Gastrointestinal Examination in Children

Gastrointestinal Examination in Children Component What to do/rationale Basics Activity and alertness Distress Growth Jaundice Pallor Weight Syndrome General Inspection Tall/short Syndromic facial features NG/NJ tube Gastrostomy Colostomy/ileostomy IV lines Special feeds Medications Pallor Anaemia -> malignancy, GI bleeding, malnutrition Peripheral edema Nephrotic syndrome -> albumin loss Liver disease -> reduced albumin production Koilonychia Spoon shaped nails -> IDA -> malabsorption in Crohn’s disease Leukonychia Whitening of the nail bed, associated with hypoalbuminemia Hands Hypoalbumenia Protein losing enteropathy Finer clubbing Uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed Look for small diamond-shaped window -> Schamroth’s window In clubbing this window is lost Pulse Palpate with tips of index and middle finger Note rate and rhythm Oedema and pallor of the face Eyes Pallor conjunctival pallor Anaemia Scleral jaundice Liver disease, hypothyroidism, rhesus factor disease Aniridia Complete or partial absence of coloured part of the eye WAGR syndrome Also associated with Wilm’s tumor Kayser-Fleischer rings Dark circles that encircle the iris -> Wilson’s disease Abnormal copper processing by the liver Accumulation and deposition in various tissues Xanthelasma Face Hypercholesterolaemia Mouth Angular stomatitis Inflammatory condition Many causes including IDA Glossitis Smooth erythematous enlargement of tongue associated with iron, B12 and folate deficiency E.g. malabsorption secondary to IBD Oral candidiasis Fungal infection commonly associated with immunosuppression Characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa Dental caries Associated with neglect or GERD Erosion Left supraclavicular lymph node Neck Virchow’s node Palpate the supraclavicular fossa on each side Scars Abdominal distention Constipation Hirschsprung’s disease Ascites Abdomen inspection Organomegaly Malignancy Caput medusae Engorged paraumbilical veins Portal hypertension Hernias Drains/tubes/stomas Kneel down Warm hands Ask child to relax Abdominal wall muscles must be relaxed Ask the child if there is pain Light palpation Deep palpation Tenderness Localised RIF -> appendicitis RUQ -> hepatitis Flank -> pyelonephritis Generalised Mesenteric adenitis Peritonitis Abdomen Palpation Masses Size Shape Consistency Mobility Causes of masses in children: Neuroblastoma Irregular firm mass -> crosses the midline Child is very unwell on presentation Faeces masses Mobile, non-tender, identifiable Localised to LIF Intussusception Palpable mass in RUQ (most common) In the context of acutely unwell child Palpate right iliac fossa Locate liver end with tips or sides of fingers Ask child to take deep breaths in Edge may be soft or firm Will be unable to get above it Edge moves with respiration Measure in cm the extension of the liver edge below the costal margin in the midclavicular line Percussion Liver Percuss downwards from the right lung to exclude downward displacement due to lung hyperinflammation (e.g. bronchiolitis) Dullness to percussion can help delineate the upper and lower boarder Record span of live in cm Causes of hepatomegaly Infection -> congenital, infectious mononucleosis, hepatitis, malaria Haematological -> sickle cell anaemia, thalassaemia Malignancy -> leukemia, lymphoma, neuroblastoma, Metabolic -> glycogen and lipid storage Heart failure Palpation A palpable one is at least TWICE the normal size Palpate RIF towards the LUQ Ask child to take deep breaths The edge is usually soft and cannot get above it Splenic notch is occasionally palpable If markedly enlarged Should move with inspiration Spleen Percuss to delineate the lower boarder Dull to percussion Causes of splenomegaly Infections – infectious mononucleosis, malaria Haematological – haemolytic anaemia Malignancy – leukemia, lymphoma Other – portal hypertension, Still’s disease Not palpable beyond neonatal period Unless enlarged or abdominal muscles are hypotonic Balloting bi-manually in each hypochondrium Can get above them Tenderness -> inflammation Kidneys Unilateral enlargement Hydronephrosis, cyst, tumor Bilateral enlargement Hydronephrosis Kidney stones Polycystic kidneys Ascites Shifting dullness on percussion Normal sounds Usually gurgling Bowel auscultation Tinkling bowel sounds Usually bowel obstruction Absent bowel sounds Ileus Male Penile abnormalities Hypospadias, chordee Descended tests With one hand over the inguinal region -> palpate testicles with the other hand Genital examination Record if testis descended, retractable or impalpable Note any scrotal swelling Hydrocele Hernia Female Inspect external genitalia to identify abnormalities Abnormal discharge: associated with pelvic inflammatory disease Not routinely done Only if indicated Look for Imperforate anus Rectal examination Anal skin tags – Crohn’s disease Anal prolapse Staining/soling of underwear Suggest constipation Masses Lower limb Peripheral edema