Obtain a lucid account of history of present illness in a chronological order without distorting the facts by asking too many direct or leading questions. Special attention should be paid to the onset (acute, subacute, insidious) and evolution (progressive, resolving, static) of the disease process and response to therapy. The common symptoms of gastrointestinal disorders include abdominal pain, bowel disturbances (diarrhea, constipation), vomiting, abdominal enlargement, jaundice, alteration in appetite (anorexia or excessive appetite) and failure to thrive.
Fever may be a dominant feature in children with tuberculosis, malaria, kala azar, viral hepatitis, cholangitis, liver abscess, leptospirosis and malignant disorders. Septicemia due to Gram-negative microorganisms is common in children with chronic hepatic dysfunction due to by-passing of reticuloendothelial barrier of the liver by opening up of porto-systemic channels.
The potbelly contour of abdomen is normal in infants and should not be considered as an evidence of liver disease. Progressive abdominal distension may occur due to enlargement of abdominal viscera, ascites, tumor or gaseous distension.
Ask for history of jaundice at the onset of disease or in the past, whether jaundice is waxing and waning or it is progressively increasing in severity. Make sure that mother is not confusing pallor with jaundice by asking relevant questions. Information should be sought regarding the color of urine and stools. The passage of persistently clay-colored or acholic stools is highly suggestive of obstructive jaundice. History of intake of any hepatotoxic drugs or concoctions should be enquired. Ask for history of transfusion of blood products as a source of transmission of hepatitis B or C virus.
When abdominal pain is a dominant symptom, ask specific questions to identify its site (whether pointed with a finger or vaguely referred to by the whole hand), severity (mild or severe enough to make the child cry), nature (constant, boring, colicky), radiation, relieving and aggravating factors. Renal colic typically starts in the loin and radiates to the groin and sometimes towards genitalia and inner thigh. Midnight pain, which awakens the child, is always pathological while morning pain may be a prank to miss the milk or school. When a child complains of pain at multiple body sites i.e. abdomen, chest, limbs, headache etc it is usually psychogenic or functional.
Forceful or persistent vomiting in association with failure to thrive and bile-stained vomitus are invariably pathological. Ask duration, severity, frequency, nature of vomitus, aggravating and relieving factors, and associated features. Ask for history of gastro-intestinal bleeding (hematemesis, dysentery, hematochezia) and any generalized bleeding tendency. Most alimentary disorders are associated with anorexia. Excessive or voracious appetite may be seen in children harbouring ascaris, recovering from hepatic dysfunction or receiving corticosteroids. Ask discriminatory details regarding bowel disturbances. History suggestive of steatorrhea and evidences of deficiency of fat soluble vitamins (A,D, E,K) should be sought. Failure to thrive and developmental retardation may occur due to chronic liver dysfunction, intrauterine infections, and inborn errors of metabolism. Family history of tuberculosis and history of a similar disorder in other siblings should be enquired.
General Physical Examination
Attitude of the patient provides useful information. Children with peritonitis are motionless, while those with abdominal colic are restless. Pinched facies are seen in cirrhosis. Dyspnea may occur due to massive ascites. Eyes should be examined for proptosis (chloroma, neuroblastoma), cataract, Kayser-Fleischer ring, macular degeneration, chorio-retinitis, and signs of deficiency of fat soluble vitamins. Oral cavity should be examined for membranous pharyngitis (infectious mononucleosis), herpangina, hypertrophied gums and macroglossia (glycogen storage disease, mucopolysaccharidosis and hepatocarcinoma). Record temperature, pulse, respiration, and blood pressure. Look for anemia, cyanosis (portal azygos shunt), jaundice and lymphadenopathy. Assessment of degree of pallor poses practical difficulties in a jaundiced child. Palpebral conjunctiva, dorsum of tongue and nails are reliable sites for clinical evaluation of anemia. Jaundice is evaluated by examining scleral conjuctiva, under surface of longue, buccal mucosa and skin in natural daylight. Muddy conjunctiva should not be mistaken with jaundice. In newborn babies, jaundice is best looked for by blanching the skin of the face around the nasolabial folds, root of the nose and cheeks.
Skin should be examined for any petechiae, ecchymoses, scratch marks, angiomas, exanthem, seborrheic dermatitis and photosensitivity. Examine nails for clubbing (cirrhosis, ulcerative colitis, chronic diarrhea).
Pedal edema, puffmess, ascites, and anasarca can occur due to hepatic and renal disorders and malabsorption.
Evidences of hepato-cellular failure. Jaundice, alterations in sensorium, fetor hepaticus (musty odor of breath due to mercaptans), “flapping tremors”, palmar erythema, hyperreflexia, extensor plantars and spider nevi should be looked for. “Liver flap” is demonstrated by asking the patient to extend both arms and try to maintain hands in a dorsiflexed position. There will be nonrhythmic asymmetric lapse or drop of hands due to inability to sustain the position. Rarely, gynecomastia and testicular atrophy may be seen in adolescent boys.
Bony tenderness is an important sign of infiltrative disorders of bones especially acute leukemia. Skeletal deformities (mucopolysaccharidosis), evidences of osteochondritis (congenital infections especially syphilis), rickets (cystinosis and tyrosinosis) and pathological fractures (Gaucher’s disease) should be looked for. Growth and development is retarded in children with inborn errors of metabolism, intrauterine infections and chronic liver dysfunction.
Spine should be examined for Pott’s disease.
Psoas sign appears due to inflammation of psoas muscle due to appendicitis, iliac adenitis and perinephric abscess. It is characterized by slight flexion of thigh, limp and pain on sudden extension of hip joint. Flexion and internal rotation of thigh may also cause abdominal pain (obturator sign).
Look for hemihypertrophy that may be associated with Wilm’s tumor, adrenal and hepatic tumors and visceral hemangiomas.
Examination of Abdomen
Clinical quadrants. Right hypochondrium, epigastrium, left hypochondrium. right lumbar, umbilical, left lumbar, right iliac fossa, hypogastrium and left iliac fossa.
Movements of all quadrants, fullness whether localised or generalised, position and shape of umbilicus (flushed or everted), discharge, inflammation, nodule etc. should be looked for. There may be umbilical granuloma or bright red polyp in a newborn baby. Polyp may have a small opening discharging urine (persistent urachus or urachal cyst) or serosanguinous or fecal matter through omphalomesenteric duct.
Look for any visible and engorged veins and assess direction of flow of blood. The direction of flow of blood may be determined by placing both the index fingers at a point over the engorged vein. The vein is emptied by stripping one of the index fingers over it. One index finger at a time is taken off the vein to ascertain the direction of flow of blood. The normal flow of blood is away from the umbilicus thus draining the blood from the umbilical veins into the portal system. In portal hypertension, there are periumbilical engorged veins with exaggerated flow of blood away from umbilicus (caput medusae). In inferior vena caval obstruction, the engorged veins are at the flanks with flow of blood from below upwards while in superior vena caval obstruction, the engorged veins are above the umbilicus with flow of blood from above downwards.
The distension and enlargement of the abdomen may be due to fluid, gas, feces, fat or a mass.
Site and direction of persistaltic waves should be looked for. Gastric peristalsis waves, passing across the upper abdomen from left to right, are classically seen in infants with pyloric stenosis.
The hands should be warm and nails should be trimmed for satisfactory abdominal examination. Divert child’s attention during palpation. Infants are generally apprehensive and often cry and strain thus tensing the abdomen. It is best to examine an infant in the mother’s lap. Breastfeeding is the best soother to elicit cooperation. Preschool children are best examined in a standing position. During palpation watch the child for any change in facial expression, wincing or screwing of eyes or forehead as an evidence of tenderness. It is unnecessary and unreliable to ask the child whether it hurts. Dipping technique is used if massive ascites is present. The viscera are explored by sudden but gentle dipping of fingers. At times satisfactory abdominal examination is possible only after paracentesis. Feel of abdomen may be normal, soft, doughy, tense and rigid. Tenderness may be localized, generalised and gurgling sounds may be palpable. Edema of abdominal wall is assessed by pinching the skin for 5 seconds.
Look for enlargement of liver (don’t forget to identify the upper border and span), spleen, kidneys, caecum and descending colon.
Liver is normally palpable upto 2 cm below the costal margin throughout childhood while spleen lip may be palpable in infants during first 3 months of age. The normal liver is soft and has a rounded margin. Ascertain the consistency of liver and whether surface is smooth, granular or nodular. When margin of the liver is sharp and well defined, it is suggestive of firm or hard consistency of the organ. Turn the child to right lateral position to feel the tip of just palpable spleen. Spleen becomes palpable when it enlarges to at least two to three times its size. The enlargement of liver and spleen is measured from the mid calvicular point over the costal margin to the lower most edge of the organ. Kidneys should be palpated by bimanual technique. Renal angles, their fullness, tenderness and pitting edema should be looked for.
Look for any mass and assess whether it is intra-abdominal or in the wall of abdomen by rising test. When a patient is asked to sit up from supine position, intrabdominal mass becomes less prominent while parietal mass becomes small and immobile. Divarication of recti is noted as a linear bulge between the recti muscles when a supine child is asked to sit up. Identify the site, size, shape, mobility of the mass with respiration and from side to side, bimanual palpability, does it cross the midline and whether it is pulsatile or not. The consistency, margins, tenderness, percussion characteristics of the mass should be ascertained. Special technique is used for palpation of pyloric tumor. While infant is being fed, the pylorus is explored with fingers of left hand by palpating gently but deeply lateral to the edge of right rectus muscle in the epigastric region. Pyloric mass is located at a point 2 to 3 cm above and to the right of umbilicus. Midline globular cystic mass over the suprapubic region is usually due to distended bladder. The swelling disappears on evacuation of urine. In children with constipation hard fecal masses (which can be indented on pressure) are felt over the left lower colon region.
The hernial sites should be examined for umbilical and inguinal hernia. Transillumination of swelling whether parietal or intrabdominal, is useful to differentiate between a cystic and solid mass. Examine external genitals for any abnormality.
|Age (years)||Liver span Boys||SEM Boys||Liver span Girls||SEM Girls|
Look for shifting dullness, fluid thrill, puddle sign, and percuss over the mass. For eliciting shifting dullness, the patient is placed in a supine position.
Percussion is performed from umbilicus towards one of the flanks (avoid the flank which is occupied by an enlarged viscus or mass) till dullness is elicited. The child is turned to the other side and held in lateral position to allow the fluid to gravitate towards the umbilicus. In this position, the nondependent flank will become resonant while percussion would be dull over the umbilicus and dependent flank. Fluid wave or thrill appears later and is elicitable when ascites becomes moderate or massive. One hand is placed over the flank and sharp taps are given over the other flank with the index finger of dominant hand of examiner. Distinct thrill due to movements of ascitic fluid shall be appreciated. To prevent transmission of tapping impulse to travel through the abdominal wall, assistant or patient is asked to firmly place hypothenar edge of his outstreched hand over the midline of abdomen. Massive ascites with non-pitting unilateral lymphedema of a limb is suggestive of chylous ascites. For the diagnosis of minimal ascites the child is placed in knee-elbow position to ensure gravitation of fluid to mid abdominal position. The chest piece of stethoscope is palced over the mid abdomen and abdominal wall is gently tapped with index finger moving from one flank towards the center till water puddle sound is audible when edge of the ascitic fluid pocket is tapped (Puddle sign). Liver dullness, which is normally present between 6th rib to costal margin may be obliterated if there is free gas in the peritoneal cavity. Splenic dullness spans from 9th to 11th ribs.
Hydatid thrill should be looked for whenever there is gross isolated hepatomegaly or splenomegaly. The displaced scolices and hydatid “sand” touch the pleximeter finger soon after the tap.
Peristaltic sounds may be normal, decreased, absent or exaggerated (borborygmi). Friction sound over the enlarged liver and spleen is suggestive of perihepatitis and perisplenitis (sickle cell anemia, abscess, leukemic infiltrates). Bruit over the hepatic area suggests the possibility of hereditary hemorrhagic telangiectasia or hemangioendothelioma. Venous hum may be audible over the epigastric region in children in whom extensive porto-systemic collateral circulation is established. Bruit over the lumbar areas anteriorily on either side of midline should be looked for in children with hypertension. The abdomen should be firmly compressed backwards with the chest piece of stethoscope to identify the bruit due to renal artery stenosis.
Hernial sites should be examined. Hernia, hydrocele, tumor of testis, epidydmitis, orchitis, torsion of testis, developmental anomalies and ambiguous genitals should be excluded. Tight prepuce or phimosis and balanitis or meatitis are important correlates of urinary tract infection in boys and must be looked for. Cryptorchidism must be excluded as it may be unrecognized by the parents. Look for any vaginal discharge, redness, foreign body, clitoral enlargement and hematocolpos in girls. Assess the sexual maturity rating. The adolescent girl must be examined in the presence of a nurse or female attendant.
It is indicated in children suspected to have intestinal obstruction (Hischsprung’s disease, intussusception), mass extending into the pelvis, rectal bleeding and urethral stone. Examine the anus for fissure and rectal prolapse. The child is made to lie in the left lateral position and the right thigh and right knee are flexed. The examination is conducted by using the smallest finger depending upon the age of the child. A well lubricated little finger is used in newborn babies and infants, and index finger in an older child. The child should be asked to relax and take deep breaths.
Clinical Characteristics of Common Organomegalies
Liver. The liver is normally palpable upto 2 cm below the right costal margin throughout childhood. It is normally soft in consistency and has a rounded margin. The pathological enlargement may occur upwards though it is generally downwards towards the right hypochondrium and iliac fossa. The margin is well defined and it moves freely with respiration. The fingers cannot be insinuated between the liver and costal margin. It is not bimanually palpable and is not mobile from side to side. The enlargement may affect any lobe of the liver but generally both lobes are simultaneously enlarged. It is dull on percussion and dullness merges with subcostal hepatic dullness.
Significant hepatomegaly with minimal or absence of splenomegaly is seen in children with CHF, liver abscess, hydatid cyst, glycogen storage disease, cirrhosis, primary or metastatic malignancy, mucopolysaccharidosis, veno-occlusive disease, Budd-Chiari syndrome, persistent hepatitis and tuberculosis.
Gall bladder. The enlargement of gall bladder is uncommon in children. It presents as a pear-shaped swelling which projects beneath the center of the undersuface of the liver. It is cystic in consistency and freely mobile from the side-to-side. Murphy’s sign may be positive. Maintain constant but gentle pressure over the gallbladder region and ask the patient to take a deep breath. The patient “catches his breath” due to pain when gall bladder touches the fingers. Choledochal cyst produces a cystic swelling at a site identical to gall bladder but swelling appears rather early in life and is fixed and non mobile.
Spleen. The spleen has to enlarge by about two to three times before it becomes palpable. It enlarges downwards and medially towards the umbilicus. It freely moves with respiration. The margin is characterized by a notch. The finger cannot be insinuated between the spleen and the costal margin. Anteriorily it is dull on percussion while posteriorily it is resonant. It is not palpable bimanually.
Massive splenomegaly with minimal hepatomeglay is seen in children with portal hypertension, thalassemia major, chronic myeloid leukemia, myeloid metalplasia, chronic mal’aria, kala azar, Gaucher’s disease and amyloidosis.
Kidneys. Either one or both the kidneys may be enlarged. The bean-shaped mass with rounded margins is located in the lumbar region. It does not move freely with respiration. It is located more posteriorily causing bulging of the renal angle. It is bimanually palpable and mobile from side to side. The kidney mass is resonant on percussion anteriorily but dull posteriorily.
|General physical Examination||Appearance, comfortable, sick, restless, nutritional status, vital signs, anemia, cyanosis, jaundice, lympabednopathy, evidences of vitamin A deficiency, proptosis, aniridia, petechiae, ecchymoses, scratch marks, angiomas, spider nevi, xanthoma, clubbing, edema, ascites, bony tenderness, skeletal deformities, hemihypertrophy, growth and development, evidences of hepato-cellular failure.|
|Inspection||Distension; localized or generalized, umbilicus, peristaltic waves, engorged veins, and spider nevi.|
|Palpation||Feel of abdomen, tenderness, edema of abdominal wall, flow of blood in the engorged veins, enlargement and characteristics of liver, spleen, kidneys and any other mass, renal angles and hernial sites.|
|Percussion||Shifting dullness, fluid thrill, percussion over various organomeglies and massess, upper border of liver, obliteration of hepatic dullness etc.|
|Auscultation||Peristaltic waves; normal, increased, decreased or absent, friction sound over the masses, bruit over the hepatic area and renal vessels.|
|Genitals and rectal examination||Hernial sites, appearance and development of external genitals, hydrocele, development anomalies, epidydmitis, orchitis, infiltration of testes and when indicated rectal examination.|