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![Spleen
Nixon technique: patient in the right lateral position. Percuss the
upper border in post axillary line. And the lower border obliquely from
below costal margin. [ sensitivity specificity]
Castell technique: patient in the supine position. Percuss the lowest
intercostal space [8th or 9th] in the anterior axillary line. Ask patient to
take strong inspiration during percussion, if dull =splenomegaly. [
sensitivity specificity]
4](https://image.slidesharecdn.com/pediatricgitexamination-200506172605/85/Pediatric-git-examination-72-320.jpg)
![Rectal examination
Normally done in
Acute abdomen
Chronic constipation
Rectal bleeding
Look for
Tone of anal sphincter and tenderness (anal stenosis loose patulous anus
[myelomeningocele], imperforate anus)
Masses ( feces, polyps, teratomas, foreign bodies)
Local abdominal tenderness
Blood or other staining
Rectal prolapse
Perianal area (thread worms, skin tags, protruding polyps, anal fissures, fecal
soiling)](https://image.slidesharecdn.com/pediatricgitexamination-200506172605/85/Pediatric-git-examination-77-320.jpg)
Uploaded byVirendra Hindustani
Pediatric git examination
This document provides an overview of pediatric gastrointestinal disorders and examinations. It discusses the anatomy of the GI tract, common signs and symptoms of digestive disorders in children, and specific pediatric GI conditions. It also provides detailed guidance on performing a complete GI examination, including inspection, auscultation, palpation, percussion, and examination of the oral cavity, abdomen, genitalia, and rectum. The goal is to gather all relevant clinical findings through the organized examination of the GI system.
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Pediatric git examination
- 1. Dr. Virendra KumarGupta MD Pediatrics Fellowship In pediatric Gastroentero-Hepatology & Liver Transplantation Assistant Professor Department Of pediatrics NIMS Medical College & Hospital , Jaipur
- 2. GI Tract• UpperGI Tract • Oral Cavity • Oesophagus • Stomach-pylorus • Duodenum • Lower GI Tract • Small intestine- • Duodenum-duodenojejunal flexure • Jejunum • Ileum-ileocaecal juction • Large intestine • Caecum • Colon- ascending/transverse/desce nding/sigmoid • Rectum • Anal canal •Foregut •Midgut •Hindgut ANATOMICAL DIVISION EMBRYOLOGICAL
- 3. SIGNS AND SYMPTOMSOF DIGESTIVE DISORDERS • Stomach pain • Nausea • Vomiting • Diarrhoea • Constipation • Abdominal Distension • Bleeding • Problems with appetite • Dysphagia
- 4. PEDIATRIC DIGESTIVE DISORDERS •Abdominal pain • Celiac disease • Colitis • Constipation • Crohn’s disease • Dysphagia • Esophagitis • Feeding problems, or failure to thrive • Food allergies • Gallbladder diseases • Gastrointestinal bleeding • Gastroparesis • GERD • Hirshsprung’s disease • Iron deficiency anemia • Irritable bowel syndrome • Inflammatory bowel disease • Intestinal pseudo-obstruction • Liver disease • Motility disorders • Pancreatic diseases • Peptic ulcers • Polyps • Obesity • Oesophageal/gastric varisces • Short bowel syndrome
- 5. Before starting GIExamination Wash hands / warm them Proceed calmly / don’t make sudden moves Shake hands and offer some candy or toy Introduce yourself / explain what you are going to do (older child/ parents) Ask the patient to point to the part which is tender(can be unreliable) Position the patient (depends upon child’s comfort) Expose the patient on required basis Approach from right side of the patient Gather as much data as possible by observation first Alter the sequence of examination if required but present it in a sequential manner Order of exam:least distressing to most distressing
- 6. COMPONENTS OF GITEXAMINATION General Physical Examination Oral cavity examination Abdominal examination Genitalia examination Rectal examination
- 7. GENERAL PHYSICAL EXAMINATION Generalappearance: Is the patient looks ill, unwell or healthy? Facial expression of the patient(e.g. anxious in case of colic). Posture in bed: Motionless in Peritonitis, appendicitis. Restless in abdominal Colic Patient suffering from renal colic rolls about on the bed like a snake. Dyspnea in case of massiveascites. Notice dysmorphic features. Vital signs: Temp,RR,PR, BP
- 8. GENERAL PHYSICAL EXAMINATION… Anthropometric measurements Height Weight BMI MAC/HC/CC Along with plotting on growth chart for assessment of nutritional state of the patient (PEM, OBESITY) due to Chronic diarrhea, malabsorption syndrome, celiac disease ,IBD and giardiasis.
- 9.
- 10. SKIN Pallor-Anaemia EchymosisRash Discoid Rash-Ulcerative colitis Petechial Rash Cyanosis Yellow-Jaundice Xanthlesma- Primary Bill. cirossis
- 11.
- 12. NAILS Koilonychia- Vit B12 def,IDA Clubbing- •PrimaryBiliary Cirrohis •IBD •Coeliac disease •Polpososis •GI lymphoma Leuconychia- hypoalbuminemia – liver failure / enteropathy
- 13.
- 14. ARMS • Spider naevi(telangiectatic lesions) • Scratch marks (chronic cholestasis)
- 15. Xanthelasma (primary biliarycirrhosis) EYESConjuctival pallor (anaemia) • Sclera: jaundice, iritis Kaiser Fleischer’s rings (Wilson’s disease)
- 16. General Physical Examination… Anemiais examined in: Palpebral conjunctivae,dorsum oftongue,nails,palms. Jaundice is examined in: Scleral conjunctivae,under surfaceof tongue,buccal mucosa,skin. In newborn babies jaundicen is best looked for by blanching the skin of the face arround the nasolabial folds,root of the nose and checks. Edema (Puffiness,ascites,anasarca, sacral, pedal)due to hepatic and renal disoeders andmalabsorption. Inspection of stools and urine.
- 17.
- 19.
- 20.
- 22. Jaundice Fapping tremor Palmar erythema Spidernevi Caput medusa Ascites HEPATO- CELLULAR FAILURE(ACUTE/CHRONIC) Alteration in sensorium,,Behavior changes,Irritability Sleep disturbance,drowsiness Fetor hepaticus,
- 23. ACUTEAPPENDICITIS. Mc- burney Tenderness Rovsings Sign Obturator Sign Psoas Sign Rebound tenderness
- 24. Examinationof : 1- Oralcavity. 2-Abdomen. 3- Rectum.
- 25. Examination of OralCavity Oral cavity is the window to the GI-system and is likely to mirror or exhibit the inflammatory changes of Gi-system.
- 26.
- 27. LIPS Colour Blue in cyanosis Palein anemia Any deformity Clift lip Corners of lips(fissuring or angularstomatitis) Any vesicles(HSV) Ulceration
- 28. GUMS Colour : Anemia Cyanosis Pigmentation Lead poisoning-blueline. Hypertrophy Bleeding
- 29. TEETH Number -Growth AndAge Congenital teeth in newborn babies Hutchison’s teeth- (Congenital syphilis)
- 30. TONGUE Colour Size Symmetry Dry(dehydration)or wet Surface of tongue(coated or raw) Bald tongue (Smooth tongue)in Vit-B12 deficiency,IDA Strawberry tongue in scarlet fever and kawaski disease Scrotal tongue in down syndrome Geographical tongue isbenign Tongue tie(ankyloglossia)
- 31. Tremors Dry Macroglossia Tremors Nervousness,Parkinsonism Size of tongue Macroglossia (cretins) Surface of tongue Dry tongue (dehydration) Bald tongue (Anemia) Furred tongue (smoking, mouth breathing) Ulceration (Whooping cough, T.B.) furred Ulceration Bald tongue
- 32. Atrophic glossitis ThrushGeographical tongue Baldtongue Pale tongue Cyanosis
- 33. PALATES,ORO-PHARYNX MOUTH Oral cavityand oro-pharynx is examined with the help of a tongue depressor for: • Colour • Ulcers • Deformity • Inflammatory changes Thrush(oral candidiasis) Membranouspharyngitis in strep,diphtheria,infecious mononucleosis
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- 35.
- 36.
- 37. Patient's position Infant in mother 'slap Infant in mother 's lap
- 38. INSPECTION :General 1.General condition 2.Jaundice 3.Pallor 4. Vircow’s Node: left supraclavicular LN enlargement. 5. Clubbing, palmar erythem, white nails, duptryn contracture. 6.Odema. 7.Gynecomastia 8. Mouth ulcers of IBD, Peutz-gagher perioral pigmentation, talangiectasia , MOUTH THRUSH.
- 39. INSPECTION: Abdomen Size &Shape (abdominal Contour) (up to 3Ys its protuberant) Any distension(localized orgeneralized) Skin: Tone/Colour/ Scar/Striae Prominent veins Visible loops of bowel/visible peristalsis Oedema Movements with Respiration Umbilicus(Inverted/Flat/Everted/Smiling ) Hernial orifices
- 40.
- 41. CAUSES OF DISTENSION •Gross distension (5 F) • Fluid • Flatus • Feces • Fetus • Fat • Localized distension • Loculated fluid • Mass • Hernia • Organomegaly • Impacted feces
- 42.
- 43. PROMINENT VEINS Caput MeduceCollateral veins Umbilicus(Inverted/Flat/Everted/Smiling )
- 44. VISIBLE LOOPS OFBOWEL/VISIBLE PERISTALSIS
- 45. Pitting edema ofAbd.wall Umbilicus(Inverted/Flat/Everted/Smiling )
- 46.
- 47.
- 48. AUSCULTATION Need to listenbefore percussion or palpation since these maneuvers may alter the frequency of bowel sounds Peristaltic sounds(bowel sounds): Normal (Gurgle) every 5-10 seconds Increase (intestinal obstruction/Diarrhoea) Absent (Paralytic ileus/Late Intestinal obstructuon) VENOUS HUMS B/W XIPHISTERNUM AND UMBILICUS Renal Bruit/Hepatic Bruit: Narrowing (stenosis) of arteries Succussion Splash Borborygmi - long, prolonged gurgles of hyperperistalsis - the familiar stomach growling Puddle Sign
- 49. EXAMINATION OF BOWELSOUNDS
- 50. Ausculatory percussion todetect small amount of ascetic fluid even up to 150ml which is not detectable by fluid thrill and shifting dullness. Knee-elbow position PUDDLE SIGN
- 51.
- 52. KEY POINTS INPALPATION Empty bladder Patient supine Flex Hip & Knee Arms at sides or folded across chest Before begin,point to areas of pain and examine last Warm hands and stethoscope Avoid long nails Approach slowly Distract the patient with conversation or questions
- 53. • Step 1:ask for any pain and location. • Step 2: – Start superficial palpation away from the site. – If none proceed with anticlockwise move starting from the LLQ : – look for tenderness, temperature, mass, rigidity, guarding, pulsation • Step 3: – Deep palpation starting from the LLQ. – Examine the Left large bowel, Spleen, Epigsatrium, Liver, RUQ, suprapubic and periumblical,Bimanual palpation for both kidneys • Step 4: Flank fullness and fluid thrill, Succusion splash STEPS IN PALPATION
- 54. Palpation of liver Inpalpation of liver consider its: Size, edge, surface, consistency, tenderness, pulsations Liver palpation can be done by four ways: 1. With tip of the fingers(preferred / Standerd method) 2. With radial edge of the right hand(Alternative method) 3. Hooking method 4. Dipping method
- 55.
- 56. With radial edge(alternative method)
- 57.
- 58. Dipping method ofpalpation In cases of massiveascites. How to dothis: Placing hand over the abdomen and making quick and gentle dipping movements (also known as one hand ballottement) Also with bimanual ballottement.
- 59. One hand ballottement Bimanualballottement
- 60.
- 61.
- 62. Bimannual method ofspleen palpation
- 63. PALPATION OF KIDNEYS Bimanualtechnique Palpated by standing on respective side lower pole may normally be palpable Asses anyTenderness (Murphy’s renal punch) Left kidney
- 64.
- 65. DIFFERENCE IN SPLEEN& Lt. KIDNEY EXAMINATION
- 66. Palpation… Palpable masses otherthan viscera: Hard feces Abdominal aorta Gastric mass (HPS) Abdominal lymph nodes • Para aortic lymph nodes / mesenteric lymph nodes When a mass is palpable consider its: Site,size,shape,any inflammatory signs over the • mass,pulsations,tenderness,mobility. Based on its location a mass could be:Inta-abdominal Extra-abdominal In theabdominal wall To distinguish between thesedo Rising test
- 67. PERCUSSION Objects of percussion: Todifferentiate between fliuds,solid masses,cyst,gases To elicit shiftingdullness To elicit fluid wave(fluidthrill) Puddle sign To determine liverspan.
- 68. PERCUSSION… LIVER Percuss for bothupper and lower borders Spleen Start percussing from RIF to LHC Place left middle finger parallel to the LCM Urinary Bladder Percuss from epigastrium towards hypogastrium
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- 70.
- 71.
- 72. Spleen Nixon technique:patient in the right lateral position. Percuss the upper border in post axillary line. And the lower border obliquely from below costal margin. [ sensitivity specificity] Castell technique: patient in the supine position. Percuss the lowest intercostal space [8th or 9th] in the anterior axillary line. Ask patient to take strong inspiration during percussion, if dull =splenomegaly. [ sensitivity specificity] 4
- 73. Spleen Traube’s area: Examined while fasting. Is a triangle composed of a)left 6th rib superiorly b) left MAL laterally c) left costal margin inferiorly. If dull: a) obesity b) food c) effusion d) splenomegaly.
- 74. Examination of Genitaliaand Groin Male Urethral orifice (hypospadias,epispadias) Size of penis: Penile length less than 2cm in infants is defined as micro- penia
- 75. Genitalia… Testes (swelling, cryptchordism,retractile testes, inguinal hernia, torsion) Developmental abnormalities / ambiguous genitalia Orchidometer (precocious puberty, macro orchidism)
- 76. Examination of Genitaliaand Groin Female Vulva Vagina (discharge, FB, suspected abuse) Clitoris Developmental abnormalities / ambiguous genitalia
- 77. Rectal examination Normally donein Acute abdomen Chronic constipation Rectal bleeding Look for Tone of anal sphincter and tenderness (anal stenosis loose patulous anus [myelomeningocele], imperforate anus) Masses ( feces, polyps, teratomas, foreign bodies) Local abdominal tenderness Blood or other staining Rectal prolapse Perianal area (thread worms, skin tags, protruding polyps, anal fissures, fecal soiling)