11/13/24, 7\:07 PM Guide | Paediatric abdominal exam

Paediatric abdominal exam

Table of contents

Background

A paediatric abdominal examination is often performed as part of the assessment of abdominal pain and/or distension. Care
must always be taken to make sure no undue pain or discomfort is caused to the child. Rapport and trust can be lost very
quickly and further examination might then be impossible.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the parents and the child, including your name and role.
Con
Brie
y o u r c h i l d' s a b d o m e n , w h i c h w i l l i n v o l v e
t h e n ge n t l y f e e l i n g t h e i r t u m m y .
"
Gain consent from the parents/carers and/or child before proceeding\: " A r e y o u h a p p y f o r m e t o c a r r y o u t t h e e x a m i n a t i o n ?"

General inspection

Appearance and behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour\:
Activity/alertness\: note if the child appears alert and engaged, or quiet and listless.
Jaundice\: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g.
breastfeeding related, hypothyroidism, rhesus factor disease).
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. gastrointestinal bleeding, malnutrition).
Weight\: note if the child appears a healthy weight for their age and height.
Syndromic features
Pay attention to features that may indicate the presence of an underlying genetic condition\:
Stature (e.g. tall/short)
Syndromic facial features
See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with gastrointestinal system
pathology.

Equipment

Observe for any equipment in the child's immediate surroundings and consider why this might be relevant to the
gastrointestinal system\:
NG/NJ tube\: often used for bowel obstruction, short bowel syndrome, in
re
Gastrostomy\: typically only used if an NG/NJ is needed for more than 6 weeks (indicative that the child has a chronic
condition).
Colostomy/ileostomy\: often performed in the context of in
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Intravenous lines/drip\: suggests poor oral
Special feeds\: underlying intolerance, gastroesophageal re

Medications

Note any medications by the bedside or in the child's room and consider what underlying diagnoses they may indicate\:
Laxatives\: constipation
Antiemetics\: nausea/vomiting
Pancreatic enzymes\: cystic
Jaundice in a newborn

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspect the hands

General observations
Inspect the hands for clinical signs relevant to the gastrointestinal system\:
Pallor\: may suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).
Peripheral oedema\: associated with nephrotic syndrome (loss of albumin) and liver disease (reduced production of
albumin).
Nail signs
Inspect the nails for any of the following signs\:
Koilonychia\: spoon-shaped nails, associated with iron de
Leukonychia\: whitening of the nail bed, associated with hypoalbuminaemia (e.g. nephrotic syndrome, protein-losing
enteropathy).
Finger clubbing
Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal
angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those
most likely to appear in an abdominal OSCE station include cystic
To assess for
Ask the child to copy you in placing the nails of their index
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In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).
When
If the child is too young for this to be possible, you can simply inspect the
terminal phalanx of the digits.
Koilonychia [7]

Pulse

Radial pulse
Palpate the child's radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
In babies, assess the femoral pulse instead.
Assessing heart rate
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and
multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
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Palpate the radial pulse

Face

Observe the child's facial complexion and features, including their eyes and mouth.

General appearance

Inspect the general appearance of the child's face for signs relevant to the gastrointestinal system\:
Oedema\: associated with hypoalbuminaemia (e.g. protein-losing enteropathy, malnutrition, liver disease).
Pallor\: may suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).

Eyes

Inspect the eyes for signs relevant to the gastrointestinal system\:
Conjunctival pallor\: suggestive of underlying anaemia. Gently pull down their lower eyelid to inspect the conjunctiva.
Scleral jaundice\: a yellowish or greenish pigmentation of the eyes due to high bilirubin levels (e.g. liver disease,
hypothyroidism, rhesus factor disease).
Aniridia (partial or complete absence of the coloured part of the eye)\: associated with WAGR syndrome which also involves
the development of a Wilm’s tumour.
Kayser-Fleischer rings\: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal
copper processing by the liver, resulting in accumulation and deposition in various tissues.
Xanthelasma\: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.

Mouth

Inspect the mouth for signs relevant to the gastrointestinal system (tip – ask the child to see how long their tongue is or how
big their mouth is)\:
Angular stomatitis\: a common in
including iron de
Glossitis\: smooth erythematous enlargement of the tongue associated with iron, B12 and folate de
malabsorption secondary to in
Oral candidiasis\: a fungal infection commonly associated with immunosuppression. It is characterised by
pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.
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Aphthous ulceration\: round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are
typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate
de
Hyperpigmented macules\: pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that
results in the development of polyps in the gastrointestinal tract.
Dental caries\: may be associated with neglect or gastroesophageal re
Macroglossia\: enlargement of the tongue associated with Down's syndrome, hypothyroidism, mucopolysaccharidoses and
Beckwith-Wiedemann syndrome.
Periorbital oedema [5]

Neck

The left supraclavicular lymph node (known as Virchow’s node) receives lymphatic drainage from the abdominal cavity and
therefore enlargement of Virchow’s node can be one of the
right supraclavicular lymph node receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region
can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera).
Palpate for lymphadenopathy
Palpate the supraclavicular fossa on each side, paying particular attention to Virchow’s node on the left for evidence of
lymphadenopathy.
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Palpate for Virchow's node

Close inspection of the abdomen

Ask the parent or child (if appropriate) to expose the child's abdomen.
Position the child lying
subsequent palpation (this is often di
Inspect the child's abdomen for signs suggestive of gastrointestinal pathology\:
Scars\: there are many di
image below for examples).
Abdominal distension\: can be caused by a wide range of pathology including constipation, Hirschsprung's disease, ascites,
organomegaly and malignancy.
Caput medusae\: engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).
Hernias\: observe for any protrusions through the abdominal wall (e.g. umbilical hernia, incisional hernia).
Drains/tubes/stomas\: gastrostomy, central venous catheter, ileostomy and colostomy.
Tip\: The abdomen is normally protuberant in toddlers and young children.
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Umbilical hernia

Examples of scar locations

Number Incision type Associated procedure
1 Kocher’s incision
Biliary surgery (e.g. cholecystectomy)
Hepatic surgery
2 Midline laparotomy (variable length) Fundoplication
Major abdominal surgery
3 Transverse upper abdominal incision
Repair of congenital diaphragmatic hernia
Splenic surgery
4 Pyloromyotomy scar Treatment of pyloric stenosis
5 Grid-Iron incision at McBurney's point Appendicectomy
Hernia repairs
6 Umbilical/sub-umbilical scars
Gastroschisis repair
Exomphalos
7 Point incision marks
Laparoscopy port sites
Drain sites
VP shunts
8 Inguinal incisions
Inguinal hernia repairs
Vascular access scars
9 Lateral thoracolumbar incision Renal surgery (nephrectomy)
10'Hockey-Stick' scar Renal transplant
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Paediatric abdominal scar locations

Examining the abdomen

If appropriate, ask the child what they ate for their last meal and try to ‘
, you’ll have to listen –
leading you to auscultation (sneaky right?)

Preparing to palpate the abdomen

Before beginning abdominal palpation\:
Kneel down and/or raise the bed, your face is level with the child’s face.
Use warm hands.
Relax the child.
Keep the parent close at hand.
Abdominal wall muscles must be relaxed for palpation to be e
hand by their sides. Take away any pillows or cushions.
Expose the abdomen entirely, lowering the trousers and underwear whilst covering the child with a sheet.

Light palpation

Avoid mentioning to word "pain" or "hurt" (e.g. "Is this painful?" "Does that hurt?") when examining young children, as this can
often provoke fear and upset. Instead, observe the child's body language and facial expressions to determine if they are in pain.
Perform light palpation of the nine abdominal regions, whilst looking at the child's face and assessing for rigidity, tenderness,
guarding and palpable masses.
Guarding is suggestive of peritonitis and indicates the need for urgent surgical review.

Deep palpation

Repeat palpation of the nine abdominal regions, this time applying greater pressure to better assess intra-abdominal
structures (continue to observe the child's face for signs of discomfort).
If any masses are identi
Tenderness
Localised in appendicitis (RIF), hepatitis (RUQ) and pyelonephritis (
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Generalised in mesenteric adenitis and peritonitis.
Guarding
Pain on coughing, moving about/walking/bumps during a car journey suggests peritoneal irritation.
A child walking, whilst being
Incorporating play may be used to elicit more subtle guarding\:
" C a n y o u j u m p u p a n d d o w n ?"
- a child will not be able to jump on the spot if they have localised guarding.
" B l o w o u t y o u r t u m m y a s b i g a s y o u c a n , t h e n s u c k i t i n a s f a r a s y o u c a n"
- this will elicit pain if there is peritoneal irritation.
Abnormal masses
Wilm’s tumour typically presents as a renal mass which is sometimes visible and does NOT cross the midline.
Neuroblastoma typically presents as an irregular
Faecal masses are typically mobile, non-tender, indentable and often located in the LIF.
Intussusception typically presents with a palpable mass in the RUQ (most commonly) in the context of an acutely unwell child.
Perform light abdominal palpation

Liver palpation and percussion

Palpate from the right iliac fossa and locate the edge of the liver with the tips or sides of your
deep breaths if appropriate).
The liver edge may be soft or
centimetres the extension of the liver edge below the costal margin in the mid-clavicular line.
Percuss downwards from the right lung to exclude downward displacement due to lung hyperin
Dullness to percussion can help delineate the upper and lower border. Record the span of the liver (in cm).
Tip\: Young children may be more cooperative if you palpate
Causes of hepatomegaly
There are several potential causes of hepatomegaly including\:
Infection\: congenital, infectious mononucleosis, hepatitis, malaria
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Haematological\: sickle cell anaemia, thalassaemia
Malignancy\: leukaemia, lymphoma, neuroblastoma, Wilm's tumour, hepatoblastoma
Metabolic\: glycogen and lipid storage disorders, mucopolysaccharidoses
Cardiovascular\: heart failure
Apparent hepatomegaly\: chest hyper-expansion (e.g. bronchiolitis/asthma)
Inferior margin of the liver and spleen

Splenic palpation and percussion

A palpable spleen is at least TWICE its normal size.
Palpate from the right iliac fossa towards the left upper quadrant (ask the child to take deep breaths if appropriate). The
edge is usually soft and you will be unable to get above it. The splenic notch is occasionally palpable if markedly enlarged.
The spleen should move with respiration.
Measure the degree of extension below the costal margin (in cm) in the mid-clavicular line.
Percuss to delineate the lower border (splenic tissue will be dull to percussion).
Causes of splenomegaly
There are several potential causes of splenomegaly including\:
Infection\: infectious mononucleosis, malaria, leishmaniasis
Haematological\: haemolytic anaemia
Malignancy\: leukaemia, lymphoma
Other\: portal hypertension, Still's disease
Apparent splenomegaly\: chest hyper-expansion (e.g. bronchiolitis/asthma)
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Palpate the spleen

Kidneys

The kidneys are not usually palpable beyond the neonatal period unless they are enlarged or the abdominal muscles are
hypotonic.
Palpate the kidneys by balloting bi-manually in each hypochondrium. You can ‘get above them’ (unlike the spleen or liver)
and tenderness implies in
Causes of kidney enlargement
Unilaterally enlarged\: hydronephrosis, cyst, tumour
Bilaterally enlarged\: hydronephrosis, kidney stones, polycystic kidneys
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Ballot the kidneys

Ascites

Ascites may be present in cirrhosis, hypoalbuminaemia, infection or malignancy.
The presence of shifting dullness is highly suggestive of ascites.
Assessing for shifting dullness
It is usually not possible to formally assess for shifting dullness in young children, due to issues with co-operation. However, in
older children, it may be possible.
1. Percuss from the umbilical region to the child's left
the
2. Whilst keeping your
(towards you for stability).
3. Keep the child on their right side for 30 seconds and then repeat percussion over the same area.
4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).
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Assess for shifting dullness

Auscultation of the abdomen

Start by showing the child your stethoscope and demonstrate it on your own abdomen and/or on one of their toys to
familiarise them with this piece of equipment.
Suggest listening to their abdomen, making sure the stethoscope diaphragm isn't cold prior to it making contact with the
child.
Auscultate over at least two positions on the abdomen to assess bowel sounds\:
Normal bowel sounds\: typically described as gurgling.
Tinkling bowel sounds\: typically associated with bowel obstruction.
Absent bowel sounds\: suggests ileus which is a disruption of the normal propulsive ability of the intestine due to a
malfunction of peristalsis. Causes of ileus include electrolyte abnormalities and recent abdominal surgery. To be able to
con
case in an OSCE given the time restraints).
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Auscultate bowel sounds

Genital examination

A genital examination is often performed routinely in infants and young children, however in older children or teenagers it
should only be performed if relevant (i.e. vaginal discharge, suspicion of inguinal hernia or perineal rash).

Male genital examination

Inspect the genitals to assess penile and scrotal development and to identify any abnormalities\:
Assess for penile abnormalities\: hypospadias, chordee
Assess for descended tests\: with one hand over the inguinal region, palpate the testicles with the other hand (record if testis
descended, retractile or impalpable).
Note any scrotal swelling\: hydrocele, hernia

Female genital examination

Inspect the external genitalia to identify any abnormalities\:
Abnormal discharge\: may be associated with pelvic in

Rectal examination

Not routinely performed and if indicated, it should be performed by a specialist who has experience interpreting
The rectum may be inspected to identify relevant abnormalities\:
Imperforate anus
Anal skin tags (Crohn's)
Anal prolapse
Staining of underwear (may suggest constipation)

Lower limbs

Inspect for pedal oedema\: associated with nephrotic syndrome and liver disease.
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Pitting pedal oedema [15]

To complete the examination...

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