Pediatric abdominal examination
#Sequence of examination
(from Macleod's)
Remove the nappy.
Inspect the abdomen, including the umbilicus and groins, noting any swelling.
From the infant's right side, gently palpate with the flat of your war right hand.
Palpate superficially before feeling for deeper structures.
Palpate for the spleen. In the neonate it enlarges down the left flank rather than the
right iliac fossa.
Palpate for hepatomegaly:
o Place your right hand flat across the abdomen beneath the right costal margin.
o Feel the liver edge against the side of your index finger.
o If you feel more than the liver edge, measure the distance in the mid-clavicular
line from the costal margin to the liver's edge. Describe it in fingerbreadths or
measure it with a tape in centimeters.
Look at the anus to confirm that it is present, patent and in abnormal position
Digital rectal examination is usually unnecessary and could cause an anal fissure.
Indications include suspected rectal atresia or stenosis and delayed passage of
meconium. Put on gloves and lubricate your little finger. Gently press your fingertip
against the anus until you feel the muscle resistance relax and insert your finger up to
your distal interphalangeal joint.
#Normal findings
(from Macleod's)
Distention from a feed or swallowed air is common
You may see the contour of individual bowel loops through the thin anterior
abdominal wall in the newborn, particularly with intestinal obstruction.
The umbilical cord stump usually separates after 4-5 days. A granuloma may appear
later as a moist, pink lump in the base of the umbilicus.
A small amount of bleeding from the umbilicus is common in neonate.
The liver edge is often palpable in healthy infants.
In the neonate the kidneys are often palpable, especially if ballotted.
#Abnormal findings
(from Macleod's)
In excessive bleeding from the umbilicus, check that the infant received vitamin K,
and consider clotting factor XII deficiency.
Spreading erythema around the umbilicus suggests infective omphalitis, and
requires urgent treatment.
Umbilical hernias are common, easily reduced, have very low risk of complication
and close spontaneously in infancy.
An omphalocoele, or exomphalos is a herniation through the umbilicus containing
intestine and other viscera covered by a membrane that includes the umbilical cord.
It may be associated with other malformations or a chromosomal abnormality.
Gastoschisis is a defect in the anterior abdominal wall with intestinal herniated
thought it. There is no covering membrane. The commonest site is above and to the
right of umbilicus.
A hydrocele is a collection of fluid beneath the tunica vaginalis of the testis and/or
the spermatic cord. Most resolve spontaneously in infancy.
Inguinal hernias are common in the newborn, especially in boys and preterm
infants.
Meconium in the nappy does not guarantee that the baby has a patent anus because
meconium can be passed through a recto-vaginal fistula.
#Causes of hepatosplenomegaly
Viral infection: viral hepatitis – HIV
Bacterial infection: brucella – typhoid
Protozoal infection: kala-azar – malaria
Hematological diseases: thalassemia
Malignancy: lymphoma – leukemia
C.T disease
#Causes of massive (huge) splenomegaly
Kala-azar
Myeloid leukemia
Schistomiasis
Gaucher's disease
#Complete abdominal examination
(like that of adult) (OSCE_2010)
1- GETTING READY
Greet the patient respectfully and with kindness.
Explain the procedure to the patient.
Ask the patient or care giver to undress from the nipple line to the mid-thigh,
and cover with a clean sheet. If this is embarrassing, examine the genitalia first
and then cover them before examining the rest of the abdomen.
Wash hands thoroughly and dry them (alternatively use antiseptic gel).
The patient's position: ask the patient to lie flat on his back with the legs
extended. Older children need to flex the hips to 45° and the knees to 90°. (In
very young infants you can examine the infant in the mother’s lap).
2- INSPECTION
Abdominal movements with respiration
Breasts
Pulsations (Epigastric pulsations)
Hernias
Umbilicus
Divercation of recti
Scars or pigmentations
Veins
Visible peristalsis
Genitalia – Tanner stage
3- PALPATION
Stand by the right side of the patient (unless you are left handed)
Make sure that your hand is warm and ask the patient to flex the hips and
knees in order to relax the abdomen. (not needed in very young)
Ask the patient whether there is a painful area or a mass. Always start
palpation in the region diagonally opposite to any lesion or pain, and proceed
systematically to other regions approaching the affected area last of all.
Begin in the left iliac fossa and proceed to left lumbar, left hypochondrium,
epigastrium, umbilical, suprapubic, right iliac fossa, right lumbar and lastly
right hypochondrium. Then palpate more deeply in the same areas.
#Superficial palpation:
Tenderness
Rigidity
Swelling: (relation to diaphragm and if intra or extra abdominal)
Hernia orifices: Examine the anatomical sites of hernia for swelling (repeat while
standing)
Dilated veins: Determine the direction of the flow by placing two fingers on the vein,
sliding one finger along the vein to empty it and then releasing one finger
#Deep palpation:
A. Palpation of the liver:
Place your right hand on the right iliac fossa (MCL) resting transversely parallel to
the costal margin
Ask the patient to take a deep breath.
Keep your hand still during inspiration
As the patient to expire, slide the hand a little nearer to the right costal margin till you
palpate lower border of the right lobe of the liver.
Put your hand in the midline and repeat the above steps till you palpate the lower
border of the left lobe of the liver.
Percussion is done to get the upper border of the liver.
Record the findings:
o The degree of enlargement (span in cm between upper and lower borders in MCL)
o The character of the border (sharp or rounded).
o The surface (smooth or nodular)
o The consistency(soft like a lip, firm like a nose, hard like a bone or heterogeneous)
o The presence of pulsations
o The presence of tenderness
o Hepato-jugular (abdomino-jugular) reflux
B. Palpation of the spleen:
Start palpation from the right iliac fossa with the tips of you hand directed towards the
left axilla, and moving toward the left hypochondrium until you feel the spleen
Record the findings:
o The consistency
o The degree and direction of enlargement
o The character of the border (sharp or rounded), the presence of notch
o The surface (smooth or nodular)
o Tenderness
C. Palpation of the kidneys:
1- Bimanual palpation of both kidneys
Put your hand behind the patient's loin
Lift the loin and the kidney forward.
Put the other hand on the lumbar region and ask the patient to take a deep breath.
During expiration push your hand deeply but gently and keep it still during inspiration
Repeat as the patient takes his breath.
2- Ballottement is done to confirm renal origin of a swelling (by pushing renal angle
upwards, and palpate the kidney by the other hand
D. Palpate for other Abdominal Swellings:
Differentiate intra-abdominal from parietal swellings:
o Relation to the costal margin.
o Behavior on contraction of the abdomen.
4- PERCUSSION:
Rub your hands together and warm them up before placing them on the patient
Percuss for ascites and over any masses.
In the abdomen only light percussion is necessary.
Start from resonant to dull in the midline
A. Percussion of the liver (span of the liver):
Determine the upper border of the liver by heavy percussion starting from the 2nd
intercostal space opposite the sternocostal junction
Percuss down along each inter-costal space in the MCL and when you reach the dullness
ask the patient to take a deep breath and hold it
Percuss again, ((tidal percussion), if it became resonant this will denote infra
diaphragmatic cause (liver). If it remain dull, this will denote supra diaphragmatic
cause(pleural effusion)
Measure the distance between the upper border (by percussion) and lower border (by
palpation) in the right mid- clavicular line, this is the span of the liver.
B. Percussion of the Spleen:
Percussion of the Traube space {Area defined by the anatomical apex (5th ICS in MCL),
left sixth and eighth ribs superiorly, the left midaxillary line (9th, 10th&11th ICS)
laterally, and the left costal margin inferiorly}.
If Traube area is dull: the spleen may be enlarged, full stomach, pulmonary or pleural
disease or cardiac dullness.
C. Percussion for Ascites (Shifting Dullness)
Instruct the patient to lie in the supine position
Place your fingers parallel to the flanks. Start percussion from the region of the umbilicus
down to the flank till you elicit a dull tone.
On detecting dullness, ask the patient to turn to the opposite side, while keeping the
examining hand over the exact site of dullness. Keep your hand in position till the patient
rests on the opposite side. Repeat percussion; if the flank returns a resonant note and
percussion at the umbilicus returns a dull note, that indicates the presence of moderate
free ascites.
Testing for MINIMAL ascites in the knee elbow position: (If shifting dullness is negative)
Percuss around the umbilicus while the patient is kneeling in the knee-elbow position.
In case of MASSIVE ascites:
Detect ascites by FLUID THRILL - Detect organomegaly
by DIPPING method
5- AUSCULTATION: for intestinal sounds
It is performed before percussion or palpation as vigorously touching the abdomen
may disturb the intestines, perhaps artificially altering their activity and thus bowel
sounds.
Exam is made by gently placing the pre-warmed (accomplished by rubbing the
stethoscope against the front of your shirt) diaphragm on the abdomen and listening
for 15 or 20 seconds. Practice listening in each of the four quadrants. Normally,
peristaltic sounds are heard every 10 to 30 seconds. Comment on presence intestinal
sounds
6- EXAMINATION OF THE BACK
Ask the patient to sit
Inspect for any swellings, deformities or scars
Palpate for edema over the sacrum
Palpate for tenderness over vertebrae
7- EXAMINATION OF GENITALIA AFTER PERMISSION