Abdomen

1
Abdomen

• Adapted from Mosbys Guide to Physical
  Examination, 6th Ed.
  
• Ch. 17

2
Tips

• Perform early in the exam
• Relaxation and quiet
• Bottle/pacifier/nursing
• On parents lap
• Dr. sits facing the parent, knees touching

3
Ticklish?

• Firm touch
• Place the childs hand under your palm
• leaving your fingers free to palpate

4

• Tenderness and pain can be difficult to
  detect/assess
  
• Look for
• Change in pitch of crying
• Facial grimace
• Rejection of the opportunity to suck
• Drawing the knees to the abdomen

5
Localizing Pain

• Distract the child with a toy
• Start away from the area suspected
• Observe for changes as you move to identify the
  area of greatest pain
  
• facial expression
• constriction of pupils

6

• If a child will not stop crying
• Use the respiratory cycle
• Abdomen should be soft during inspiration
• If abdomen remains hard during both inspiration
  and expiration
  
• Noticeable rigidity
• Resistance to pressure
• suspect peritoneal irritation

7
Inspection

• Shape
• Contour
• Movement with respiration
• Note
• localized fullness
• scaphoid
• protrusion (above the level of the chest)

8
Infant abdomen should be

• Rounded and dome shaped
• musculature has not fully developed
• Abdominal and chest movements should be
  synchronous
  
• slight bulge of the abdomen at the beginning of
  respiration

9

• Distended abdomen
• Feces, mass, organ enlargement
• Scaphoid abdomen
• Abdominal contents are displaced

10

• Pulsations - epigastric area
• Common in newborns and infants
• Distended veins across
• the abdomen
• Vascular obstruction
• Abdominal distension
• or obstruction
• Spider nevi
• Liver diease

11
Newborn - Umbilical Cord

• Count the vessels
• 2 arteries, 1 vein
• Single umbilical artery
• possible congenital anomolies

12
Umbilical Stump

• Should be dry and odorless
• Inspect all skin folds for
• Discharge
• Redness
• Induration
• Skin warmth
• Granulomatous tissue

13

• Umbilicus is usually inverted
• Note any protrusion through the umbilicus or
  rectus abdominus muscle
  
• Hernia
• Diastasis recti
• Often everts with increased abdominal pressure

14
Peristaltic Waves

• Use tangential lighting
• Observe abdomen at eye level
• Usually not visible
• Sometimes seen in thin, malnourished babies
• Suggests intestinal obstruction
• Pyloric stenosis
• Frequent vomiting

15
Auscultation

• Peristalsis
• Metalic tinkling
• Heard every 10-30 seconds
• Bowel sounds should be present 1-2 hours after
  birth
  
• No bruits or venous hum should be detected

16
Renal Bruits

• Patient held upright/sitting
• Listen at the posterior flank
• Supine
• Listen over the abdomen
• Renal artery stenosis
• High frequency, soft
• Renal arteriovenous fistula (rare)
• Continuous

17
Palpation

• With infants feet slightly elevated, knees
  flexed
  
• Superficial palpation
• Identify the spleen, liver, and masses close to
  the surface

18

• Can seem tiny compared to the size of your
  hand
  
• Place your hand gently on the abdomen
• Thumb at the right upper quadrant
• Index finger at the left upper quadrant
• Press very gently at first, only gradually
  increasing pressure
  
• Palpate over the entire abdomen

19

• Spleen
• First few weeks, palpable 1-2 cm below the left
  costal margin
  
• Detectable spleen tip (left costal margin)
• common in well infants
• Increase in spleen size may indicate
• blood dyscrasias
• septicemia

20

• Liver
• Estimation of true liver size (liver span)
• Percuss the upper border
• Palpate the lower edge
• Upper edge
• 5th intercostal space at the right midclavicular
  line
  

21

• Lower edge
• Palpate the right midclavicular line 3-4 cm below
  the costal margin
  
• Gradually move your fingers up until you feel the
  mass come down as the infant inspires
  
• Newborn
• just below the right costal margin
• Infants toddlers
• 1-3cm below the right costal margin
• Children
• 1-2cm below the right costal margin

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23
Hepatomegaly

• Liver is 3 cm below the right costal margin
• Indicates possible
• Infection
• Cardiac failure
• Liver disease

24
Deep Palpation

• Palpate all quadrants for masses
• Location
• Size
• Shape
• Tenderness
• Consistency
• Transillumination
• Distinguish cystic from solid masses

25

• Fixed masses should be investigated with special
  studies if
  
• Laterally mobile
• Pulsatile
• Palpate the aorta for signs of enlargement
• Located along vertebral column
• If any suspicion of neoplasm exists, limit
  palpation of the mass.
  
• May cause injury or spread of malignancy!

26
Percussion

• May be more tympanic (vs. adults)
• Swallow air when feeding crying
• Tympany with distended abdomen?
• Gas
• Dullness with distended abdomen?
• Fluid, solid mass

27
Examine the bladder

• Palpate and percuss
• suprapubic area
• Determine size
• Distention?

28
Child Exam
29

• Toddlers
• Abdomen protrudes slightly
• Potbellied
• Seated, standing or supine
• After age 5
• Abdomen (supine) may become convex when laying
  supine

30
Abdominal Respirations

• Respirations continue to be abdominal until 6-7
  years of age
  
• If persists past the age of 7, may suggest a
  thoracic problem
  
• In young children restricted abdominal
  respiration may be related to
  
• Peritoneal irritation
• Acute abdomen

31
Rebound Tenderness

• Observe childs facial expression and pupils
• Be cautious!
• Once a child has experienced palpation that is
  too intense, a subsequent examiner has little
  chance for easy access to the abdomen.

32
Common Conditions
33
Granuloma

• Serous or serosanguinous discharge once the stump
  has separated
  
• No other signs of infection

34
Omphalocele

• Intestine present in the umbilical cord or
  protruding from the umbilical area
  
• Visible through a thick transparent membrane

35
Umbilical Hernia

• Protrusion of omentum and intestine through the
  umbilical opening
  
• Common in infants
• Reach maximum size by1 month of age
• Generally close spontaneously
• 1-2 years of age
• Reduces temporarily
• push contents in (lightly) and
• it pops right out again

36

• May be very large and impressive
• Apparent size is not cause for alarm
• To determine size
• Measure the diameter
• of the opening, not the
• protruding contents

37
Diastasis Recti

• Midline separation
• (rectus abdominus)
• 1-4 cm wide
• between xiphoid and
  umbilicus
  
• No need to repair in most cases
• Resolves by 6 years of age
• Herniation through the rectus abdominus does
  require surgery

38
What if you find ?

• Sausage-shaped mass
• Left lower quadrant
• Feces in the sigmoid colon
• Constipation
• Midline, surpapubic mass
• Feces in the rectosigmoid colon
• Hirschsprung disease

39
Hirschsprung Disease (Congenital
Aganglionic Megacolon)

• Absence of parasympathetic ganglion cells in a
  segment of the colon
  
• Absence of peristalsis
• Feces accumulate proximal to the defect
• Leads to intestinal obstruction

40

• Signs symptoms
• Failure to thrive
• Constipation
• Abdominal distention
• Episodes of vomiting and diarrhea
• Newborn
• may fail to pass meconium in the first 24-48 hrs
• Older infants and young children
• intestinal obstruction or severe constipation

41
What if you find ?

• Sausage-shaped mass
• Left or right upper quadrant
• Intussusception

42
Intussusception

• Prolapse of one segment of intestine into
  another
  
• Causes intestinal
• obstruction
• Cause is unknown
• mc 3-12 months old

43

• Signs symptoms
• Acute intermittent abdominal pain
• Abdominal distention
• Vomiting
• Stools mixed with blood and mucus
• Red current jelly appearance
• Sausage-shaped mass in R or L upper quadrant
• R lower quadrant feels empty
• (Dance sign)

44

• Dramatic onset
• Apparently well child starts crying suddenly and
  excruciatingly
  
• awaken from sleep
• Doubling up with pain
• Inconsolable
• Episode may cease abruptly but symptoms will
  most likely recur

45
Intussusception ABCDEF

• Abdominal or anal sausage
• Blood from the rectum
• Colic babies draw up their legs
• Distention, dehydration, and shock
• Emesis
• Face pale

46
What if you find ?

• Olive-shaped mass (deep palpation)
• Right upper quadrant
• Immediately after the infant vomits
• Pyloris stenosis

47
Pyloric Stenosis

• Hypertrophy of the circular muscle of the
  pylorus
  
• obstruction of the pyloric sphincter
• 1st month after birth

48

• Signs symptoms
• Regurgitation projectile vomiting
• vigorous, shoots out of the mouth, carries a
  short distance
  
• Feeding eagerly
• even after vomiting
• Failure to gain weight
• Signs of dehydration
• Small, rounded mass palpable in the R upper
  quadrant
  
• especially after the child vomits

49
Gastroesophageal Reflux

• Relaxation or incompetence of the lower esophagus
  persisting beyond the newborn period

50

• Signs symptoms
• Regurgitation and vomiting
• weight loss and failure to thrive
• Respiratory problems
• aspiration
• Bleeding from esophagitis

51
Wilms Tumor (Nephroblastoma)

• MC intraabdominal tumor of childhood
• malignant
• 2-3 years of age
• Usual sign
• Painless enlargement of the abdomen

52

• Signs symptoms
• Firm, non-tender mass deep within the flank
• Only slightly moveable
• Not usually crossing the midline
• Sometimes bilateral
• Possibly
• Low-grade fever
• Hypertension

53
Neuroblastoma

• Solid malignancy in early childhood
• Frequently appears as a mass in the adrenal
  medulla
  
• May occur anywhere along the craniospinal axis

54

• Signs symptoms
• Firm, fixed, non-tender, irregular and nodular
  abdominal mass
  
• Malaise
• Loss of appetite
• Weight loss
• Protrusion of eye(s)
• Other symptoms may occur with
• compression of the mass
• metastasis to adjacent organs

55
Meconium Ileus

• Thickening and
• hardening of meconium
• in the lower intestine
• Lower intestinal obstruction

56

• Signs symptoms
• Failure to pass meconium in the 1st 24 hrs after
  birth
  
• Abdominal distention
• Must consider cystic fibrosis

57
Biliary Atresia

• Congenital obstruction or absence of some or all
  of the bile duct system

58

• Signs symptoms
• Jaundice
• Becomes apparent at 2-3 weeks
• Hepatomegaly
• Abdominal distention
• Poor weight gain
• Pruritis
• Stools become lighter in color
• Urine darkens

59
Meckel Diverticulum

• Outpouching of the ileum
• MC congenital anomaly
• of the GI tract
• Varies in size
• Small appendiceal process up to a segment of
  bowel several inches long
  
• Often proximal to the ileocecal valve

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• Signs symptoms
• If any, similar to
• Intestinal obstruction or diverticulitis
• Bright or dark red rectal bleeding
• Little abdominal pain
• Symptoms like those of acute appendicitis
  are not uncommon

61
Necrotizing Enterocolitis

• Inflammatory disease of the gastrointestinal
  mucosa
  
• Associated with prematurity
• Immaturity of the GI tract

62

• Signs symptoms
• Abdominal distention
• Occult blood in stool
• Respiratory distress
• Often fatal
• perforation and septicemia