Paediatric Abdominal Examination – OSCE Guide


A paediatric abdominal examination 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.

Check out our paediatric respiratory examination mark scheme here.


Introduction

  • Wash your hands
  • Introduce yourself to both the parents and the child
  • Explain what the abdominal examination will involve
  • Gain consent from the parents/carers and/or child before proceeding.

Today I’d like to perform an examination of your child’s abdomen, which will involve first observing your child, then gently feeling their tummy.

Are you happy for me to carry out the examination?


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:

  • How alert is the child?
  • How active is the child?
  • Do they appear to be a normal colour? (e.g. pallor, jaundice, cyanosis)
  • Do they have an obvious rash?
  • Do they appear a healthy weight?
  • Do they look in pain?
  • Overall, do you think the child looks ‘well’ or ‘sick’

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 patient’s immediate surroundings and consider why this might be relevant to the gastrointestinal system:

  • NG/NJ tube – bowel obstruction, short bowel syndrome, inflammatory bowel disease, gastroesophageal reflux, glycogen storage disorder, chronic liver disease, malignancy, anorexia
  • Gastrostomy – typically only used in an NG/NJ is needed for more than 6 weeks – indicative that the child has a chronic condition
  • Colostomy/Ileostomy – inflammatory bowel disease, malignancy
  • Stool sample pot
  • Intravenous lines/drip
  • Medication
  • Special feeds or milks
Neonate with NG tube in situ.
Neonate with NG tube in situ.1

Medications

Note any medications by the bedside or in the patient’s room and consider what underlying diagnoses they may indicate:

  • Laxatives (e.g. Movicol/Senna) – constipation
  • Antiemetics (e.g. Ondansetron) – nausea/vomiting
  • Pancreatic enzymes – cystic fibrosis

Hands

Inspect the hands

  • Finger clubbing – cystic fibrosis, liver disease, inflammatory bowel disease
  • Koilonychia (spooning of the nails) – iron deficiency
  • Leukonychia (whitened nail bed) – hypoalbuminaemia
  • Palmar erythema – chronic liver disease, polycythaemia, Kawasaki’s disease, thyrotoxicosis
  • Peripheral oedema – nephrotic syndrome, liver disease

Pulses

Radial pulse (femoral pulse in babies) – assess rate and rhythm


Face

Observe the child’s facial complexion and features, including their eyes, ears, nose, mouth and throat.

General

  • Oedema – nephrotic syndrome, liver disease
  • Pallor – anaemia

Eyes

  • Conjunctival pallor – anaemia
  • Scleral icterus – jaundice – hepatic pathology, haemolysis
  • Aniridia (partial or complete absence of the coloured part of the eye) – Wilm’s tumour, WAGR syndrome
  • Kayser Fleischer rings – Wilson’s disease
  • Neuroblastoma – loss of the eye’s red reflex
  • Xanthelasma and corneal arcus – hyperlipidaemia

Mouth

  • Angular stomatitis – inflammation of the corners of the mouth – iron deficiency or vitamin b12 deficiency
  • Glossitis – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency 
  • Aphthous ulcers – benign, Crohn’s disease, Bechet’s disease
  • Dental caries – neglect, gastroesophageal reflux disease
  • Macroglossia – Down’s syndrome, hypothyroidism, mucopolysaccharidoses, Beckwith-Wiedemann syndrome
  • Pigmentation/Polyps – Peutz-Jeghers syndrome
  • Tip: Ask the child to see how long their tongue is or how big their mouth is
jaundice
A 5-day-old infant with noted jaundice and scleral icterus.2

Neck

  • Palpate the cervical lymph nodes
  • Palpate supraclavicular lymph nodes
  • Lymphadenopathy may indicate infection (most commonly) or malignancy (e.g. Virchow’s node)

Expose The Abdomen

Ask the parent or child (if appropriate) to expose the child’s abdomen.

If possible, the child should lay on a bed at 45-degrees initially for inspection and then lay flat for the examination of the abdomen (however, this is often difficult to achieve in reality).

Inspect the abdomen for any abnormalities:

  • Distension – constipation, Hirschsprung’s disease, ascites, organomegaly, malignancy
  • Striae – obesity, Cushing’s syndrome
  • Caput medusae – portal hypertension
  • 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

Abdominal scars
Common surgical scars which may be found during the examination of a child’s abdomen.
1Kocher’s incision Biliary surgery (e.g. cholecystectomy)
Hepatic surgery
2Midline laparotomy (variable length)   Fundoplication
Major abdominal surgery
3Transverse upper abdominal incision   Repair of congenital diaphragmatic hernia
Splenic surgery
4Pyloromyotomy scar Treatment of pyloric stenosis
5Grid-Iron incisions at McBurney’s point   Appendicectomy
6Umbilical/Sub-umbilical scars   Hernia repairs
Gastroschisis repair
Exomphalos
7Point incision marks   Laparoscopy port sites
Drain sites
VP shunts
8Inguinal incisions   Inguinal hernia repairs
Vascular access scars
9Lateral thoracolumbar incision Renal surgery (nephrectomy)
10‘Hockey-Stick’ scar Renal transplant

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.

Light palpation

  • Perform light palpation of the 9 abdominal regions, whilst looking at the child’s face and assessing for rigidity, tenderness, guarding and palpable masses.
  • 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.

Deep palpation

  • Repeat palpation of the 9 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 identified, determine their location, approximate size, shape, consistency and mobility.

Tenderness

  • Localised in appendicitis (RIF), hepatitis (RUQ) and pyelonephritis (flank).
  • 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 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

Abnormal masses

  • 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

Liver palpation

  • Palpate from 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.
  • Percuss downwards 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:

  • Infection – congenital, infectious mononucleosis, hepatitis, malaria
  • Haematological – sickle cell anaemia, thalassaemia
  • Malignancy – leukaemia, lymphoma, neuroblastoma, Wilms tumour, hepatoblastoma
  • Metabolic – glycogen and lipid storage disorders, mucopolysaccharidoses
  • Cardiovascular – heart failure
  • Apparent hepatomegaly – chest hyper-expansion (e.g. bronchiolitis/asthma)
Liver edge
Normal findings. The liver edge is 1–2 cm below the costal margin in infants and young children. The spleen may be 1–2 cm below the costal margin in infants 3

Splenic palpation

  • 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)

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).
  • Tenderness implies inflammation.
  • Unilaterally large – hydronephrosis, cyst or tumour
  • Bilaterally large – hydronephrosis, kidney stones, polycystic 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 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)

Auscultation

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

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

  • Ensure normal penile and scrotal development
  • 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 external genitalia look normal

Rectal examination

  • 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)
  • Anal prolapse
  • Staining of underwear (may suggest constipation)

Lower limbs

  • 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
  • Wash your hands

Further clinical assessments to consider

  • Nutritional assessment
  • Examination of hernial orifices
  • Pelvic examination in female adolescents if indicated

Further investigations

  • Record a full set of vital signs
  • Plot the height and weight on a growth chart
  • Perform urinalysis
  • Stool analysis

Syndromes that may impact the gastrointestinal system

Down syndrome

Down syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21.

Epicanthic folds
Brushfield spots
Protruding tongue
Low set ears
Duodenal atresia
Hirschsprungs disease

Turner syndrome

Caused by loss of part or all of an X chromosome, affecting only females.

Short stature
Delayed puberty
Webbed neck
Shield chest
Horseshoe kidney

Williams syndrome

Caused by the deletion of genetic material from a specific region of chromosome 7.

Short palpebral fissures
Upturned nose
Cupid bow lip
Nephrocalcinosis

Alagille syndrome

In 90 percent of cases, caused by mutations in the JAG1 gene.

Broad forehead
Small chin
Flat face
Biliary atresia
Jaundice

Thalassaemia

A group of disorders in which the normal ratio of alpha-globin to beta-globin production is disrupted due to a disease-causing variant in one or more of the globin genes.

Enlarged cheekbones
Enlarged forehead
Bone deformity
Massive splenomegaly

Glycogen storage disorder  

A glycogen storage disease is a metabolic disorder caused by enzyme deficiencies affecting either glycogen synthesis, glycogen breakdown or glycolysis, typically in muscles and/or liver cells.

Myopathy/weakness
Hepatosplenomegaly

Beckwith-Wiedemann syndrome

An overgrowth disorder involving a predisposition to tumour development.

Hemi-hypertrophy
Macroglossia
Omphalocele
Wilms’ Tumour
Kidney anomalies

Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar


References

  • Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
  • Miin Lee & Fawbert (2014). Abdominal Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics [LINK] (Accessed 22 Mar 2019)
  • Paeds.co.uk (2009) Surgical Scars – Abdomen. Paeds.co.uk the online paediatrician’s encyclopaedia. [LINK] (Accessed 4 Mar 2019)
  • Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.

Photo credits

  1. “Eyes wide open” by Jim Champion, Flickr is licensed under CC BY-SA 2.0
  2. “Livia Fair 5 days old” by Jon Haynes Photography, Flickr is licensed under CC BY-SA 2.0
  3. Photo by Irina Murza on Unsplash

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