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Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Abdominal
Examination Guide
General
1. On approaching a child:
Look around room: Any medications /
nutritional drink lying on the table
View from Distance
Nutritional status: I would like to plot his
height and weight on a growth chart
? Failure to thrive
Well/ unwell: conscious level (hepatic
coma)
2. Dysmorphic features (mucopolysaccharidoses)
3. Skin Colour (sallow / yellow / green / brown)
- Increased body hair / facial hair (ciclosporin)
- Skin rashes: Dermatitis herpetiformis ,
Telangiectasia (Osler Weber Rendu)
- Perioral freckling (Peutz-Jeghers)
- Pigmentation: Caf-au-lait spots
(Neurofibromataosis 1 GI stromal tumours
palpable abdominal mass), Incontinentia
pigmentosa
4. Nutritional support
Nasogastric tube
Total parenteral nutrition
PEG tube

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Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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5. Peritoneal dialysis catheter
6. Urinary catheter spina bifida
7. Older child in nappies incontinent (neuro/
behavioural)
Hands:
Finger clubbing (Cystic fibrosis, liver disease,
Inflammatory bowel disease, coeliac disease)
Koilonychia (Iron deficiency anaemia)
Leuconychia (Cirrhosis)

Palms:
Palmar erythema (chronic liver disease)
Pallor of palmar crease
Hepatic flat (Liver failure, renal failure, CO2
retention)

Arms
Tuberous (elbow) / tendon xanthomas
(hypercholesterolaemia)
Bruising (Liver dysfunction, haematological
disorders)
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Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Scratch marks
Spider naevi

Face
Eyes: Jaundice (Sclera), anaemia (Conjunctiva),
Kayser- Fleischer Ring
Face plethora: Chronic liver disease
Cyanosis: Hepatopulmonary syndrome -
Transplantation
Mouth: Pigmentation (Peutz- Jeghers syndrome)
Ulcers (Apthous ulcers: Crohns disease, ulcerative
colitis, coeliac disease, behcets disease)
Gum hypertrophy (myeloid leukaemia, ciclosporin,
phenytoin)
Tongue: Macroglossia (hypothyroidism, Beckwidth-
Wiedemann, mucopolysaccaridoses, Pompss
GSD, Amyloid, haemangioma, lymphagioma)
Glossitis : Iron, folate, B12 deficiency

Neck and Chest
Spider naevi
Gynaecomastia (chronic liver disease)
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Abdomen
Inspection:
1. Shape
2. ? Distension (central flank?, generalised/
localised, symmetrical?)
- 5Fs : Faeces (Hirschsprung constipation), flatus,
fat, fluid (ascities, nephrotic syndrome), fetus
3. Obvious masses
4. Scars: Renal angle scars / Laparoscopic
surgery / Liver Biopsy
Groins inguinal hernia repair, renal transplant
(will also be palpable mass)
Below right subcostal margin (Kochers incision)
think cholecystectomy, especially in sickle cell
disease, any liver procedure, e.g.
hemi-hepatectomy for hepatoblastoma
Rooftop scar liver transplant
Transverse upper abdominal incision repair of
congenital diaphragmatic hernia more common
on the left
Upper abdominal midline incision Nissens
fundoplication
Small right upper transverse incision
Ramstedts pyloromyotomy
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Umbilicus consider gastroschisis or exomphalos,
umbilical hernia repair
Laparoscopy scars more common, very small
and multiple (often one at umbilicus)
Lateral thoracolumbar incision nephrectomy
5. Striae
6. Caput medusae (Blood flows away from
umbilicus)
Differentiate from superior vena cava
obstruction (flows inferiorly)/ Inferior vena
cava obstruction (flows superiorly)
7. Other: Stomas: Ileostomy vs Colostomy ;
Mucous fistula
Caecostomy tube for entergrade enemas in
children with chronic constipation (MACE
procedure Malone antegrade colonic enema)
Mitrofanoff, Peritoneal dialysis catheter
8. Get patient to blow tummy up / flatten tummy
9. Get patient to raise head : hernia
/ Divarification of recti
Palpation
Patient should be on a supine position.
However, if patient has gross ascites, you
might want to ask him whether it is
comfortable for him to lie flat as he might
have difficulty breathing if lying flat.
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Be sensitive. Tell the child: I am going to
feel your tummy. Please let me know if you
feel any pain or if you want me to stop, ok?
. Whist palpating, look at the childs face. If
the childs winced, stop and apologise and
ask the child if he is ok.
If you are tall or the bed position is low,
you might want to kneel down when doing
palpation.

1. Superficial palpation
Palpate systematically. You may start from left iliac
fossa and proceed in the direction above.

2. Deep palpation (palpate deeper for deeper
masses. Again, warn the child that you are going to
feel deeper and ask him to tell you if he feels any
pain.
3. Liver (Palpation + Percussion)
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Palpate upwards from right iliac fossa towards
right subcostal margin until you feel the liver edge.
Ask the patient to take a deep breath and try to
feel the liver edge as it descends.
If you feel a mass, describe the surface (smooth or
nodular) , consistency (hard/ soft) , edge (regular/
irregular)
Percuss from right lower quadrant of the
abdomen upwards until the sound changes from
resonant to dull. This denotes the livers lower
border.
Then percuss from right upper chest downwards,
starting in the midclavicular line at about the 3rd
intercostal space. Percuss inferiorly until dullness
denotes the livers upper border. Measure the liver
span in centimetres

4. Spleen
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Palpate from right iliac fossa towards left subcostal
margin to feel for spleen. As you reach the left
subcostal margin, ask the patient to turn slightly
towards you (his right side) , and palpate in the left
subcostal area.

5. Kidney
Place one hand under the patient in the right flank
region and the other hand on top and try to ballot
the kidney between the two hands. Repeat for the
left side.


How to differentiate between liver, spleen and
kidney
Liver Spleen Kidney
Dull Dull Resonant
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Moves with
respiration
Moves with
respiration
Does not
move with
respiration
Notch Ballotable
Cannot get
above it
Cannot get
above it
Can get
above it
Right
hypochondrium
Left
hypochondrium

Percussion
Shifting Dullness (if distended)
Fluid thrill

Auscultation
Bowel sounds
Liver bruit
Renal bruit (hypertension,
neurofibromatosis)

Other (Mention that I would also like to
examine the patients.)
Hernia orifices 1.
External genitalia 2.
Back and perianal area 3.
Inspect stool 4.
For renal examination:
BP 1.
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Urinalysis 2.
Assess for signs of steroid toxicity 3.



GI Revision Notes

Portal hypertension consists of:
Splenomegaly
Ascites
Portosystemic shunts (Caput medusae,
haemorrhoids, oesophageal varices)

Causes of portal hypertension:
Prehepatic-Portal vein thrombosis
(thrombophilia), postnatal umbilical vessel
catheterization, sepsis
1.
Hepatic cirrhosis, congenital hepatic
fibrosis
2.
Posthepatic Budd-Chiari syndrome,
(hepatic vein obstruction), heart failure
3.

Causes of hepatomegaly
1. Structural: Extahepatic biliary atresia,
choledochal cyst, intrahepatic biliary hypoplasia,
congenital hepatic fibrosis, polycystic disease
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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2 . Storage/ metabolic:
- Carbohydrate- glycogen storage disease (Type
1,3,4,6), hereditary fructose intolerance,
galactosaemia,, mucopolysaccaridoses-
- Mineral: Wilsons disease, juvenile
haemachromatoses
-Nutrition: Protein calorie malnutrition, TPN-Bile
flow: progressive familial intrahepatic cholestaisis
syndrome
-Protease: Alpha-1-antitripsin
-Electrolyte: CF
- Amino acid: Tyrosinaemia type 1, urea cycle
disorder
-Lipid Gaucher, Nieman-Pick diease, cholesteryl
ester storage disease
3. Haematological: Thalassaemia, sickle cell
disease, ALL, AML CML
4. Heart/ Vascular: Conestive heart failure,
constrictive pericarditis, obstructive IVC,
Budd-Chiari syndrome
5. Infection: Viral rubella, CMV, coxsackie virus,
echovirus, hepatitis ABCDE, EBV ; Bacteria E.coli
TI, TB, syphilis ; Parasite Malaria, toxoplasmosis,
Schistosomiasis
Causes of splenomegaly
Haematological causes
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Lymphomas 1.
Leukaemia 2.
Myeloproliferative disorder (myelofibrosis,
CML)
3.
Haemolytic anaemia (Hereditary
spherocytosis, sickle cell anaemia, G6PD,
thalassaemia)
4.
Extramedullary haemopoiesis
(Thalassaemia)
5.
Infections
Acute: Endocarditis, typhoid 1.
Chronic: TB, brucellosis 2.
Parasite: Malaria, schistosomiasis, Kala
azar, toxoplasmosis
3.
Inflammation
Rheumatoid Arthritis (Feltys syndrome) 1.
SLE 2.
Sarcoidosis 3.
Idiopathic Thrombocytopenic purpura 4.
Other
Portal hypertension 1.
Amyloidosis 2.
Gauchers disease, Nieman Picks disease 3.
Tropical splenomegaly 4.
Causes of hepatosplenomegaly
Hepatic: Cirrhosis, congenital hepatic
fibrosis, biliary atresia, sclerosing
cholangitis
1.
Haematological: Thalassaemia, hereditary
spherocytosis, sickle cell anaemia
2.
Infection: EBV, TORCH 3.
Malignancy: Leukaemia, lymphoma 4.
Abdominal Examination Guide | MRCPCH Clinical Revision http://mrcpch.paediatrics.co.uk/abdominal/abdominal-examin...
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Metabolic: alpha1-antitripsin, tyrosinaemia,
cystic fibrosis
5.
Storage disease: Gaucher (long term),
Niemann-Pick disease,
mucopolsaccharidoses
6.
Causes of ascites
Cirrhosis
Congestive heart failure
Hypoalbuminaemic states (nephrotic
syndrome, malnutrition)
Infection: TB
Malignancy
Hepatic vein thrombosis
Meigs syndrome
Pancreatitis

Indications of liver transplant
Acute liver failure
Decompensated chronic liver disease
Liver-based metabolic disease
Liver tumour
Pictures of ACE/ Stoma/ PD/ PEG / PEJ/ mitrofanoff

Author: Dr. Katherine Fawbert and Dr. Huey Miin
Lee

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"
2014 Trainees Committee, London
School of Paediatrics
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