Abdominal Cases

Inspection:
1- Abdominal Contour:
- Normally: convex from side to side & from front to back
- Scafoid (concavity): Dehydration, Diaphragmatic hernia, starvation, wasting
- Distended:
(I) Generalized:
1- (5F):
a) Fat (obesity): sunken umbilicus
b) Fluid ascites: marked in flanks
c) Flatus (gas): generalized
d) Faetus (pregnancy): central
e) Faeces (stool) in constipation
2- Bowl obstruction
3- Hypothyroidism
4- Rickets
(II) Localized bulging:
1- Hernia
2- Masses
3- Organomegaly
2- Movement of abdomen during respiration:
- Normally: is thoracico abdominal & is abdomino thoracic
- Diminution or absence of movement:
a) Peritonitis
b) Huge ascites
c) Paralytic ileus
- Seasaw abdominal movement ( paradoxical breathing)--. Collapse of
abdomen during inspiration & distension during expiration ( reverse
of normal) it indicates diaphragmatic paralysis
3- Visible Peristalsis:
- Normally Not seen, But may be in children & thin children
- If present intestinal obstruction (Absence of intestinal obstruction
& Need surgical operation
- Functional intestinal obstruction: absence of intestinal sound without
the need of surgical operation
4- Subcostal Angle:
a) Right or acute angle: normal.
b) Obtuse angle: hepatomegaly, splenomegaly.
It is referred to Intra- abdominal pressure
5. Umbilicus:
a) Shape:
- Normally slightly inverted.
- Eversion umbilical hernia, pregnancy, ascitis.
b) Site:
- Normally midway bet. xiphoid process & symphysis pubis.
- Displaced upwards masses from pelvis or lower abdomen.
- Displaced downwards masses from upper abdomen & ascites.
- Displaced sidewards tumour or organomegaly.

c) Colour:
- Bluish discoloration: acute pancreatits & intra-abdominal haemorrhage.
d) Infiltration:
- Malignancy.
- A reddish swelling in TB peritonitis.
e) Discharge:
- Pus discharge infection
- Urinary discharge patent urachus.
- Fecal discharge fecal fistula.
f) Impulse on cough: umbilical hernia.
6. Divarication of the Recti:
- Detected by asking the patient to rise from the supine position
without support
- It is due to weakness & stretching due to chronic distension of the
abdomen.
7. Dilated Veins
a) Visible veins: (without engorgement & tortuosity)no significance.
b) Dilated tortuous veins: IVC obstruction, Portal vein obstruction.
c) Dilated veins around umbilicus (caput medusae): due to opening of anastomosis bet. portal
& systemic veins around the umbilicus (portal hypertension).
Direction of Filling in the Dilated Veins:
1. The bl. is milked away from a segment of dilated vein by 2 index fingers
2. Apply firm pressure on both ends of the segment
3. The fingers are lifted one by one; while observe the rate & direction of bl. flow
8. Hernial Orifices:
- Epigastrium, umbilical inguinal & femoral Hernias should be inspected for hernial swellings
while the patient coughing, in case of acute abdomen to exclude strangulation.
9. Cutaneous Lesions:
- Skin rashes, Scars of previous operation, Striae due to abnormal stretching of the abdominal
wall from obesity, ascitis, cushing syndrome & corticosteroid therapy, Hyperpigmentation
10. Secondary sexual characters

Palpation:
The abdomen is divided to:
a) 2 horizontal Lines:
1- Subcostal
2- Intertuberrcular
b) 2 vertical planes which connect:
1- Tips of the 9th ribs.
2- Femoral arteries just below the inguinal canal.
i.e., the vertical lines pass each midway bet. the ant. superior iliac spine & the middle line.
Regions of abdomen:
1- Rt & Lt hypochondrium
2- Epigastrium
3- Rt & Lt Lumbar
4- Umbilical
5- Rt & Lt iliac
6- Hypogastrium or suprapubic

A) Superficial Palpation:
- Start from a point away from pain or from the Rt iliac fossa & proceed clock-wise to end in
the umbilical area
- Significance: Tenderness( by looking at the face during palpation), rigidity & masses
ex: Soft, relaxed, No tenderness, No abdominal Rigidity
B) Deep Palpation:
- Significance: to feel organs & masses.
1- Dipping Method:
- The fingers tips are suddenly pushed into the abdomen to displace the fluid momentarily &
causing the enlarged organ to rebound against the finger tips
- To feel organs & masses in presence of massive ascites
2- Bimanual Palpation:
- One hand is placed on the ant. abdominal wall & the other in the lion
- This method is useful in palpating the kidneys & sometimes the liver & spleen

Liver:
- Normally may be palpable, 1-2 cm below the Rt costal margin with rounded border in the
newborns & infants.
- The liver is palpated in 2 lines: MCL & midline.
- Start from the Rt iliac fossa, proceed towards the Rt costal margin.
1. Size:
Right lobe: measure the palpable liver in cm from the Rt costal margin in the midclavicular line.
Left lobe: measure the palpable liver in cm from the xiphisternum in the mid line.
2. Nature of the Border:
a) Roundedacute inflammation or congestion.
b) Sharpcirrhosis or fibrosis.
3. Consistency: Soft, firm or hard.
4. Surface: Smooth, nodular.
5. Tenderness.
6. Percussion:
- Percusse over it & then percusse from Rt 2nd intercostal space in the mid-clavicular line to
detect the upper border of the liver.
- The lower border of the liver is palpated then the distance bet. upper & lower borders are
measured in cm in MCL to get the liver span
- The left lobe is palpated from the suprapupic areatill the lower border then measure from the
Xiphisternum
Normal Liver Span:
-1st week: 4.5 cm to 5 cm.
- 6 month: 5 cm to 6 cm.
- 12 years: boys: 7cm to 8 cm. Girls: 6cm to 6.5 cm.
If the liver span is > normal values or if the lower border > 2 cm below the right costal margin;
the liver is considered enlarged.
Comment on liver: Rounded borders, firm in consistency, smooth surface, No tenderness, How
much cm from the costal margin
Causes of Hepatomegaly:
I. Infection:
1- Viral: Hepatitis A,B,C,D & E, EBV & CMV.
2- Bacterial: T.B., Brucella & typhoid.
3- Protozoal: Bilharziasis, leishmaniasis, malaria & toxoplasmosis.

II. Chronic Hemolytic Anemia:

1- Thalassemia.
2- Sickle cell anemia.
III. Collagen Vascular Diseases:
1- Systemic onset of JRA
2- Systemic lupus erythematosus (SLE)
3- Inflammatory Bowel disease.
IV. Neoplastic Disorders:
1- Leukemia & lymphoma.
2- Neuroblastoma.
3- Hepatoma.
4- Histocytosis.
5- Secondary deposits.
V. Metabolic Disorders:
1- Carbohydrate metabolism:
a) Glycogen storage disorders.
b) Galactosemia.
c) Hereditary fractose disorders.
2- Lipid metabolism
a) Gaucher's disease.
b) Niemann-pick disese.
c) Wolman's disease.
d) Gangliosidosis.
3- Protein metabolism
a) tyrosinosis.
b) Mucopolysaccharidosis.
c) Alpha-I-antitrypsin deficiency.
VI. Cardiac Causes:
a) Congestive cardiac failure.
b) Hepatic vein thrombosis.
c) I.V.C obstruction.
d) Constrictive pericarditis.
VII. Structural Liver Disorders:
a) Biliary atresia.
b) Polysystic disease.
c) Congenital hepatic fibrosis
Spleen:
- Normally maybe palpable 1-2 cm below the Lt costal margin in newborns & infants.
- Start from the Rt iliac fossa & proceed towards the Lt hypochondrium .
- If the spleen is not palpable roll the patient over to the Rt lateral position, splint the lower rib
cage with your Lt hand & palpate again while the patient is taking deep breaths.
- If the spleen is palpable:
1- Feel for the notch.
2- Detect the size, border, surface, tenderness
Causes of splenomegaly:
I. Infection:
1- Viral: e.g., E.B. virus. cytomegalovirus, viral hepatitis,
2- Bacterial: typhoid, brucellosis, septicemia, endocarditis.
3- Protozoal: malaria, leishmaniasis, schistosomiasis, toxoplasmosis.

II. Hemolytic disorders:

1-Thalassemia
2- Sickle cell anemia.
3- Spherocytosis
4- Autoimmune hemolytic anemia.
III. Inflammatory conditions:
1- SLE
2- Systemic rheumatiod artheritis
3- Polyarteritis nodosa.
IV. Neoplastic diseases:
1- Leukemias.
2- Lymphoma.
3- Histocytosis.
V. Storage diseases:
1- Gaucher's disease.
2- Niemann-pick disease.
3- Mucopolysaccharidosis.
Kidneys:
- Palpated bi-manually,
- Put the lt hand in the renal angle (posteriorly) & Rt hand in lumber area, Push the lt hand
upward & Rt hand downwards.
- Normally kidneys are not palpable except in the early infancy or very thin child where only
the lower pole is palpable, Rounded & firm
- If palpable look for:
Ballotment, Size, Consistency, Tenderness.
It Percussion note (band of resonance in front).
N.B.: Gross structural disease of the kidney causes pain which is felt in the renal angle in the
loin region bet. 12th rib above & the edge of erector spinales muscle medially
Difference bet. Lt Renal angle & splenic swelling
splenic swelling
1. Enlargement.
Downwards & medially
2. Hand insinuation (to get above the swelling). Not possible
3. Notch
May be felt.

Lt Renal angle
Renal Downward
Possible
Not felt

4. Ballottement

-ve

+ve

5. Traube's area
6. Renal angle
7. Movement with respiration

Dull
Resonant
Moves.

Resonant
Dull
Does not move

Dull.

Band of resonance (colon)

8. Percussion note.
Causes of renl enlargement:
1. Hydronephrosis & pyonephrosis.
2. Polycystic kidneys.
3. Tumors.
4. Renal thrombosis
Urinay Bladder:

- Distended bladder is felt in the supra-pubic area, It is globular arising from the pelvis.
- Percussion note is dull with a desire for micturition on handling.
Causes of distended bladder:
1- Normal child.
2- Outflow tract obstruction: post. urethral valve, stricture, stone.
3- Neurological: spina bifida, neurogenic shock.
Abnormal Abdominal Masses:
1- Rt hypochondirumHepatic enlargement, riedle's lobe of liver, gall bladder mass.
2- Lt hypochondirumSplenic enlargement, colonic mass, neuroblastoma.
3- Rt lumbarRt renal mass ( wilrn's tumor), Rt suprarenal mass.
4- Lt lumbarLt renal mass, Lt suprarenal mass.
5- Rt iliac fossaAppendicular mass, Crohn's disese, intest TB, ovarian cyst.
6- Lt iliac fossaFecal mass, ovarian cyst, sigmoid calon (thin child).
7- Epigastric: Hypertrophic pyloric stenosis (alive shaped mass elicited by a test meal),
choledochal cyst, pancreatic psuedocyts, bezoar

Percussion:
Look for:
1. Ascitis.
2. Any mass felt by palpation.
3. Borders of organs.
Ascitis:
a) Minimal: elbow knee position.
b) Moderate: shifting dullness.
c) Huge: transmitted thrill.
Knee elbow position:
- Put the child in knee elbow position (a puddle of ascitic fluid accumulates in the most
dependent part of the belly & may be percussed out
- Percuss over the umbilicus & note the dullness (normally it is resonant).
Shifting dullness:
- Start with the child in the supine position then pecuss from the umbilicus towards the Rt flank
note the point of dullness. Keep your finger at that point then turn the child over the Lt side &
wait for 30 sec. over the same area & note the resonance then repeat it on the opposite side
Fluid thrill
- Start with the child in the supine position & Put your hand flat on the child lumber region.
- Put the ulnar side of the assistant or the child's hand in the middle of the abdomen to cut off any
vibrations transmitted by the abdominal wall & tap the opposite lumber region & feel the
impulses by the flat hand .
Causes of asitis:
1. Transudate:
a) Nephrotic syndrome
b) Malnutrition.
c) Protein loosing enteropathy.
d) Hepatic failure.
e) Hepatic cirrhosis.
f) Portal hypertension.
g) Budd-chiari syndrome.
h) Congestive heart failure.
i) Constrictive pericarditis.

2. Exudate: Peritonitis.
3. Chylous:
a) Lymphatic obstruction.
b) Lymphangiectasia.
Auscultation:
1 . Intestinal Peristaltic Sounds:
Normally heard by the bell of the stethoscope every few min. as gurgle over the Rt iliac fossa &
1 cm to the Lt & above the umbilicus.
A) peristalsis: early stage of intestinal obstruction.
B) or absent peristalsis: paralytic ileus or late stage of intestinal obstruction.
2. Renal Bruit:
- Auscultate on both sides over renal arteries two centimet2 cm lateral to the umbilicus.
- Present in renal artery stenosis.
3. Venous Hum: Continuous murmur heard over the epigastric area in portal hypertension.
4. Splenic friction rub: Perisplinis.
5. Hepatic fridon rub: perihepatitis.
Back:
1- Swellings: meningocele, meningomyelocele.
2- Tuft of hair.
3- Defect on the spine (kyphosis, scoliosis, lordosis).
4- Discolouration.
5- Scar.
6- Spina bifida.
Genitalia:
Rectal Examination:
- Done at the end of abdominal examination,not performed in routine abdominal examination &
reserved for children with lower abdominal pain, masses, rectal bleeding & child abuse.
- Explain to the child and parents & Use lubricant.
- Keep the child in the left lateral position with knees flexed.
Inspect for:
1- Anal fissure.
2- Skin tags.
3- Fistula.
4- Signs of child abuse e.g.. abrasions.
5- Thread worms.
Palpate:
1- Anal tone: Tight in anal stenosis & Absent in spina bifida.
2- Mass: Fecal mass, Intussusception, Appendicular mass.
3- Tenderness: Look at the finger-tip for bl., current Jelly stools.