Mobile voiced

Introduction When the examination is performed, the patient is placed on his back and the patient is examined from the middle to the left side. When the voiced sound is found, the plate is not moved, and the patient is placed on the right side of the patient for further examination. If the drum sound indicates that the voiced sound moves. This phenomenon in which the voiced area moves due to the change in body position is called "moving voiced sound". Movable voiced sound is the result of the loss of homeostasis in the production and absorption of fluid in the peritoneal cavity. The formation mechanism of ascites in each disease is caused by several factors combined or alone. When there is more liquid in the abdominal cavity (about 1000ml or more), the gravity fluid accumulates in the lower part of the abdominal cavity, so the percussion is voiced.

Cause

(1) Plasma colloid osmotic pressure reduction:

Plasma colloid osmotic pressure mainly relies on albumin to maintain plasma albumin below 25g / L or accompanied by portal hypertension, liquid easily leaked from the capillary into the interstitial space and abdominal cavity, if the water leaked into the abdominal cavity to form ascites. This condition can be seen in severe hepatic insufficiency, intermediate cirrhosis (reduced protein synthesis), nutritional deficiencies (insufficient protein intake), nephrotic syndrome and protein-losing enteropathy.

(2) Sodium water retention:

Common in heart and kidney dysfunction and advanced cirrhosis with secondary aldosteronism. In cirrhosis and right heart failure, the decrease in the activity of the natriuretic factor increases the reabsorption of sodium by the renal proximal tubules. In recent years, it is considered that the sodium reabsorption mechanism of the proximal convoluted tubule is more important than the action of aldosterone on the distal convoluted tubule.

(3) Endocrine disorders:

When liver cirrhosis or liver dysfunction, liver degradation is reduced. On the one hand, the inactivation function of antidiuretic hormone and aldosterone reduces sodium and water retention. On the other hand, the concentration of some vasodilators in the blood circulation is increased. These substances cause the peripheral and visceral arteriolar resistance to decrease, the cardiac output increases, and the internal organs are in a high power circulation state. Due to visceral vasodilation, visceral congestion, resulting in a relatively low circulating blood volume and hypotension, the body compensates for angiotensin and norepinephrine to maintain blood pressure. This causes the sympathetic nervous system to release some vasoconstrictor substances, which reduces the renal blood flow and reduces the glomerular filtration rate. In addition, the release of vasopressin causes the renal tubular sodium and water absorption to increase, resulting in sodium retention. Form ascites.

an examination

Related inspection

Abdominal percussion endocrine function test

an examination:

The doctor stands on the right side of the patient, starting from the umbilicus, and escaping to the left side of the umbilical plane to the left side, directly to the left iliac crest muscle edge, such as percussion becomes voiced, the percussive plate finger position is fixed (without leaving the skin), the patient is In the right lateral position, re-examine the place and listen to the tone for changes. Then move the percussion to the right side, directly to the voiced area, the percussive plate refers to the fixed position, and the patient turns to the left side for the left lateral position, and then palpates again to hear the change of the tone.

Differential diagnosis

Differential diagnosis of symptoms that are confusing with mobile dullness:

First, you need to identify the different causes of mobile voiced:

1. Increased portal pressure: normal sinus pressure is very low (0-2mmHg), when the portal hypertension is high, the sinus hydrostatic pressure is increased (door pressure lommHg, which is the basic condition for the formation of peritoneal effusion), a large amount of liquid flows to the Disse gap , causing excessive liver lymph production. Patients with cirrhosis are often 20 times more likely than normal people. When the thoracic duct can not drain too much lymph, the peritoneal cavity is directly leaked from the liver capsule to form ascites. Elevated sinusoidal pressure can also cause activation of intrahepatic pressure receptors, reduce renal excretion of sodium through liver and kidney reflexes, and aggravate sodium and water retention.

2. Visceral artery dilatation: In the early stage of cirrhosis, visceral blood vessels dilate, and the effective blood volume is maintained in the normal range by increasing cardiac output and heart rate. In the advanced stage of cirrhosis, visceral artery dilatation is more obvious, resulting in a significant decrease in effective arterial circulation blood volume, decreased arterial pressure, and thus activation of the sympathetic nervous system, renin-angiotensin-aldosterone system, and increased release of vasopressin (ADH) to maintain Arterial pressure, causing renal vasoconstriction and sodium retention. Portal hypertension interacts with visceral vasodilation, altering the capillary pressure and permeability of the intestine, facilitating the accumulation of fluid in the abdominal cavity.

3. Plasma colloid osmotic pressure decreased: the intake of liver cirrhosis patients decreased, the liver reserve function decreased, the ability to synthesize albumin decreased, resulting in a decrease in plasma albumin, and thus the plasma colloid osmotic pressure decreased, a large amount of liquid entered the interstitial space, forming a peritoneal cavity product. liquid.

4. Other factors: relative lack of plasma central sodium and decreased sensitivity of the body, decreased estrogen inactivation, decreased drainage dysfunction caused by increased secretion of antidiuretic hormone and decreased prostaglandin secretion, resulting in renal vasoconstriction, decreased renal perfusion The redistribution of renal blood flow is related to the formation and persistence of peritoneal effusion.

2. TCM syndrome differentiation and treatment of mobile dullness:

1. Qi stagnation and blood stasis syndrome: abdominal swelling is full, ribs attack pain, or pain such as acupuncture, irritability, dark complexion, skin is not honorable, dark purple tongue or freckle, sputum, pulse astringent. Regulating qi and dissipating phlegm and diminishing water.

2. Spleen deficiency qi stagnation: ascites swell, under the fullness or pain under the threat, diet reduced, swollen after eating, discomfort discomfort, sputum uncomfortable, short urine, pale tongue, white, pulse string. Regulate qi and spleen, and benefit the water.

3. Cold and dampness syndrome: a large abdominal fullness, according to the water wrapped in the sac, even the face is slightly floating, the lower limbs are swollen, the abdomen is swollen, the heat is slightly comfortable, the spirit is sleepy, the cold is lazy, the urine is short, The stool is thin, the tongue is greasy, and the pulse is slow. Dispelling cold and dehumidification, diuresis and swelling.

4. Damp heat spleen syndrome: ascites is full, abdominal swell, irritability, bitterness, thirst, no drink, short yellow urine, constipation or stagnant, red tongue, yellow greasy moss or grayish black, pulse The number of slides. Clearing away heat and dampness, and diminishing water.

5. Spleen heat syndrome: anxious ascites fullness, suddenly a lot of vomiting blood, blood, hot thirst, red tongue, yellow greasy moss or gray, pulse number. Clearing the spleen, releasing heat and detoxifying, diluting water and swelling.

6. Liver and spleen and blood stasis syndrome: Ascites is full, the venous anger is violent, the two threats are tingling, the complexion is dark, the neck and chest are bloody, silky red sputum, the palm is red, the lip color is purple, but the water is not desired. Pharynx, black stool, dark purple tongue, fine veins or sputum. Promote blood circulation, qi and water.

7. Spleen and kidney yang deficiency syndrome: bloating has water, squatting, sullen, pale, pale, stunned, tired, cold, cold, cold, or lower limbs edema, low urine, unfavorable, thin stool, tongue Light fat, white moss, and weak pulse. Warming the spleen and kidney, turning off the gas and water.

8. Liver and kidney yin deficiency syndrome: abdomen with water, blue veins exposed, complexion, stagnation, lip purple, dry mouth, dry throat, upset, insomnia, bleeding gums, nose, shortness of urine, red tongue, less moss Jin, the pulse string is fine. Nourish liver and kidney, qi and water.

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