Pediatric Abdominal Examination Guide

This app focuses on the clinical examination of the abdomen in pediatrics, providing a structured approach for both medical students and healthcare professionals. It covers all essential steps of the abdominal examination, from inspection to palpation, percussion, and auscultation, ensuring a thorough understanding of each clinical maneuver and its significance in pediatric assessment.

Designed to be an educational tool, this app helps users gain confidence in performing abdominal examinations on children by offering practical insights and detailed explanations. Whether for learning purposes or as a quick reference during practice, it is a valuable resource for improving diagnostic skills and enhancing patient care.

Inspection

Technique for Assessing Abdominal Shape

1. Position the child:
   • Supine on a flat examination table
   • For infants, examine on caregiver's lap if necessary
   • Ensure good lighting
2. Observe from multiple angles:
   • Stand at the foot of the bed, looking towards the head
   • Move to the side of the bed, observing the profile
   • If possible, observe the child standing (for older children)
3. Assess contour:
   • Look for symmetry between right and left sides
   • Note any protrusions or depressions
   • Observe the transition from chest to abdomen
4. Evaluate movement:
   • Observe respiratory movements of the abdomen
   • Look for visible peristalsis or pulsations
5. Consider age-specific norms:
   • Newborns and infants often have protuberant abdomens
   • Older children should have relatively flat abdomens

Normal Abdominal Shapes in Pediatrics

1. Newborns and Infants (0-12 months)

• Slightly protuberant, especially after feeding
• Symmetrical
• Moves with respiration
• No visible masses or distension

2. Toddlers (1-3 years)

• Less protuberant than infants
• Symmetrical
• No visible masses or distension
• May have a slight outward curve below the umbilicus

3. Older Children (4-12 years)

• Generally flat or slightly convex
• Symmetrical
• No visible masses or distension
• Umbilicus centrally located

4. Adolescents (13-18 years)

• Flat or slightly convex
• Symmetrical
• May see outline of rectus abdominis in athletic individuals
• No visible masses or distension

Abnormal Abdominal Shapes and Associated Conditions

Abnormal Shape	Description	Possible Associated Conditions
Generalized Distension	Uniform enlargement of the entire abdomen	Ascites Bowel obstruction Gaseous distension (functional ileus) Peritonitis
Localized Distension	Protrusion in a specific area of the abdomen	Organomegaly (e.g., hepatomegaly, splenomegaly) Abdominal mass or tumor Localized bowel distension Abdominal abscess
Scaphoid Abdomen	Sunken or concave appearance	Diaphragmatic hernia Severe malnutrition
Asymmetry	One side appears larger or more protuberant than the other	Unilateral organomegaly Abdominal mass Psoas abscess
Visible Peristalsis	Wave-like movements visible on the abdominal surface	Pyloric stenosis (in infants) Intestinal obstruction Hirschsprung's disease
Umbilical Abnormalities	Protrusion or abnormal appearance of the umbilicus	Umbilical hernia Omphalitis Umbilical granuloma

Palpation

Technique for Abdominal Palpation

1. Preparation:
   • Ensure warm hands and a relaxed environment
   • Position the child supine with knees slightly flexed
   • For infants, palpation can be done between feeds
2. Light Palpation:
   • Use the flat of the hand, not fingertips
   • Start in a non-tender area, often the right lower quadrant
   • Palpate all four quadrants systematically
   • Observe the child's face for signs of discomfort
3. Deep Palpation:
   • Use gentle but firm pressure
   • Palpate for masses, organ edges, and areas of tenderness
   • Pay special attention to the right upper quadrant (liver) and left upper quadrant (spleen)
4. Organ-Specific Palpation:
   • Liver: Palpate from right lower quadrant upwards
   • Spleen: Palpate from right lower quadrant towards left upper quadrant
   • Kidneys: Attempt bimanual palpation in older children

Normal Findings in Pediatric Abdominal Palpation

• Soft, non-tender abdomen
• No palpable masses
• Liver edge may be palpable up to 2 cm below the right costal margin in infants and young children
• Spleen typically not palpable
• Kidneys generally not palpable in older children

Abnormal Findings and Associated Conditions

Finding	Description	Possible Associated Conditions
Localized Tenderness	Pain on palpation in a specific area	Right lower quadrant: Appendicitis Right upper quadrant: Cholecystitis, hepatitis Left upper quadrant: Splenic enlargement or infarction Suprapubic: Urinary tract infection, bladder distension
Generalized Tenderness	Diffuse pain on palpation	Peritonitis Gastroenteritis Bowel obstruction
Guarding	Involuntary muscle tension on palpation	Peritoneal inflammation Appendicitis Perforated viscus
Rebound Tenderness	Pain upon sudden release of deep palpation	Peritonitis Appendicitis Perforated viscus
Hepatomegaly	Liver palpable more than 2 cm below the right costal margin	Hepatitis Congestive heart failure Metabolic storage diseases Malignancy
Splenomegaly	Palpable spleen below the left costal margin	Infectious mononucleosis Leukemia Hemolytic anemia Portal hypertension
Palpable Mass	Abnormal solid or fluid-filled structure	Wilms' tumor Neuroblastoma Intussusception Fecal impaction

Percussion

Technique for Abdominal Percussion

1. Position the child supine with abdomen exposed
2. Use the middle finger of your dominant hand as the striking finger
3. Place the middle finger of your non-dominant hand firmly against the abdominal wall
4. Strike the middle phalanx of the placed finger with the tip of the middle finger of your dominant hand
5. Use quick, sharp strokes
6. Percuss systematically in all four quadrants
7. Pay special attention to liver and splenic areas
8. Assess for shifting dullness if ascites is suspected

Normal Findings in Pediatric Abdominal Percussion

• Tympanic sound over most of the abdomen due to gas-filled bowel
• Dull sound over the liver in the right upper quadrant
• Liver span typically 6-8 cm in the midclavicular line
• Tympanic sound in the left upper quadrant (splenic area) in most children

Abnormal Findings and Associated Conditions

Finding	Description	Possible Associated Conditions
Generalized Dullness	Dull percussion note over most of the abdomen	Ascites Large abdominal mass Pregnancy in adolescents
Localized Dullness	Dull percussion note in a specific area	Organomegaly Abdominal mass Fecal impaction Full bladder
Hyperresonance	Drum-like sound on percussion	Pneumoperitoneum Severe gaseous distension
Enlarged Liver Span	Liver span >8 cm in the midclavicular line	Hepatomegaly Congestive heart failure Hepatitis
Shifting Dullness	Dullness that moves with change in position	Ascites
Splenic Dullness	Dull percussion note in left upper quadrant	Splenomegaly

Auscultation

Technique for Abdominal Auscultation

1. Preparation:
   • Ensure a quiet environment
   • Warm the stethoscope to avoid startling the child
   • Position the child supine with abdomen exposed
2. General Bowel Sounds:
   • Use the diaphragm of the stethoscope
   • Start in the right lower quadrant
   • Listen for at least 30 seconds in each quadrant
   • Note the frequency, pitch, and quality of sounds
3. Vascular Sounds:
   • Use the bell of the stethoscope
   • Listen over the aorta and renal arteries
   • Check for bruits or venous hums
4. Specific Areas:
   • Epigastrium: Listen for stomach sounds
   • Right upper quadrant: Listen for hepatic bruits
   • Left upper quadrant: Listen for splenic bruits

Normal Findings in Pediatric Abdominal Auscultation

• Bowel sounds:
  • Frequency: 5-30 sounds per minute
  • Character: Gurgling, clicking, or rushing sounds
  • Pitch: Variable
• No vascular sounds or bruits
• No high-pitched or tinkling sounds

Abnormal Findings and Associated Conditions

Finding	Description	Possible Associated Conditions
Hyperactive Bowel Sounds	Frequent, loud, or high-pitched sounds	Gastroenteritis Early intestinal obstruction Laxative use
Hypoactive or Absent Bowel Sounds	Infrequent or absent sounds	Ileus Late intestinal obstruction Peritonitis
High-Pitched or Tinkling Sounds	Musical or bell-like sounds	Intestinal obstruction Pneumoperitoneum
Abdominal Bruit	Swishing or blowing sound over major vessels	Renal artery stenosis Abdominal aortic aneurysm (rare in children) Arteriovenous malformation
Hepatic Bruit	Vascular sound over the liver	Hepatic hemangioma Hepatocellular carcinoma (rare in children)
Venous Hum	Continuous low-pitched sound	Portal hypertension Caput medusae

Special Maneuvers in Pediatric Abdominal Examination

Murphy's Sign

Technique:

1. Position the child supine
2. Place your left hand on the right upper quadrant, just below the costal margin
3. Ask the child to take a deep breath
4. Observe for abrupt cessation of inspiration due to pain

Interpretation:

• Positive: Suggests inflammation of the gallbladder (acute cholecystitis)
• Note: Less reliable in children than in adults due to the lower incidence of gallbladder disease in pediatrics

McBurney's Point Tenderness

Technique:

1. Locate McBurney's point: One-third of the distance from the anterior superior iliac spine to the umbilicus
2. Apply gentle pressure at this point
3. Observe for localized tenderness

Interpretation:

• Positive: Suggests acute appendicitis
• Note: The position of the appendix can vary, so tenderness may not always be exactly at McBurney's point

Rovsing's Sign

Technique:

1. Position the child supine
2. Apply deep pressure in the left lower quadrant
3. Quickly release the pressure
4. Observe for pain in the right lower quadrant

Interpretation:

• Positive: Suggests acute appendicitis
• Mechanism: Displacement of bowel contents towards the inflamed appendix causes pain

Psoas Sign

Technique:

1. Position the child on their left side
2. Extend the right hip
3. Observe for pain in the right lower quadrant

Interpretation:

• Positive: Suggests retrocecal appendicitis or psoas abscess
• Mechanism: Stretching of the inflamed psoas muscle causes pain

Obturator Sign

Technique:

1. Position the child supine with right hip and knee flexed
2. Internally rotate the right hip
3. Observe for pain in the right lower quadrant

Interpretation:

• Positive: Suggests pelvic appendicitis or pelvic inflammatory disease
• Mechanism: Stretching of the inflamed obturator internus muscle causes pain

Cullen's Sign and Grey Turner's Sign

Technique:

1. Inspect the periumbilical area (Cullen's sign)
2. Inspect the flanks (Grey Turner's sign)
3. Look for bluish discoloration

Interpretation:

• Positive: Suggests retroperitoneal hemorrhage or severe acute pancreatitis
• Note: These signs are rare in children but can be seen in cases of severe trauma or pancreatitis