Technique for determining liver size using Kurlov. Palpation and percussion of the liver: technique, interpretation. The liver performs many vital functions

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

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

The liver performs many vital functions:

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

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

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

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

Kurlov method

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

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

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

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

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

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

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

In children

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

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

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

The table below shows the normal liver size in children:

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

Percussion

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

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

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

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

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

Palpation

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

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

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

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

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

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

Diseases with changes in liver size

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

Lowering the upper diaphragm is possible in the following cases:

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

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

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Methodology:

Percussion dimensions of the liver according to Kurlov determined using topographic percussion using the following anatomical landmarks: the right midclavicular line, the anterior midline and the left costal arch.

The pessimeter finger is placed parallel to the liver border. They percussion from a clear (tympanic) sound to a dull one, using quiet percussion blows. After each pair of percussion blows, the pessimeter finger is shifted by 0.5-1 cm. The found boundary is marked along the edge of the pessimeter finger facing the direction of the clear sound.

First liver size– this is the distance between its upper and lower borders along the right midclavicular line.

The upper border is found by percussion along the chest along the right mid-clavicular line in the direction from top to bottom.

The lower limit is by percussion along the abdomen along the right midclavicular line from the level of the pectineal line from bottom to top.

In this case, the finger-pessimeter is placed horizontally, parallel to the desired border of the liver.

The found boundaries are marked with a dermograph on the skin and the distance between them is measured.

Normally, the first size of the liver is 8–10 cm.

Second liver size is the distance between its upper and lower borders along the anterior midline.

When the second size of the liver is found, the upper limit is not determined by percussion due to the close location of cardiac dullness.

As a conditional upper border, use the point formed by the intersection of the anterior midline and the perpendicular lowered onto it from the point corresponding to the upper border of the liver along the right midclavicular line. The found point on the sternum is marked with a dermograph.

The pessimeter finger is placed at the level of the navel across the anterior midline and percussed along it in the direction of the xiphoid process until the border of the transition of tympanitis into a dull sound is detected. The point is marked with a dermograph.

The distance from the found lower boundary to the conditional upper boundary is measured.

Normally, the second size of the liver is 7–9 cm.

Third liver size– this is the distance from the conditional upper border of the liver on the anterior midline (see point 4) to the lower border along the left costal arch.

The pessimeter finger with the middle phalanx is placed on the left costal arch in a direction perpendicular to it. Maintaining this position of the pessimeter finger, they percussion along the costal arch from the midclavicular line in the direction of the xiphoid process until a dull sound appears. The resulting point is marked with a dermograph.

After this, measure the distance from the found border to the conditional upper border along the anterior midline.

Normally, the third size of the liver is 6–8 cm.

The obtained data is recorded in the medical history as follows: liver dimensions according to Kurlov are 10 – 9 – 8 cm.

In the human body, located in the lower right zone of the chest. The organ performs many functions, filters out harmful substances, and maintains the stability of the intraorganismal system. Used for diagnostic purposes, liver percussion makes it possible to indicate the size of the organ, which is important for assessing the quality of functioning of the liver tissue. This diagnostic method helps to identify certain diseases at an early stage without additional research.

Why is percussion performed?

In the lower part, the liver has two edges - diaphragmatic and visceral. The upper edge of the organ is limited by the parasternal, midline and mammillary lines. But changes in the structure of the gland are judged mainly by the deformation of the lower edge.

In the human body, the liver:

• participates in metabolism;
• eliminates toxic accumulations;
• produces bile;
• prevents the development of tumors.

Liver pathologies at the initial stage are often completely asymptomatic, and there are no structural changes in the cells of the organ. But when the diseased gland begins to enlarge, pain occurs due to tissue stretching.

The edge of the filtration organ at the top reaches the cartilage of the fifth right rib, where it is closed by the diaphragm, and the sixth left rib. The edge of the gland below in a healthy state should not protrude beyond the costal arch, and on the left side it should not extend beyond the cartilaginous base of the seventh and eighth ribs. Relative to the midline, the edge is located between the upper and central third of the distance from the navel to the xiphoid sternal process. Relative to the costal arch on the left - along the border of the sternum.

The weight of an adult organ is not the same in people of different builds. Also, the mass changes significantly in various pathologies. Most often, the liver becomes swollen and becomes heavier during hepatitis of an infectious nature and in the initial stages of cirrhosis caused by alcohol abuse.

Healthy adult liver:

• about 28 cm wide;
• in height along the right lobe - up to 20 cm;
• in height along the left lobe - 15 cm.

What diseases cause changes in the size of the liver?

The upper hepatic margin changes with:

• neoplasm;
• pleurisy caused by cirrhosis;
• pathological change in the diaphragm;
• purulent formation under the diaphragm;
• pulmonary emphysema;
• splanchnoptosis;
• pneumothorax.

The lower edge of the liver rises with advanced cirrhosis, hepatic dystrophy, ascites. Occurs with hepatitis, heart failure, malignant neoplasms of the organ.

The attending physician cannot make an accurate diagnosis of a patient who is worried about one of the most important human organs - the liver, and prescribe effective treatment therapy without examination results. Patients are usually prescribed the following research methods:

• blood test - both general and biochemical;
• instrumental types of research;
• liver percussion using the Kurlov method.

The first two types of research are probably known to everyone, but only a few know what the Kurlov method is based on, and in which case palpation or percussion of the liver is used. What this type of research is, which doctors use in the early stages of the disease, we will analyze further in the article.

How does the analyzed technique work?

Unfortunately, the disease that affects hepatocytes occurs with virtually no symptoms at an early stage. That is, a person may not experience any unpleasant symptoms, but at this time the disease will begin to manifest its negative effects. Pain will make itself felt in both children and adults only after the size of the liver increases, therefore, the capsule of the internal organ stretches. For example, viral hepatitis has a long incubation period - up to six months. During this time, the disease may not manifest itself at all, but pathological changes inside the liver tissue will occur, and at a rapid pace.

Using instrumental techniques, it is quite problematic to identify the disease at an early stage of development, but palpation of the liver allows the doctor to confirm that the lesion has begun its detrimental development. This method does not require much time and is accessible to all patients without exception. After percussion, the attending physician prescribes a comprehensive diagnosis and, based on the results obtained, treatment therapy individually selected for each patient.

Percussion of the internal organs is considered an important diagnostic test, which helps to determine both the border of the liver and the presence of structural internal abnormalities. In addition, this type of research gives an idea of ​​the size of the liver and the correct location of the internal organ.

One of the founders of effective research is Kurlov, a domestic scientist who made a great contribution to the development of the percussion examination mechanism.

How does liver palpation occur?

Each internal human organ has a different density, this has long been proven by doctors. Using a percussion examination mechanism based on finger tapping, the doctor reacts to sound phenomena to check whether the density of human internal organs is normal. If the norm of sound manifestations is rejected, the patient is immediately prescribed additional types of examinations, since this moment proves that the disease has begun its negative impact and is rapidly developing.

The analyzed technique was proposed in the 18th century, but, unfortunately, liver percussion was used only a century later. Currently, this type of research is considered one of the most reliable among the numerous methods of primary surveys.

In medicine, palpation is divided into 2 types:

1. The direct view is based on finger tapping on both the patient's abdomen and chest.
2. Performing a mediocre research method, the doctor uses special plates, tapping them on a plessimeter. During the examination, the amplitude of tapping also changes, which makes it possible to find out the state of the human internal organs, located at a depth of 5 to 7.5 cm.

With any type of palpation, attention is paid to the thickness of the walls of the abdominal cavity, the presence of free liquid or gas, since these manifestations can change the results of the research.

Size limits and standards

When percussing the liver, a dull sound indicator is considered to be the norm, since the internal organ has a dense structure and contains air inside.

The Kurlov method is based on the use of 5 points that display the boundaries of the liver:

• the lower part of the 5th rib is the border of the 1st point;
• the edge of the 2nd point is the level of the costal arch relative to the clavicular line;
• norm of the 3rd point – boundary 1;
• the 4th point should be located between the center of the navel and the location of the xiphoid process;
• the last border of the 5th point is the middle of the line of the left costal arch.

After the boundaries of all points have been determined, the doctor can take measurements and compare the data with the results shown in the table.

The table shows the normal size of the liver - both in children and adults:

• the norm for the size of the upper and lower boundaries in adults should not exceed 10 cm, in children – 7 cm;
• the normal size of the 3rd line relative to the midline of the clavicle in adults is 8 cm, in children – 6 cm;
• oblique, the last size, diagonally from the top line to the bottom line, normally 7 cm for an adult, 5 cm for children.

After the doctor performs percussion, it is recommended to perform another effective study called “palpation”. Using this technique, in medical institutions, attending physicians are able to determine the shape of the lower part of the liver, find out whether there are seals on the organ, and find out its consistency.

The liver is one of the largest human organs. There are certain standards that it must meet depending on the gender and age of the person. Any deviation from these indicators is the first signal that it is not working correctly. Let's consider what liver sizes are normal and what it means if the diagnosis reveals that the organ does not meet the norms.

The most optimal examination method is ultrasound. Ultrasound allows you to fully study the boundaries and structure of the organ. The specialist takes into account the fact that the size of the liver can fluctuate within a certain range depending on the gender and age of the patient.

Ultrasound diagnostics are permitted for patients of all age categories and have no contraindications. Ultrasound is indicated when the patient complains of pain, discomfort in the right hypochondrium, in the presence of diseases (for example, cirrhosis, hepatitis) to determine the progression of the pathology.

An ultrasound examination is prescribed in the presence of symptoms such as:

• aching pain, a feeling of heaviness in the liver area;
• nausea;
• vomit;
• a feeling of bitterness in the mouth;
• lack of appetite;
• yellowness of the skin, mucous membranes, sclera of the eyes.

The procedure is fairly quick, painless and does not cause the patient any discomfort. In most cases, ultrasound is performed with the patient on the couch in a supine position. If necessary, for a more detailed examination, the doctor may ask the patient to change position.

A special gel is applied to the area to be examined, and then the doctor conducts an examination using an ultrasound probe. An ultrasound sensor emits sound waves of a certain frequency and strength. Visualization occurs on a computer monitor.

The location of the liver allows us to examine the organ in as much detail and in an accessible form as possible. However, it is impossible for a doctor performing an ultrasound procedure to immediately visualize the entire liver at once due to its large dimensions. Therefore, the doctor takes several slices of images to create a single picture. Using ultrasound, it is possible to determine the contour of an organ, its size, shape, and structure.

The caudal lobe, quadrate lobe and their segments are examined in as much detail as possible. Using this diagnostic technique, existing pathologies are identified.

When diagnosing a patient using ultrasound, the following indicators are determined:

• vertical size (VSD);
• vertical oblique dimension (VSR);
• thickness;
• length;
• elasticity;
• echogenicity.

Doctors note that the main result and diagnosis is made on the basis of data on the vertical oblique size, especially in relation to the right lobe of the liver. Normally it should not exceed 150 mm. If this indicator is increased, there is a high probability of hepatomegaly (poisoning by poison or toxic waste). Deciphering this data is very important for further diagnosing the patient.

During ultrasound diagnostics, a specialist determines the density of the organ (echogenicity). Overestimated or underestimated values ​​are another sign of serious pathology. If data on liver size have a certain error depending on the age and weight of the patient, then these parameters do not have any effect on echogenicity.

Normal values

As you know, the liver is one of the largest unpaired organs. Normally, for an adult (male), it can weigh up to 1.6 kg. Women weigh slightly less - about 1.3 kg. A healthy organ has a clear contour, a pointed edge, and a smooth, even structure.

Functions of the organ

The liver performs the following functions:

The liver performs extremely active work every day. It is extremely important to monitor its operation, as well as the overall condition of the organ, since the risk of failure is high. It is worth familiarizing yourself with the normal sizes for an adult (Table 1) and for a child (Table 2).

Table 1 - Normal indicators for an adult

Experts note that women have slightly different organ sizes compared to men. Men have larger livers.

Table 2 - Optimal liver sizes for children

Research according to Kurlov

When diagnosing, a method for determining the size of an organ according to Kurlov can be used. A doctor of medical sciences suggested determining the size by visually dividing the organ with borders and points:

1. 1 border. It is determined from the upper region of the organ to the lower edge of the fifth rib.
2. 2 border. It is determined from the lower edge of the liver (in the region of the costal arch) to the midline of the clavicle.
3. 3 border. From level 1 border to the midline.
4. 4 border. It is determined at the level of the uppermost border of the organ to the middle third (in the navel area).

According to the distribution of the liver along these boundaries, the specialist identifies the true size of the organ. According to Kurlov’s method, the right lobe in an adult has a size from 9 to 11 cm (determined by the distance of the first and second boundaries), and the left lobe – from 7 to 8 cm (borders 3 and 4).

Why do changes occur?

A change in the size of the organ is a direct signal that there are liver pathologies. If the overall size of the organ does not correspond to acceptable values, then we may be talking about a progressive inflammatory process.

It can be caused by various diseases, such as hepatitis, fibrosis or cirrhosis. Also, such a violation may indicate stagnant processes. If a deviation from the norm is observed in only one lobe of the organ, this may mean the presence of a tumor, growing metastases of cancer or a cyst.

However, liver enlargement is not always caused by any disease. Often such a violation is observed with uncontrolled consumption of medications, as well as with bad habits (and not only with a special love for alcoholic beverages, but also for cigarettes). But this is only possible if, with liver enlargement, the structure of the organ does not change and remains smooth and even.

Enlargement of the organ and detection of fibrous tissue is the most likely sign of a severe inflammatory process. Moreover, it is accompanied by unevenness and heterogeneity of the surface, changes in structure, and the appearance of uncharacteristic spots.

Opinions and reviews of specialists and patients

According to statistics from diagnostic centers, the liver is one of the most frequently examined organs using ultrasound. Let's consider the opinions of specialists and patients regarding this procedure:

Elena, St. Petersburg:“The attending physician sent me for an ultrasound, which showed the results of the borders of the liver with very strange indicators. The left lobe is determined to be 54 mm in size, and the right lobe is 98 mm. The surface is homogeneous, smooth, the contour is clear, the bile ducts are not dilated. The only thing is that the echogenicity is slightly increased. The concern was that 3 years ago I had an ultrasound, and the dimensions were much larger - the right lobe was 130 mm!

The first thought is cirrhosis at the progression stage. The doctor sent me for a second examination, reassuring me that errors were possible during the ultrasound. He also prescribed fibroscan diagnostics. As a result, it turned out that in fact the first results were false, but this time they revealed fibrosis of the 1st degree. The doctor noted that the pathology was detected at an early stage and is quite treatable.

My conclusion is this: if the examination results look incorrect, it is better to undergo a re-examination. However, in any case, modern equipment is not capable of producing a global error. If a deviation from the norm is noted (even taking into account the error of the research methodology), there is a high probability of pathologies.”

Harutyunyan K.V., hepatologist:“When performing an ultrasound, it is important to take into account not only the data obtained on the size of the organ, but also compare it with the height, weight and gender of the patient. For example, I had a case in my practice where an ultrasound showed a CVR of 155 mm. If you look at the table indicating normal indicators, then this value is perceived as an excess.

However, the patient’s height was 195 cm. And it is for him that such indicators are normal. Experts have come to the conclusion that for patients with a height of within two meters, values ​​up to 160 mm can be considered normal. Therefore, you should not diagnose yourself when reading the results of a liver ultrasound. This should only be done by a doctor. There is always the possibility of individual deviations from the norm.”

Panfilov K.V., doctor:“Ultrasound diagnostics is a mandatory procedure for identifying liver pathologies. Ultrasound allows you to most accurately determine the boundaries of an organ, its size, and structure. If the results of the study indicate deviations from the norm, this is the first signal of the presence of pathology.

It is important to determine whether the entire liver is enlarged or just one of its lobes. If there is a discrepancy between the size of both lobes, such a violation may be associated with serious diseases, such as hepatitis or cirrhosis. If only one lobe has undergone changes, then the risk of cancer is high. It could be a benign tumor, a cyst or cancer.”

Kondratyeva T.V., doctor:“The norms for liver size are associated with the patient’s gender, weight and height. However, when diagnosing children using ultrasound, it is important to remember that in this case the question of gender and age is not relevant. Children develop differently: one child may weigh 8 kg at one year of age, while another may weigh 13 kg.

In addition, girls often grow more actively than boys. And this clearly contradicts the statement that in the male body the liver is larger than in the female. When it comes to ultrasound diagnostics of children, it is important to compare the obtained research indicators only with the physical development of the young patient. Table standards in this case are not always relevant.”

The size of an organ has a direct bearing on its condition. When it comes to diagnosing the liver, minor deviations from the norm are acceptable due to the individual characteristics of the patient.

However, if the boundaries of the organ go beyond what is acceptable, the problem may be the presence of pathology. This may be due to drug poisoning, cancer, or actively spreading metastases. In any case, only a specialist should diagnose the patient and interpret the results.