A paediatricabdominalexamination is generally performed in one of three major clinical settings – as part of a routine clinical examination, in the assessment of an ‘acute abdomen’ or in cases of recurrent abdominal pain, distension or constipation.
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.
Spider naevi (may be noted on abdomen or chest) – chronic liver disease
Hernia – inguinal, umbilical
Drains/tubes/access – gastrostomy, central venous catheter, ileostomy, colostomy
Scars (see diagram below)
Tip: The abdomen is normally protuberant in toddlers and young children.
Examples of scar locations
Biliary surgery (e.g. cholecystectomy) Hepatic surgery
Midline laparotomy (variable length)
Fundoplication Major abdominal surgery
Transverse upper abdominal incision
Repair of congenital diaphragmatic hernia Splenic surgery
Treatment of pyloric stenosis
Grid-Iron incisions at McBurney’s point
Hernia repairs Gastroschisis repair Exomphalos
Point incision marks
Laparoscopy port sites Drain sites VP shunts
Inguinal hernia repairs Vascular access scars
Lateral thoracolumbar incision
Renal surgery (nephrectomy)
Examine The Abdomen
Preparing to palpate the abdomen
Kneel down and/or raise the bed, your face is level with the child’s face.
Use warm hands, explain and relax the child.
Keep the parent close at hand.
Abdominal wall muscles must be relaxed for palpation to be effective. Ensure the child is lying down entirely flat, with their hand by their sides. Take away any pillows or cushions.
Expose the abdomen entirely, lower the trousers and underwear, cover the child with a sheet.
Perform lightpalpation of the 9 abdominal regions, whilst looking at the child’s face and assessing for rigidity,tenderness, guarding and palpablemasses.
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.
Guarding is suggestive of peritonitis and indicates the need for urgent surgical review.
Repeat palpation of the 9 abdominal regions, this time applying greaterpressure to better assess intra-abdominal structures (continue to observe the child’s face for signs of discomfort).
If any masses are identified, determine their location, approximate size, shape, consistency and mobility.
Localised in appendicitis (RIF), hepatitis (RUQ) and pyelonephritis (flank).
Generalised in mesenteric adenitis and peritonitis.
Pain on coughing, moving about/walking/bumps during a car journey suggests peritoneal irritation.
A child walking, whilst being flexed forwards suggests psoas irritation (e.g. appendicitis).
Incorporating play may be used to elicit more subtle guarding.
“Can you jump up and down?” – a child will not be able to jump on the spot if they have localised guarding
“Blow out your tummy as big as you can, then suck it in as far as you can” – this will elicit pain if there is peritoneal irritation
Wilm’s tumour – renal mass, sometimes visible, does NOT cross the midline
Neuroblastoma – irregular firm mass, may cross the midline, the child is usually very unwell
Faecal masses – mobile, non-tender, indentable, often in the LIF
Intussusception – acutely unwell, the mass may be palpable, most often in RUQ
Palpatefrom the right iliac fossa and locate the edge of the liver with the tips or sides of your fingers (ask the child to take deep breaths if appropriate).
The liver edge may be soft or firm and you will be unable to get above it. The edge will move with respiration.
Measure in centimetres the extension of the liver edge below the costal margin in the mid-clavicular line.
Percussdownwards from the right lung to exclude downward displacement due to lung hyperinflation (i.e. in bronchiolitis).
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 first with their hand or by putting your hand on top of theirs.
Causes of hepatomegaly
There are several potential causes of hepatomegaly including:
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).
Tenderness implies inflammation.
Unilaterally large – hydronephrosis, cyst or tumour
Bilaterally large – hydronephrosis, kidney stones, polycystic kidneys
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 shiftingdullness in young children, due to issues with co-operation. However, in older children, it may be possible.
1. Percuss from the centre of the abdomen to the flank until dullness is noted
2. Keep your finger on the spot at which the percussion note became dull
3. Ask the patient to roll onto the opposite side to which you have detected the dullness
4. Keep the patient on their side for 30 seconds
5. Repeat your percussion in the same spot
6. If fluid was present (ascites)then the area that was previously dull should now be resonant
7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull (i.e. the dullness has shifted)
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.
Perform auscultation of the abdomen, listening for
Normal bowel sounds – should occur a minimum of every 2 minutes
‘Tinkling’ bowel sounds – obstruction
Absent bowel sounds – peritonitis/ileus
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
Ensure normal penile and scrotaldevelopment
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
Confirm the externalgenitalia look normal
Not routinely performed and if indicated, it should be performed by a specialist who has experience interpreting findings
Confirm the anus looks normal and perforate
Anal skin tags (Crohn’s)
Staining of underwear (may suggest constipation)
Inspect for ankle oedema (nephrotic syndrome/liver disease)
To Complete the Examination…
Ensure the child is re-dressed after the examination
Thank the child and/or parents
Explain your findings to the parents and/or child
Ask if the parents and/or child have any questions