Contents
Below is a brief summary of what to check for in a paediatric abdominal examination. For a detailed explanation of these features, and for adult abdominal examination, please see the abdominal examination article.
General inspection
Get the child to take their top off
Look around the bed for:
- Medications
- Drip
- Special dietary requirements
- Stool sample pot
Look at the patient for:
- Obvious signs of illness
Abdomen:
- The 5 ‘Fs’ (only 4 apply in children! – Fat, faeces, flatus, fluid (+ fetus)
- Scars
- Bruising
- Stoma
- Mass / discolouration (e.g. in Pancreatitis:)
- Grey-Truner’s sign – discolouration in the flank
- Cullen’s sign – discolouration around the umbilicus
- Obvious movements e.g.: Pyloric stenosis – sometimes you can see a peristaltic movement from left to right, particularly after a feed
Hands
- Leukonychia – white nails – hypoalbuminaemia (liver failure)
- Koilonychia – spoon shaped nails – iron deficiency anaemia
- Polished nails – sign of scratching – rash (e.g. jaundice)
- Clubbing – Crohn’s, UC, coeliac’s
- Beau’s lines – horizontal white lines – caused by any acute severe illness – grow out in 12 weeks
- Asterixis – high levels of urea – liver failure
- Dupytrens contracture – idiopathic / liver failure
- Bruising – liver failure / vitamin K deficiency (in neonates)
Face
Mouth
- Ulceration – Crohn’s
- Angular stomatitis – iron deficiency anaemia
- Gum hypertrophy – leukaemia, scurvy, anti-epileptics (phenytoin)
- Glossitis – big red smooth tongue – iron deficiency anaemia / B12 deficiency
- Candida – immunodeficiency (AIDs, leukaemia)
- Freckling around the mouth – Putz-Jehger’s syndrome – associated with polyps in the bowel. High risk of cancer / obstruction
Eyes
- Yellow sclera – jaundice
- Pale conjunctiva – anaemia
- Keyser-Fleischer rings – Wilson’s disease (mean age of presentation 6-20)
- Xanthelasma – Hyperlipidaemia (can be inherited in an autosomal dominant fashion but unlikely to present in children)
- Corneal arcus – cholesterol deposits
Abdomen
Inspect if you didn’t earlier
Palpation
Palpation
- Palpate all 9 areas
- Look at the patients face for signs of pain as you palpate
- Abdo pain in children
- Many causes!
- Classical signs of appendicitis may / may not be present if there is appendicitis.
- Pain tends to be less localised than in adults
- Superficial palpation first
- Then deep palpation
- Faeces?
- Other masses?
- Size / placement of the liver
- In children it is likely to be up to 2 fingers palpable. This is normal, and prevalence of this decreases with age
- Technique same as adult
- Size / placement of the spleen
- Same technique as adult
- Tipping for the spleen – ask the patient to lie on their right hand side, and bring their left knee towards their chest. Put their left hand on your left shoulder, and ask them to take a deep breath in, as you feel under the costal margin. You might just feel the edge of the spleen.
- Traube’s note – percussion at the 9th intercostals space at the mid-axillary line – normally resonant, but in splenic enlargement, becomes dull
- Ballot for the kidneys
- Gallbaldder – not usually palpable. If painful and palpable, then not gallstones!
Percussion
- Size of the liver
- Shifting dullness
Auscultation
Listen 2cm above the umbilicus
- Should be able to hear any renal artery bruits if present
- Should be able to hear bowel sounds
- Normal bowel sounds – aka borborygmi occur at least every 2-3 minutes
- High pitched, tinkling bowel sounds – obstruction
- Absent bowel sounds – peritonitis
Causes of Hepatomegaly in children
- Herpes infection including CMV and EBV
- Leukaemia
- Lymphoma
- Congestive cardiac failure – possibly due to congenital heart defects
- Infection –toxins / sepsis
- Drugs –eg. Anti-tuberculosis drugs
- Hepatitis
- Metabolic disorders
- TORCH infections – these are usually referred to as infections of the pregnant mother which can cause congenital defects: Toxoplasmosis, Other (syphilis, Hepatitis B, HIV), Rubella, Cytomegalovirus, Herpes
Causes of splenomegaly in children
10% of neonates will have a palpable spleen normally
- TORCH Infections
- Sepsis
- Haemolytic anaemias (rare)
- Juvenile Rheumatoid arthritis (rare)
Finishing off
- Check external genitalia / hernia orifices– e.g. testicular atrophy in liver disease, hernias
- Do a PR – lumps, constipation, bleeding, lesions – Rarely performed in children, but may be indicated in some cases
- Ankle oedema – liver failure
- Urine dipstick – renal failure, diabetes, infection
- COVER UP THE PATIENT AND THANK THEM!