Pediatric git examination

Examination of GIT in children

1. Dr. Virendra Kumar Gupta MD Pediatrics Fellowship In pediatric Gastroentero-Hepatology & Liver Transplantation Assistant Professor Department Of pediatrics NIMS Medical College & Hospital , Jaipur GIT EXAMINATION

2. GI Tract Upper GI 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/descending/sigmoid Rectum Anal canal   Foregut Midgut Hindgut ANATOMICAL DIVISION EMBRYOLOGICAL

3. SIGNS AND SYMPTOMS OF 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 GI Examination 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 GIT EXAMINATION General Physical Examination Oral cavity examination Abdominal examination Genitalia examination Rectal examination

7. GENERAL PHYSICAL EXAMINATION General appearance: 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 massive ascites . Notice dysmorphic features. Vital signs: Tem p ,RR,PR, BP

8. GENERAL PHYSICAL EXAMINATION … Anthropometric measurements Height Weight BMI MAC/HC/CC A long 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. INSP E C TION

10. SKIN Pallor- Anaemia Echymosis Rash Discoid Rash- Ulcerative colitis Petechial Rash Cyanosis Yellow-Jaundice Xanthlesma - Primary Bill. cirossis

11. PROTEIN-DEFICIENCY MALNUTRITION. HAIR

12. NAILS Koilonychia - Vit B12 def,IDA Clubbing- Primary Biliary Cirrohis IBD Coeliac disease Polpososis GI lymphoma Leuconychia - hypoalbuminemia – liver failure / enteropathy

13. HANDS Palmar erythema Dupuytren’s contractures Pallor- Anaemia Yellow- Jaundice

14. ARMS Spider naevi (telangiectatic lesions) Scratch marks (chronic cholestasis)

15. Xanthelasma (primary biliary cirrhosis ) EYES Conjuctival pallor ( anaemia ) Sclera: jaundice, iritis Kaiser Fleischer’s rings (Wilson’s disease)

16. General Physical Examination… Anemia is examined in: Palpebral conjunctivae,dorsum of tongue,nails,palms. Jaundice is examined in: Scleral conjunctivae,under surface of 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 and malabsorption. Inspection of stools and urine .

17. l o c a l i s ed P ALLOR

18. EDEMA

19. LYMPHADENOPATHY

20. Jaundice F apping tremor P almar erythema S pider nevi C aput medusa A scites HEPATO- CELLULAR FAILURE(ACUTE/CHRONIC) Alteration in sensorium,,Behavior changes,Irritability Sleep d i stu r b an c e,d r o ws i n es s Fe t or hepaticus ,

21. ACUTE APPENDICITIS . Mc- burney Tenderness Rovsing s Sign Obturator Sign Psoas Sign Rebound tenderness

22. Examination of : 1- Oral cavity. 2- Abdomen. 3 - R e c t u m .

23. Examination of Oral Cavity  Oral cavity is the window to the GI-system and is likely to mirror or exhibit the inflammatory changes of Gi-system.

24. Lips Gums Teeth Tongue Palate Br e ath

25. LI P S Colour Blue in cyanosis Pale in anemia Any deformity Clift lip Corners of lips (fissuring or angular stomatitis) Any vesicles(HSV ) U lceration

26. GUMS Colour : A nemia C yanosis P igmen tation Lead poisoning - blue line . Hypertrophy Bleeding

27. TE E TH Number - Growth And Age Congenital teeth in newborn babies Hutchison’s teeth- (Congenital syphilis)

28. T ONGUE 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 is benign Tongue tie(ankyloglossia)

29. T r e m o r s D r y Ma c r og l os si a 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 U lceration Bald tongue

30. Atrophic glossitis Thr u sh Geographical tongue Bald tongue Pale tongue Cyanosis

31. PALATES,ORO-PHARYNX MOUTH Oral cavity and oro-pharynx is examined with the help of a tongue depressor for: Colour Ulcers Deformity Inflammatory changes Thrush(oral candidiasis) Membranous pharyngitis in strep,diphtheria,infecious mononucleosis

32. ABDOMINAL EXAMIN A TION

33. ANATOMICAL AREAS

34. Order of examination  Inspection  A us c ul t ation  Palpation  Percussion

35. Patient's position Infant in mother 's lap Infant in mother 's lap

36. INSP E C TIO N : G e n er a l General condition Jaundice Pallor Vircow’s Node: left supraclavicular LN enlargement. Clubbing , palmar erythem , white nails, duptryn contracture. O dema . 7.Gy n eco ma s ti a 8. Mouth ulcers of IBD, Peutz-gagher perioral pigmentation, talangiectasia , MOUTH THRUSH.

37. INSP E C TION : Abdomen Size & Shape ( abdominal Contour ) (up to 3Ys its protuberant ) Any distension(localized or generalized ) Skin: Tone/ Colour / Scar/ Striae Prominent veins Visible loops of bowel/ visible peristalsis Oedema Movements with Respiration Umbilicus( Inverted/Flat/ Everted / S miling ) Hernial orifices

38. ABDOMEN ABNORMAL COUNTERS

39. CAUSES OF DISTENSION Gross distension (5 F) Fluid Flatus Feces Fetus Fat Localized distension Loculated fluid Mass Hernia Organomegaly Impacted feces

40. SKIN TONE Increase/ Shine:Ascitis Decrease:Prune-Belly synd STRIA Pink:Nephrotic Synd White:Pregnency PIGMENTATION STRIA Mc cullan’s sign Grey Turner sign

41. PROMINENT VEINS Caput Meduce Collateral veins Umbilicus(Inverted/Flat/ Everted / Smiling )

42. VISIBLE LOOPS OF BOWEL/ VISIBLE PERISTALSIS

43. Pitting edema of Abd.wall Umbilicus(Inverted/Flat/ Everted / Smiling )

44. UMBILICUS Everted Smilling Normal:inverted

45. HERNIAL ORIFICES

46. AUSCULTATION Need to listen before 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

47. EXAMINATION OF BOWEL SOUNDS

48. Ausculatory percussion to detect small amount of ascetic fluid even up to 1 5 0ml which is not detectable by fluid thrill and shifting dullness. Knee-elbow position PUDDLE SIGN

49. P AL P A TION

50. KEY POINTS IN PALPATION E mpty bladder Patient supine Flex Hip & Knee A rms at sides or folded across chest Before begin,point to areas of pain and examine last Warm hands and stethoscope A void long nails A pproach slowly Distract the patient with conversation or questions

51. 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

52. Palpation of liver In palpation of liver consider its:  Size, edge, surface, consistency, tenderness, pulsations Liver palpation can be done by four ways: With tip of the fingers(preferred / Standerd method ) With radial edge of the right hand(Alternative method ) Hooking method Dipping method

53. Preferred method

54. With radial edge (alternative method)

55. Hooking method

56. Dipping method of palpation In cases of massive ascites. How to do this: Placing hand over the abdomen and making quick and gentle dipping movements (also known as one hand ballottement) Also with bimanual ballottement.

57. One hand ballottement Bimanual ballottement

58. ENLARGEMENT SPLEEN

59. Palpation of spleen -Classical Method

60. Bimannual method of spleen palpation

61. PALPATION OF KIDNEYS B imanual technique P a l p a t e d b y stand i ng o n respe c t i ve side lower pole may normally be palpable Asses any Tenderness (Murphy’s renal punch) Left kidney

62. Palpation of Kidneys R i g h t k i d n e y

63. DIFFERENCE IN SPLEEN & Lt. KIDNEY EXAMINATION

64. P alp a tion… Palpable masses other than 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 m a s s ,pu l sat i on s , t endern e s s , m obilit y . Based on its location a mass could be: Inta-abdominal Extra-abdominal In the abdominal wall To distinguish between these do Rising test

65. PERCUSSION Objects of percussion : To differentiate between fliuds,solid masses,cyst,gases To elicit shifting dullness To elicit fluid wave(fluid thrill) Puddle sign To determine liver span.

66. PERCUSSION… LIVER Percuss for both upper 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

67. PERCUSSION FOR ASCITES

68. Fluid Thrill

69. Shifting Dullness

70. Sple e n 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 [8 th or 9 th ] in the anterior axillary line. Ask patient to take strong inspiration during percussion, if dull =splenomegaly. [  sensitivity  specificity] 4

71. Sple e n Traube’s area: Examined while fasting. Is a triangle composed of a)left 6 th rib superiorly b ) left MAL laterally c ) left costal margin inferiorly . If dull: a) obesity b) food c) effusion d) splenomegaly.

72. Examination of Genitalia and Groin Male Urethral orifice (hypospadias, epispadias) Size of penis:  Penile length less than 2cm in infants is defined as micro- penia

73. Geni t alia… Testes (swelling, cryptchordism, retractile testes, inguinal hernia, torsion) Developmental abnormalities / ambiguous genitalia  Orchidometer (precocious puberty, macro orchidism)

74. Examination of Genitalia and Groin F emal e V u l v a Vagina (discharge, FB, suspected abuse) Clitoris Developmental abnormalities / ambiguous genitalia

75. 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)