physical examinationgi

7/31/2019 Physical Examinationgi

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HISTORY

ANDPHYSICAL

EXAMINATION

THEABDOMEN


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HISTORY


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History

Infants and young children may be erratic eaters

A toddler might eat insatiably or refuse to consume food

during a meal.

Toddlers and young children also tend to eat only a limitedvariety of foods.

Infancy and adolescence are periods of rapid growth; high

nutrient requirements for growth may be associated with

voracious appetites. Demonstration of age-appropriate growth on a growth

curve is reassuring


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History

The number, color, and consistency of stools can varygreatly in the same infant and between infants of similar

age.

The earliest stools after birth consist of meconium, a

dark, viscous material that is normally passed within the1st 48 hr of life.

normally passed within the 1st 48 hr of life.

With the onset of feeding, meconium is replaced by

green-brown transition stools, often containing curds,and, after 4-5 days, by yellow-brown milk stools.


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History

Stool frequency is extremely variable in normal infantsand can vary from none to 7 per day.

Breast-fed infants can have frequent small, loose stools

early (transition stools), and then after 2-3 wk can have

very infrequent soft stools

Some nursing infants mightnot pass any stool for 1-2 wk

and then have a normal soft

bowel movement.


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History

The color of stool has little significance except for thepresence of blood or absence of bilirubin products (white-

gray rather than yellow-brown).

The presence of vegetable matter, such as peas or corn, inthe stool of an older infant or toddler ingesting solids is

normal and suggests poor chewing and not malabsorption.

A pattern of intermittent loose stools, known as toddler'sdiarrhea, occurs commonly between 1 and 3 yr of age.


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PHYSICAL EXAMINATIONINSPECTION


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INSPECTION

Newborn lying supine (and, optimally, asleep)

abdomen is protuberant as a result of poorly developed

abdominal musculature

abdominal wall blood vessels and intestinal peristalsis areeasily noticeable


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INSPECTION What to look for?

Abnormalities? Ompalocoele- is a type of abdominal wall defect in which

the intestines, liver, and occasionally other organs remain outside of

the abdomen in a sac because of a defect in the development of

the muscles of the abdominal wall(exomphalos)


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INSPECTION

What to look for?Abnormalities?

Gastrochisis- intestines not covered by peritoneum

Scaphoid abdomen- associated with congenital diaphragmatic hernia


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INSPECTION

Newborn's umbilical cord Two thick-walled umbilical arteries and one larger but thin-walled

umbilical vein, which is usually located at the 12-o'clock position

May have a long cutaneous portion (umbilicus cutis), which is covered

with skin, or an amniotic portion (umbilicus amnioticus), which is covered

by a firm gelatinous substance Amniotic portion dries up and falls off within 2 weeks, whereas the

cutaneous portion retracts to be flush with the abdominal wall.

A single umbilical artery may be associated with congenital anomalies or

as an isolated anomaly (Patent urachus or Omphalitis)


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PATENT URACHUS AND OMPHALITIS


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INSPECTION

Inspect the area around the umbilicus for redness or swelling.

Bleeding? Any discharge?

Color should be translucent; greenish-yellow color suggest meconium staining

Umbilical granuloma at the base of the navel

-development of pink granulation tissue formed during the

healing process

Umbilical hernias are detectable at a few weeks of age (most disappear by1 year, nearly all by 5 years)

Umbilical hernias in infants-caused by a defect in the abdominal wall and can be up to 6

cm in diameter and quite protuberant with intra-abdominal

pressure.


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INSPECTION

In some normal infants

diastasis recti

-separation of the two rectus abdominis muscles, causing a

midline ridge, most apparent when the infant contracts the

abdominal muscles.

-benign-in most cases, it resolves during early childhood

-chronic abdominal distention may also

predispose to this condition


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INSPECTION

Older Children

Size and shape

Prominent vessels, Striae, Pulsations

Peristaltic movements

Umbilical hernia

Movement in relation to respiration


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INSPECTION

commonly have protuberant abdomens

most apparent when they are upright

Abdominal distention- measure Abdominal Circumference

(AC) An exaggerated pot-belly appearance may indicate

malabsorption from:

celiac disease

cystic fibrosisConstipation

aerophagia


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INSPECTION

FINDINGS CLINICAL IMPLICATIONSScaphoid or Flat Diaphragmatic hernia (new born)

Malnutrition

Full or Globular or

Protuberant

Normally seen infants and toddlers due to weak

abdominal musculature, relatively large abdominal

organs and lumbar lordosis

In other instances think of 5F-flat, flatus, feces, fluid , fetus

Peristaltic waves Normal in thin individuals

May signify pressence of obstruction as in pyloric

stenosis, intussusception

Distended veins In epigastric area may indicate obstruction of inferior

vena cava

In periumbilical areas-portal hypertension

Paradoxical abdominal

movements with breathing

Diaphragmatic paralysis or impending respiratory failure

in severe status asthmaticus


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PHYSICAL EXAMINATIONAUSCULTATION


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Auscultation

Done before palpation and percussion

May alter the results

Done to detect bowel sounds

Warm steth with palm of the hand

Diaphragm is used


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Auscultation

BOWEL SOUNDS

RLQ/Mid-abdomen

One spot is sufficient Character

Frequency

**Characteristics of BS are not diagnostic of specific conditions exceptHigh-Pitched = Obstruction/Gastroenteritis


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Auscultation

Important to observe BS change over a period of time

Bowel obstruction may progress to strangulation and

ischemia

Ischemia = BS may decrease


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Auscultation

BS are gurgling in nature

Episodically at 5-10 secs interval or longer

Infants and younger childer

10-30/min Adults

5-34/min

If BS are absent, auscultate again for 1-2min

before concluding so.


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Auscultation

Inactive bowel sounds

Infants on their first days of life

Extremely premature

Never fed for several days


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Auscultation

Scratch Test Place the diaphragm of stethoscope just above the right costal

margin at the midclavicular line

With your fingernail, lightly scratch the skin of the abdomen along the

midclavicular line

Move from below the umbilicus toward the costal margin

When your scratching finger reaches the liver's edge, you will hear a

change in the scratching sound


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Auscultation


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PHYSICAL EXAMINATIONPERCUSSION


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PERCUSSION

Newborn

NOT BEING DONE


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PERCUSSION

Older Children

Normally tympanitic except for areas of dullness

(solid organs like liver or full bladder)

TUMOR or FLUID- dullness on areas that are normally tympanitic

COLIC, INTESTINAL OBSTRUCTION, ILEUS- highly tympanitic


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PERCUSSION

WHY PERCUSS??

to detect presence of fluid in the peritoneal cavity

through 2 methods

FLUID WAVE

SHIFTING DULLNESS


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PERCUSSION

FLUID WAVE Palpate the flank of the abdomen with one hand and tap on

the opposite flank with fingers of the other hand

An aide or patient places his hand on the midline to obliteratethe feeling of stretching of the skin why may affect

transmission of fluid waves If present, will be felt by the patient.


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PERCUSSION

SHIFTING DULLNESS

Patient in supine

Percuss abdomen from midline to the right flank until

dullness is perceived

Mark the area of transition from tympanism to dullness


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PERCUSSION

SHIFTING DULLNESS

Then, ask the patient to roll over and lie at the right side atleast 30 seconds

After the fluid settled, percuss again from left to right flank

Mark the area of transition AREA OF DULLNESS WILL SHIFT UPWARD


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PERCUSSION

LIVER SPAN

Percuss along RMCL anteriorly with the pleximeter finger held

parallel to the ribs along intercostal pace using heavy percussion

Percuss downward until resonance shifts to dullness

Mark this as the UPPER BORDER OF THE LIVER


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PERCUSSION

LIVER SPAN

Percuss from RUQ moving upward along RMCL until dullness is

perceived and mark as the LOWER BORDER OF THE LIVER

(palapationas alternative)

Measure UPPER BORDER-LOWER BORDER


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PHYSICAL EXAMINATIONPALPATION


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Palpation

Supine with both lower extremities slightly flexed at kneesand hips

Position yourself on where your dominant hand for palpation

is at

Warm the hand before palpation Distract the child when palpating

Ask the patient to inhale slowly and deeply

Use flat side of fingers


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Palpation

Newborn Easily palpated when quiet

Stand at the right side of the infant

Left hand raising the legs Raise pelvis slightly

Right hand, finger pads are used topalpate

Start below the umbilicus on both sidesthen proceed towards the diaphragm


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Palpation

In Crying infant = place hand on the abdomen

Palpate when infant takes inspiration after

crying

With pain = ask where the pain is Start palpate away from the pain

Proceed gently to the painful area


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Palpation

Direct tenderness

Pain elicited on pressure

Visceral pain

Rebound tenderness

Pain is felt or greater on release

Peritoneal irritation


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Palpation

Patients who are unable to verbalize feelings/patients whotalks a lot

Observe facial expressions upon palpation

Wincing, grimacing, sudden crying


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Palpation

Detecting Organs and Masses

1. Location

2. Upper and lower borders

3. Attached to abdominal wall?4. Firm, hard, soft, cystic?

5. Movement during respiration

6. Movable?

7. Pulsations


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Palpation

Liver size

Below the right subcostal margin

Look for the lower liver edge

RLQ -> RMCL Hepatomegaly

Liver can be palpated over the epigastrium

extending to the left subcostal area


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Palpation

Infants and young children

Liver is normally palpable

Length along RMCL -> RSCM

0-6 months 3.0 3.5 cm

6 months - 4yrs 0 3 cm

4 -10 yrs < 2 cm

> 10 yrs < 1 cm


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Palpation

Spleen

Usually splenic tip is palpable as soft with

a sharp edge in infants

Supine, RLQ -> Left costal margin Right hand, Px inspires deeply

May use left hand for lifting flanks


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Palpation

Spleen Shorts Maneuver if spleen is not

palpable

Px lie in right lateral decubitus Examiners left hand placed over left lower

ribs on midscapular pushing spleen

forward Right hand palpates from RLQ -> LUQ


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Palpation

Spleen When palpable usually slides downward

during inspiration and upward during

expiration


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Palpation

Psoas Sign Place hand on px right knee

Ask px to flex right hip against resistance

Abdominal pain (+) sign

Indicative of appendicitis Obturator sign

Px raises right leg with flex knee then rotating

internallyAbdominal pain (+) sign suggests

appendicits


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Palpation

Anus Prepare child for the exam

Expose anus left lateral decubitus with

legs flexed against the abdomen What to look for?

1. Location

2. Patency

3. Fissures

4. Hemorrhoids

5. worms


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Palpation

Rectum Left lateral decubitus, right leg drawn up

into abdomen, head curled down

Use gloved index finger/little finger

Apply lubricant on finger/tip

What to look for?

1. Sphincter tone

2. Mass or impacted feces

3. tenderness


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THE CASEINTUSSUSCEPTION


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Case

Infant with Intussusception


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Intussusception

Intussusception occurs

when a portion of the

alimentary tract is

telescoped into anadjacent segment.


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Intussusception

It is the most common cause of intestinal obstructionbetween 3 mo and 6 yr of age and the most common

abdominal emergency in children


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Intussusception

Intussusceptions are most often ileocolic, less commonlycecocolic, and rarely exclusively ileal.

Intussusceptum leading invaginating segment

Intussuscipiensreceiving segment

Pulling of its mesentery along with it Constriction of the mesentery obstructs venous return

Engorgement of the intussusceptum follows, withedema, and bleeding from the mucosa leads to a bloody

stool, sometimes containing mucus. The apex of the intussusception can extend into the

transverse, descending, or sigmoid colon, even to andthrough the anus in neglected cases.


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Intussusception

Clinical Manifestations Sudden onset of severe paroxysmal colicky pain that recursat frequent intervals

Accompanied by straining efforts with legs and knees flexedand loud cries.

The infant may initially be comfortable and play normallybetween the paroxysms of pain; but if the intussusception isnot reduced, the infant becomes progressively weaker andlethargic.

A shocklike state with fever The pulse becomes weak and thready

The respirations become shallow and grunting, and the painmay be manifested only by moaning sounds.

I i


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Intussusception

Clinical Manifestations Vomiting occurs in most cases and is usually more frequent

in the early phase.

In the later phase, the vomitus becomes bile stained.

Stools of normal appearance may be evacuated in the 1stfew hours of symptoms.

Later, fecal excretions are small or more often do not occur,

and little or no flatus is passed.

Blood is generally passed in the 1st 12 hr, but at times notfor 1-2 days, and infrequently not at all

I t ti


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Intussusception

Clinical Manifestations

60% of infants pass a stool

containing red blood and

mucus, the currant jelly

stool.

I t ti


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Intussusception

Clinical Manifestations Some patients have only irritability and alternating or

progressive lethargy.

The classic triad (


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Intussusception

Inspection

Distended abdomen

Legs are drawn into the abdomen

Auscultation

Absent or diminished bowel sounds

Pecrussion Tender but ussually not done

Palpation

Sausage-shaped abdominal mass may be palpable in the right

upper quadrant or in the midepigastric area if the transversecolon is involved

Tender abdomen, with some guarding over the intussusceptionsite

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