Examination of Pediatric Gastrointestinal tract

1. CLINICAL
EXAMINATION
OF GIT
Dr. Harish Kumar Singhal
Associate Professor
University College of Ayurved
Dr. S. R. Rajasthan Ayurved
University, Jodhpur
Email:-drharish_md@yahoo.co.in

2. EXAMINATION OF
GASTROINTESTINAL TRACT
The common symptoms of gastrointestinal disorders are-
• Abdominal pain
• Bowel disturbances (diarrhea & constipation)
• Vomiting
• Abdominal enlargement
• Jaundice
• Alteration in appetite(anorexia or excessive appetite)
• Failure to thrive.

3. ABDOMINAL PAIN
• Ask question-
• Severity of the pain-(mild, moderate, on& off pain)
• Nature of the pain - (constant , burning colicky)
• Radiation of the pain –
• Renal colic typically starts in loin and radiates to
the groin.
• Relieving & Aggravating factors.
• When the pain is coming.-(midnight or morning)
• Identify its site -
(Pointed with a finger or whole hand.)
• Associated symptoms - (Fever, vomiting & stool
pattern.
• Relationship with food.
• Family history.
• Medical history.
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4. SITE OF PAIN
•Epigastric pain-
•Liver
•Pancreas
•Origin from stomach
•Lower esophagus.
•Right hypochondriac
•Liver
•Gall Bladder
•Peri-umblicus
•Small Intestine
•Proximal Transverse Colon
•Right Iliac
•Appendix
•Caecum
•Hypogastric pain
•Distal Colon & Urinary Bladder
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5. SITES OF ABDOMEN
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6. Vomiting.
• Ask the duration
• Severity.
• Frequency
• Nature of vomits
• Aggravating and relieving factors
• Associated features
• Vomiting is forceful or persistent
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7. • Frequency of Vomiting
• acute, frequent or recurrent
e.g. Acute gastroenteritis
Acute Intestinal obstruction
• Chronic, frequent or recurrent
e.g. peptic ulcer disease
• Nature of Vomits
i. Vomits persistenly not bile stained
e.g. congenital hypertrophic pyloric stenosis
acquired pyloric obstruction
ii. Bile mixed ( yellow or greenish yellow colored) vomitus indicates – duodenal
contents coming to stomach.
e.g. obstructive cause – where the site of obstruction is distal to opening of bile
duct.
iii. Faeculent vomitus – distal part of small gut or large gut obstruction .
iv. Foul smelling vomitus, projectile usually in the afternoon / evening containing
old food particles - pyloric obstruction.
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8. THE MOUTH & THROAT
• Inspection
• Lips
• Palate
• Look corners of the mouth for cracks or fissures.
• Observe any desquamation or inflammation of the lips.
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9. Chilosis present on the corners of lip
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10. ORAL CAVITY
• Look for thrush (monilial, stomatitis).
• Oral ulcers
• Membranous pharyngitis.
(streptococcal pharyngitis diphtheria infectious)
• Hypertrophied gums and
• Macroglossia. (glycogen storage disease
mucopolysaccharidosis and hepato carcinoma)
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11. Oral ulcers
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13. • Oropharyngeal candidacies
(cell mediated immuno deficiency )
• Aphthous ulcers --are small superficial pain full ulcers with a white or
yellow base with an erytheatous halo of hyperemia
(it is distributed on gums buccal mucosa tongue & plate)
• Pigmentation of lips and buccal mucosa
(PEUTZ-JEGHERS SYNDROME.)
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14. Aphthous ulcers
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15. Peutz jehers syndrome -
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16. •Strawberry tongue
(bright red enlarge papillae jutting against the bright red suffice of
the tongue)
• SCARLET FEVER
• KAWASAKI DISEASE.
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17. • Bald and Smooth-tongued
• Vitamin B12 deficiency,
• iron deficiency anemia,
• pellagra, &
• celiac disease
• Scrotal tongue
• Scrotal tongue is also known as
grooved, furrowed, wrinkled, fluted,
plicated or ribbed tongue.
• According to Prinz and
Greenbaum scrotal tongue affects
about one half per cent of the
population.
• The anomaly is usually familial or
congenital.
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18. Con genital fissuring of tongue found in Down syndrome
Tongue is coated in the center and clear at margins- in(ENTERIC FEVER)
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19. • Gum problems.
Scurvy –soft & bleeding
cyanotic
Chronic lead poisoning-
punctuate blue line over gum. congenital heart
diseases-spongy
,bluish, some time
bleeding
Acute non
lymphoblastic
leukemia –soft
hypertrophied and
bleeding.
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20. TEETH
Particularly to
look for caries
Dental caries
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21. • Inspection.
• For clinical purposes the abdomen is divided in to nine parts
1. Right hypochondrium.
2. Left hypochondrium
3. Epigastrium.
4. Right lumbar.
5. Left lumbar.
6. Umbilical.
7. Right iliac.
8. Left iliac .
9. Hypo gastrium.
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23. INSPECTION
• Shape of abdomen
• Normal shape
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24. SCAPHIOD ABDOMEN
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25. • Distension of abdomen
• Generalize distension and enlargement of the abdomen may be
i. Fluid
ii. Gas
iii. Feces
iv. Fat
v. Mass
• Intestinal distension
• Ascites.
• Obesity.
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26. Distended abdomen on PEM
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27. • Localized distension may occur
around .
a) umbilicus small bowel obstruction.
b) Hypochondriac regions liver, spleen.
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28. UMBILICUS
• Position and shape of umbilicus.
• Any discharge from the umbilicus.
• In the ascites umbilicus appears as transverse slit .
• Any umbilical hernia.
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29. UMBILICAL HERNIA
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30. EVERTED UMBLICUS OF BABY IN ASCITES
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31. UMBILICAL GRANULOM
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32. INSPECTION FOR ENGORGED VEIN
• Look for any visible and engorged
veins and assess direction of flow of
blood.
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33. ENGORGED VEIN’S OVER THE ABDOMEN 4/24/2021
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34. •Atrophic white or pink wrinkled
stare may appear on the
abdominal wall.
Rupture of elastic fibers
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35. Site and direction peristaltic
waves.
upper abdominal from left to right.
(can seen infants with pyloricstenosis)
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36. PALPATION
• Hands should be warm and nails should be trimmed for satisfactory abdominal
examination.
• Best to examine an infants in the mother's lap.
• Breast feeding is the best soother to elicit cooperation.
• Pre school children are best examined in a standing position.
• During palpation watch the child for any change in facial expression.
• Wincing or screwing of eyes.
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37. • Forehead as an evidence of tenderness.
• Feel of abdomen may be normal, soft, doughy, tense and rigid.
• Tenderness may be localized generalized and gurgling sounds
may be palpable.
• Edema of abdominal wall is assessed by pinching the skin for five
seconds.
• Look for enlargement of liver spleen kidneys caecum and
descending colon.
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38. LIVER
• Liver is normally palpable up to 2cm below right costal margin it is soft and
has a rounded margin.
• Patient will be in supine, abdomen relaxed with smooth respiration
• Palpation from right iliac fossa gradually upwards.
• The border and surface is palpated.
• With deep inspiration liver normally descends 1-3cm.
• Liver pathological enlargement may occur up wards though it is generally
downwards to the right hypochondriac and iliac fossa.
• (C.H.F.,liver abscess, glycogen storage disease 4/24/2021
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40. HEPATOMEGALY
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41. • When the surface is smooth granular or nodular .
• When margin of the liver is sharp and well defined
• The liver may pulsatile(tricuspid regurgitation)
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42. SPLEEN
• Turn the child to right lateral position to feel the tip of just
palpable spleen. spleen is palpable when enlarged to at least
two or three times its size
• Spleen tip is palpable in infants during the first three months..
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43. RIGHT LATERAL POSITION
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44. PALPATION OF SPLEEN
• First methods
• Child in right lateral position abdomen relaxed and
smooth respiration
• Examiner on left side of the child.
• Examiner places left hand over splenic area of lower
chest wall and the fingers curled below left costal
margin when the child is taking deep
respiration.(hooking method)
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45. • Second Method
• Child supine abdominal wall relaxed, smooth and
deep respiration .
• Examiner on right side of child.
• Examining finger palpating from right iliac fossa
upwards towards left hypochondria.
• With each inspiration the palpating fingers pressing
gently upwards and inwards.
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46. • The enlargement of liver and spleen is
measured from the mid calavicular point
over the costal margin to the lower most
edge of organ.
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47. •Percussion.
• look for
 Shifting dullness.
 Fluid thrill.
 Puddle sign.
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48. FOR ELICITING SHIFTING
DULLNESS
• The patient is placed in a supine position.
• Percussion is performed from umbilicus
toward one of the flanks 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.
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49. FLUID THRILL
• Fluid wave or thrill
appears later and is
elicitable when ascites
become 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.
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50. PUDDLE SIGN
• Child is placed in knee-elbow position to ensure
gravitation of fluid to mid abdominal position .
(for the diagnosis of minimal ascites.)
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51. AUSCULTATION
• Peristaltic sound may be-
• Normal
• Decreased
• Absent- Intestinal Perforation, Paralytic Ileus, Generalized
Peritonitis
• Exaggerated – Intestinal Obstruction, Intestinal Colic
• Friction sound over the enlarged liver &spleen-
• Sickle cell Anemia, Liver abscess and Leukemic Infiltrates
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52. Bruits
Heard over the hepatic area - hereditary hemorrhagic
telangiectasia.
Bruit over the lumbar areas
Anteriorly on either side of midline -
Hypertension
Venous hum
• May be audible over the epigastria region
• (hepatic or post hepatic cause of portal hypertension)..
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53. RECTAL EXAMINATION
• Perianal excoriation
• Muco cutaneous lesion
• Inflammation
• Skin tag
• Nappy rush
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54. SKIN TAG
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55. RECTAL PROLAPSE
Prolapsed of a polyp appears as a dark beefy red
mass as compared to lighter pink mucosal
appearance of rectal prolapes .
• Can be seen in
• Malnutrition
• Acute or persistent diarrhea
• Chronic constipation
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56. RECTAL POLYP
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57. Anal fissure
due to severe constipation.
ANAL FISSURE
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58. ANORECTAL ABSCESS
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59. Rectal examination.
• Child is made to lie in the left lateral position and the right thigh and knee
are flexed the examination is conducted by using small finger.
• Look for staining with mucus, pus ,and blood.
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