberance/bulge:
ascites, frog belly, apical belly
peritoneal air ; pneumoperitoneum
abdominal enclosed mass
Local: 局部包块:炎性、肿瘤、粘连。
注意包块的部位、外形、移位、搏动。
腹部凹陷 (abdominal concavity)
全腹凹陷:舟状腹(scaphoid abdomen)，
见于恶液质、糖尿病、甲亢、
Sheehan病等。
局部凹陷:疤痕收缩。
腹壁情况
Rash皮疹:部位、形态、色彩、时间等。
Pigment色素:Addison’s disease;Cullen sign;GreyTurner sign。
Abdominal striae腹纹:白纹、妊娠纹、紫纹。
Scar 瘢痕:手术史的证实。
Hernia 疝:腹股沟斜、直疝；腹壁疝；脐疝。
Umbilicus 脐部：
Body hairs 体毛:男、女性差异。
Groin 腹股沟：包块、结节、疤痕、异常搏动。

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.
√ 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.
腹壁静脉及其血流方向
上腔静脉阻塞: 向下
下腔静脉阻塞: 向上
门静脉阻塞: 脐为中心,放射状,
水母头(caput medusae)。
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).
Remember:
√ 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.
maneuver:
√ 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.
Remember
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.
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.
呼吸运动
正常表现：男性、小儿：腹式为主。
女性：胸式为主。
病理状态：腹式受限—腹部炎症、包块、
积液、膈肌麻痹。
腹式增强—癔症性呼吸、胸部疾病。
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.
胃肠型和蠕动波
gastric or intestinal pattern and peristalsis
正常人：见于经产妇与消瘦腹壁松软者。
幽门梗阻：上腹部逆蠕动。
小肠梗阻：不规则隆起，此起彼伏。
结肠梗阻：全腹膨隆、宽大肠型。
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
上腹部搏动
由腹主动脉搏动传导，可见于正常较瘦者。
异常情况：1.腹主动脉瘤和肝血管瘤
2.右心室增大：二尖瓣狭窄
或三尖瓣关闭不全
腹部听诊
肠鸣音(bowel sound,gurgling
sound)
正常：4-5次/分
活跃：10次/分
亢进：次数多、调高
减弱：少于1次/分
消失：3-5分
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.
Bowel sounds(borhorygmus) 肠鸣音
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.
血管杂音(vessel murmurs)
动脉性：中腹部或腹部一侧、动脉瘤或
主动脉狭窄、收缩期杂音。
静脉性：脐周、门脉高压、无收缩期与
舒张期性质。
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 .
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 belltype head of stethoscope:
摩擦音(friction rubs)
脾梗塞、脾周围炎、肝周围炎、或胆囊炎累
及腹膜。
搔刮试验(scratch test)
确定肝脏边缘； 确定腹水。
水坑试验（puddle test)
确定腹水少至120ml
叩
诊
正常腹部叩诊音
鼓音 (tympany)为主;
实音仅见于肝脾(肿大)部位.
Percussion
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.
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).
Percussion of the liver
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 liver
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.
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.
肝 脏 叩 诊
正常肝脏上界位置:右锁中线第5肋间。
肝浊音界扩大:肝癌、肝脓肿等。
肝浊音界缩小:暴发性肝炎、肝硬化等。
肝浊音界下移:肺气肿、张力性气胸等。
肝区叩痛:肝炎、肝脓肿等。
肝浊音界消失：消化道穿孔等。
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.
胃泡鼓音区与脾脏叩诊
Traube tympanic area (9.56cm):
上界：膈肌及肺下缘 下界：肋弓
左界：脾脏
右界：肝左缘
正常脾浊音界:左腋中线9~11肋间,长
4~7cm
脾浊音区增大:脾肿大
脾浊音区缩小:气胸、胃扩张、肠胀气等。
Percussion of the spleen
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.
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.
移动性浊音
(shifting dullness)
检查体位与方法:
侧卧位: >1000ml;
肘膝位 (elbow-knee position): 200500ml以上。
注意点：
肠道梗阻, 积液过多;
腹腔巨大肿瘤(如卵巢):
体位改变 (shifting dullness)；
尺压试验 (ruler pressing test)。
Percussion for shifting dullness(移动
性浊音)
The examiner should first tell the patient
to lie on his back (in the supine position).
, tympany at midabdomen could be found
because of the underlying bowel.
At the same time, dullness at the bilateral
flanks could be found during percussion
due to the accumulation of ascites. The
reason is that when the patient with
ascites lies on his back, the fluid will
migrate into the flanks, producing
dullness laterally.
Percussion for shifting dullness(移动
性浊音)
When dullness is found in the flanks, The line of
demarcation between the dullness and tympany is marked.
The examiner percusses the patient’s abdomen at the
umbilicus level from the midabdomen toward the patient’s
left side. If the examiner finds the point where percussion
sound of tympany changes into dullness, the examiner
should hold his pleximeter on that point, simultaneously,
ask the patient to turn on his right side and then continue to
percuss the 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.
Percussion for shifting dullness(移
动性浊音)
Similarly, the examiner percusses the patient’s
abdomen toward the patient’s right side. If the
examiner finds the point where percussion sound
of tympany changes into dullness, the examiner
should hold his pleximeter on that point,
simultaneously, ask the patient to turn on his left
side and then continue to percuss the same point
again to confirm the shift of dullness.
A volume of free fluid in the peritoneal cavity
greater than 1000ml can be detected with this
method.
If the amount is too little, shifting dullness
could not be found, the examiner could
ask the patient to take elbow-knee
position, letting the umbilicus at the
lowest level, and then percusses the
patient from flanks toward the umbilicus.
If percussion sound could change from
tympany to dullness, it indicates ascites.
Huge ovary cyst
Huge ovary cyst may also cause a
large area of dullness, but at
midabdomen with tympany at laterals,
because bowels could be pushed to
the bilateral flanks.
The dullness of ovary cyst could not
shift.
Huge ovary cyst
Ruler pressing test could be used to differentiate
huge ovary cyst from real ascites.
The patient should take the supine position, and
the examiner puts a hard ruler on the patient’s
abdominal wall horizontally and then presses the
ruler downward with two hands.
If huge ovary cyst exists, the pulsation of
abdominal aorta will conduct to the ruler via the
cyst, leading to rhythmic pulsation of the hard
ruler.
If free fluid not cyst exists in the abdominal cavity,
the pulsation of abdominal aorta could not
conduct, so the hard ruler has no such rhythmic
pulsation.
膀胱叩诊：
确定膀胱内是否有尿，必要时导尿
证实。
肋脊角叩诊：
肋脊角叩痛: 肾盂肾炎、肾结石、
肾结核、肾周围炎等。
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.
触诊基本方法
浅部触诊(light palpation)
深部触诊(deep palpation)
深部滑行触诊(deep slipping palpation)：
腹腔包块、器官
双手触诊(bimanual palpation)：
肝、脾、肾、腹腔肿物。
深压触诊 (deep press palpation):
确定腹腔压痛点与反跳痛
冲击触诊(ballottement):
适用于腹部大量积液时肝脾及腹腔包块难以触
及者。
触诊的注意点
对被检查者——
1. 仰卧体位、曲膝、垫枕。
2. 腹部充分暴露。
对检查者——
1.右侧站立；手臂与腹部表面同一水平
2.先左下逆时针；先正常后异常部位
3.边触诊边观察反应与表情，边谈话，减少患
者紧张
√ 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.
压痛与反跳痛
压痛(tenderness)
腹壁与腹内病变的鉴别；检查力度。
压痛+反跳痛(rebound tenderness)
压痛的部位与范围。
压痛与全身表现。
腹膜刺激征（peritoneal irritation sign)
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 tuberculose
peritonitis or cancerous
peritonitis.
The decrease of abdominal tenseness
√ 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
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)
√ 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.
√ sveral characteristics: dull, poorly
localized, and difficult for the patient to
characterize
2. Somatic(躯体的；体壁的)
√ similar to the distress noted in painful lesions
of the skin
√ sharp, bright, and well localized.
√ not caused primarily by involvement of the
viscera
√ indicates involvement of one of the
somatic structures, such as the parietal
peritoneum or the abdominal wall itself
√ 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.
√ 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 intraabdominal 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(壁层
腹膜) 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.
√ 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.
√ At times, if the area involved is small,
rebound tenderness may be elicited only
over the most tender area of the abdomen.
Palpation of Viscera
----- liver
u To palpate liver at
midclavicular and midsternal
lines
腹部脏器触诊
肝脏触诊
方法:
单手触诊法
双手触诊法
钩指触诊法
肝脏触诊手法的注意点
四指并拢,食指前端桡侧（非指尖）接触
肝脏。
右锁中线、前正中线为描述部位。
腹直肌外缘稍外。
密切配合呼吸运动,吸气时手指上抬速度
落后于腹壁抬起，呼气时手指下压提前于
腹壁下陷。
大量腹水——冲击触诊。
不要误判(腹直肌腱划、肾、胃肠病变)。
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.
√ Normally the liver is not palpable, but
sometimes 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.
Note:
（1）When felt more than 2cm. 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 2cm 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 or even 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.
√ Sometimes 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).
√ unidirectional pulsation is usually a
conductive one(传导性搏动), 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.
√ 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
肝脏触诊判断描述的内容
大小
质地
表面与边缘
压痛
搏动(单向性.扩张性）
摩擦感
肝-颈回流征（hepatojugulor reflux)
u To palpate spleen from umbilicus
to left costal margin
脾 脏 触 诊
手法和体位;
脾脏测量三线法;
脾肿大的鉴别(左侧肾、肝、胰、
结肠);
脾肿大意义。
√ 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 . (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
脾脏肿大的意义
轻度肿大:急慢性肝炎、SBE、败血症、重
症结核、伤寒、急性疟疾等;
中度肿大:肝硬化、慢淋、慢性溶贫、淋巴
瘤、SLE、等;
高度肿大:慢粒、骨髓纤维化、慢性疟疾、
黑热病。
u
To palpate gall bladder
胆 囊 触 诊
胆囊触诊的方法:
必需记住的两个重要体征:
Murphy’s sign
Courvoisier’s sign
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.
√ 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
sign
To check for Murphy’s
√ 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
complaints of pain.
√ The sign indicates the inflammation of
gallbladder.
u
To palpate kidneys bimanually
肾 脏 触 诊
方
法:
尿路感染的5个压痛点:
前3: 季肋点；上、中输尿管 点；
后2: 肋脊点；肋腰点。
√ 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.
关于膀胱触诊
只有尿潴留时才可以触到膀胱；
非常容易与增大子宫、卵巢肿块等
鉴别。
d)
abdominal masses
腹部正常包块
腹直肌肌腹及腱划
腰椎椎体及骶骨岬
乙结肠粪块
横结肠
盲肠
腹部异常包块
位
置
大
小
形
态
质
地
压
痛
搏
动
移 动 度
Fluid wave thrill
(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.
Fluid wave thrill
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, usually 3000-4000 ml. So the fluid
wave thrill is not so sensitive as shifting
dullness.
succussion splash振水音
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.
振水声与液波震颤
液波震颤(fluid wave thrill,fluctuation)
液体震动传向对侧的波动感；敏感
性差于移动性浊音。3000~4000ml。
振水声(succussion splash)
幽门梗阻的特征表现，确诊依据。
空腹6小时以上。
腹部触诊的特殊手法
1.腰大肌试验（iliopsoas test)
2.闭孔内肌试验(obturator maneuver)
3.牵涉性触痛(referred tenderness)
4.结肠充气试验(Rovsing试验)
5.腹主动脉触诊
腹部异常发现及其鉴别
1.腹水
2.腹部肿块
3.肝肿大
4.脾肿大
腹
水
1.病因
心血管系统疾病
肝脏及门脉系统疾病
肾脏疾病
腹膜疾病
营养缺乏
淋巴系统疾病
女性生殖系统疾病
腹腔脏器破裂
其他：黏液性水肿、Meig综合征
发生机制
液体静水压增加
血浆胶体渗透压下降
淋巴回流受阻
肾脏因素
诊断与鉴别
1.确定是否有腹水
2.腹水的类型和病史
病史：
体检：
实验室检查和特殊检查：腹水检
查（渗出液与漏出液）、其他检
查。
渗出液与漏出液鉴别
漏出液
渗出液
外观
清或微浑
浑浊
细胞数
<100106/L
>500106/L
比重
<1.018
>1.018
蛋白定量 <25g/L
>30g/L
SAAD
>11g/L
<11g/L
腹部肿块
常见病因：
炎症性:
肿瘤性：
梗阻性：
先天性：
症状与体征
1.症状：
2.体征：
全身检查：
腹部检查：视、触、叩、听
诊断与鉴别
1.病史资料
2.是否腹部肿块
3.肿块的来源：腹壁内、外。
4.肿块的病理类型：炎症性、肿瘤性、
梗阻性、先天性、
损伤性
腹部包块诊断步骤
腹壁
腹块
普通外科
活检、手术
实质脏器
超声、CT、MRI
空腔脏器
内窥镜、BE、GI
腹腔
肝肿大
病因与发病机制：
1.感染：
2.中毒性、药物性肝炎：
3.瘀血：
4.瘀胆：
5.代谢异常：
6.肿瘤：
7.血液病：
8.其他：免疫损伤
诊断与鉴别
1.病史：
2.体征：程度、质地、表面、触痛、
搏动、肝区摩擦音
3.伴随症状与体征：
4.实验室检查和特殊检查：WBC、肝功、
三对半、肿瘤标记、B超、X线、肝
穿、腹腔镜等。
脾肿大
病因与发病机制：
1.感染性疾病：
病毒感染：
细菌感染：
螺旋体感染：
寄生虫感染：
立克次体感染
2.非感染性疾病：脾瘀血：
血液病：
结缔组织病：
其他：
诊断与鉴别
1.病史：
2.体征：程度、质地、表面、触痛、
搏动、肝区摩擦音
3.伴随症状与体征：贫血、黄疸、肝肿大、
皮肤表现、脾区压痛。
4.实验室检查和特殊检查：血象、肝功、
粪便检查、骨髓检查、病原体分离和免疫
学检查、B超、核素检查、脾穿刺检查等。
Case
A 57-year-old female patient was
admitted on Jan. 20th 2003 because of
“fatigue and anorexia for 2 months,
abdominal swelling and oliguria for half
a month”. Two months before, the
patient began to feel fatigue, decreased
tolerance of physical activities and
anorexia without any identifiable causes.
She used to eat 100g rice every meal,
but now she could only eat 50g. She
also had low fever and felt better after
taking anti-cold medications.
Case
Half a month before, the patient began to feel
abdominal swelling. Her pants’ waist belt
became tight for her. Urine volume decreased
to 500 ml everyday and the color was dark.
Then the patient went to the district hospital
nearby and took the abdominal ultrasound
examination. The result showed she had liver
cirrhosis, splenomegaly, and large volume of
ascites. The patient had acute hepatitis B 20
years ago. During the years after the acute
infection, her liver function was abnormal
intermittently.
Case
She had no habit of smoking and
alcohol. She was married and had one
son and one daughter. Her daughter
and husband were both healthy. Her
son had hepatitis B infection. Her father
died of primary hepatic cancer. Her
mother is still alive.
Case
Physical Examination: T: 37.5C,
BP:16/10KPa, R:18/min, HR: 100/min.
Conscious, hepatic face, mild jaundice of
sclera, liver palm(+), spider angioma on left
neck, no palpation of lymph nodes, lung
auscultation negative, heart (-). Abdominal
findings: obvious abdominal bulge (marked
protuberance of the abdomen), no distention
of abdominal wall veins, soft, no pain, shifting
dullness(+), normal active intestinal sound,
moderate edema of the lower limbs, NS(-).
CLINICAL THINKING
According to the patient’s symptoms, physical signs
and the result of the abdominal ultrasonography, we
confirmed the diagnosis of ascites.
Among the causes of ascites, liver cirrhosis accounts
for 80% while other causes such as cancer, heart
failure, tuberculosis, renal disease and pancreatic
disease account for 20%. Because the patient had
the history of hepatitis B infection and the abdominal
ultrasonography also suggested liver cirrhosis, the
cause for this patient’s ascites was most likely
secondary to liver cirrhosis.
CLINICAL THINKING
To ascertain the cause of ascites is very
important for the diagnosis and treatment of
ascites.
Before we start the treatment, diagnostic
paracentesis is necessary. According to the
analysis of ascites, including routine tests,
biochemical tests, and etiological tests, we
could further verify the cause of ascites and
make differential diagnosis of simple ascites
of liver cirrhosis and ascites of cirrhosis with
spontaneous bacterial peritonitis.
CLINICAL COURSE
Blood test showed WBC 2.3×109/L, RBC
3.5×1012/L,Hb95g/L, BPL45×109/L. Liver
function test showed TB/CB 21/37μmol/L, A/G
32/49g/L, ALT 75U/L, AST 94U/L. Serologic
tests for hepatitis B showed HBsAg(+), antiHBe(+), anti- HBc(+), others(-). A diagnostic
paracentesis was performed on the day of
admission and the analysis of the ascitic fluid
was as follows.
CLINICAL COURSE
Routine tests showed the fluid was clear
in appearance, an absolute RBC count
of 10/μL and a WBC count of 25/μL.
Biochemical tests of the fluid showed
protein concentration of 5g/L，albumin
concentration of 2g/L and gravity of
1.010. Culture for bacteria showed
negative result. Cytology study of the
fluid was also negative.
CLINICAL THINKING
The patient’s blood test showed that the blood counts
were low. This is consistent with the diagnosis of liver
cirrhosis and hypersplenism. The patient’s liver
function test showed a reversed ratio of albumin to
globulin, mild hyperbilinemia and elevated
transaminases. This is also consistent with the
decompensated stage of liver cirrhosis. Serologic
tests in hepatitis B suggested that the cause of liver
cirrhosis was chronic hepatitis B infection. All the
laboratory tests further confirmed the diagnosis of
liver cirrhosis.
CLINICAL THINKING
For this patient with ascites, the most
valuable examination is paracentesis.
Let’s go over the standard in the
differential diagnosis of ascites.
According to the traditional standard,
ascitic fluid can be divided into exudate
or transudate.
CLINICAL THINKING
Transudate is characterized by clear
appearance, protein concentration
<25g/L, gravity <1.018, cell count
<100/μL and negative bacteria culture,
whereas exudate is characterized by
cloudy appearance, protein
concentration >25g/L, gravity >1.018,
cell count >500/μL and often with
positive bacterial culture.
CLINICAL THINKING
Transudate is often caused by liver cirrhosis,
heart failure and renal disease. Exudate is
more often caused by tumor, tuberculosis and
pancreatic disease. The transudate ascitic
fluid could become exudate when
spontaneous bacterial peritonitis occurs. It is
obvious that the analysis of this patient’s
ascitic fluid confirms its classification as
transudate.
CLINICAL THINKING
Serum ascites albumin gradent [(SAAG)
= (32-2)g/L =30g/L(>11g/L)] in this
patient indicated that the ascites was
due to portal hypertension. Therefore,
the diagnosis of liver cirrhosis with
ascites could be confirmed.
Thanks for
Your Attention