Paediatric Abdominal Examination
A paediatric abdominal examination is a key part of assessing a child with gastrointestinal or urinary issues. A structured, gentle, and systematic approach is essential to avoid causing distress and to elicit accurate findings. The exam should start with a broad, top-to-toe assessment before focusing on the abdomen.
General Examination
Begin by observing the child from the end of the bed.
Overall Well-being: Note if the child appears well or ill, pale, or jaundiced. Plot their weight, height, and head circumference on a growth chart, as failure to thrive is a key indicator of chronic GI disease.
Signs of Systemic Disease:
Skin: Look for rashes (e.g., in dermatitis herpetiformis associated with coeliac disease) and oedema (e.g., in malnutrition or renal disease).
Mouth: Inspect for ulcers, which can be a sign of inflammatory bowel disease (IBD).
Hands: Check for clubbing of the fingers, a sign of chronic disease, and for palmar erythema or leukonychia, which can suggest chronic liver disease.
Lymph Nodes: Palpate for lymphadenopathy, especially in the cervical region.
Focused Abdominal Examination
The abdominal exam should follow the order of inspection, auscultation, percussion, and palpation.
Inspection
Abdominal Contour: Observe the abdomen for distension. A “lax belly” can be seen in chronic malabsorption. Visible peristalsis in an infant can be a sign of obstruction, such as in pyloric stenosis.
Skin: Look for any scars from previous surgery, such as a gastrostomy or bowel resection. Note any dilated veins (caput medusae), which can indicate portal hypertension.
Hernial Sites: Inspect the inguinal and umbilical regions for hernias.
Perineum: Examine for rashes or tags, which can be seen in IBD.
Auscultation
Bowel Sounds: Listen for bowel sounds in all four quadrants.
Hyperactive bowel sounds may suggest an obstruction.
Absent bowel sounds are a red flag for a paralytic ileus.
Bruits: Listen for bruits over the renal arteries or liver, which can indicate vascular pathology.
Percussion
Abdomen: Percuss all four quadrants.
Tympanic sounds suggest gas-filled loops of bowel (e.g., in bowel obstruction).
Dull sounds may indicate fluid (e.g., ascites). Check for shifting dullness to confirm ascites.
Palpation
Superficial and Deep: Palpate all four quadrants gently, starting superficially and then moving deeper.
Guarding and Tenderness: Note any tenderness or involuntary guarding, which can be a sign of peritonitis.
Specific Signs:
McBurney’s Point: Tenderness over McBurney’s point is a classic sign of appendicitis.
Murphy’s Sign: Palpation of the right upper quadrant causes pain on inspiration, which suggests gallbladder inflammation.
Organomegaly:
Liver: Palpate the liver edge. Note if it is firm, smooth, or irregular. Hepatomegaly can be a sign of hepatitis, heart failure, or other systemic diseases.
Spleen: Palpate for the spleen, which is typically not palpable. A palpable spleen can indicate a haematological disorder or portal hypertension.
Kidneys: Perform a bimanual palpation for the kidneys to feel for any enlargement or masses.
External Genitalia: In boys, a testicular exam is required, as abdominal pain can sometimes be referred from testicular torsion.
Per Rectal (PR) Exam: A PR exam is rarely performed in children unless there is a specific indication, such as suspected appendicitis, rectal bleeding, or a perianal abscess.