Symptomatology and Examination of the Gastrointestinal System in Paediatrics

Key Principle

Part 1: Symptomatology

1. Abdominal Pain

• Onset - sudden (obstruction, volvulus, intussusception) vs. gradual (appendicitis, IBD)
• Character - colicky (colic, obstruction, intussusception) vs. constant (peritonitis, appendicitis)
• Location
  • Periumbilical - functional pain, early appendicitis, mesenteric adenitis
  • Right iliac fossa (RIF) - appendicitis, Crohn's disease, ovarian pathology
  • Generalised - peritonitis, constipation, gastroenteritis, DKA
  • Epigastric - peptic ulcer, gastritis, GORD
• Relieving/aggravating factors - position (pancreatitis: sitting forward), defaecation (IBS, constipation), eating (peptic ulcer)
• Associated features - fever, vomiting, change in bowel habits, haematuria, rash

• Pain away from the umbilicus (especially RIF or RUQ)
• Pain that wakes the child from sleep
• Fever, weight loss, bloody stool
• Perianal disease, family history of IBD or coeliac disease
• Delayed puberty, declining growth

2. Vomiting

• Age of onset - neonatal vomiting has a very different differential to toddler/school-age
• Nature of vomit:
  • Bilious (green) - always pathological in a neonate; suggests obstruction distal to ampulla of Vater (malrotation with volvulus, duodenal atresia, jejuno-ileal atresia)
  • Non-bilious - pyloric stenosis (projectile in 2-8 week infant), GORD, gastroenteritis, raised ICP
  • Blood (haematemesis) - oesophageal varices (portal hypertension), Mallory-Weiss tear, peptic ulcer
  • Faeculent - suggests distal obstruction/peritonitis
• Timing - post-prandial vs. early morning (raised ICP), cyclical (cyclic vomiting syndrome)
• Projectile - hallmark of pyloric stenosis (hypertrophic pyloric stenosis, HPS)

3. Diarrhoea

• Acute (< 2 weeks): gastroenteritis (viral most common - rotavirus, norovirus; bacterial - Salmonella, Campylobacter, E. coli), antibiotic-associated
• Chronic/persistent (> 2-4 weeks):
  • Coeliac disease - steatorrhoea, failure to thrive, after gluten introduction
  • IBD (Crohn's, UC) - bloody diarrhoea, weight loss, perianal disease
  • Toddler's diarrhoea - loose undigested stools in well-thriving child (functional)
  • Cystic fibrosis - steatorrhoea, FTT, recurrent chest infections
  • Lactose intolerance - watery, frothy, acidic stools; explosive; perianal rash
  • Giardiasis - pale, greasy, offensive stools; bloating
• Bloody diarrhoea - bacterial dysentery (Shigella, Campylobacter), IBD, intussusception (red-currant jelly stool), HUS (after E. coli O157)

4. Constipation

• Defined as <3 stools/week, hard/painful stools, or withholding behaviour
• Functional constipation - most common (>90%); may cause encopresis (faecal soiling/overflow incontinence)
• Organic causes to exclude:
  • Hirschsprung's disease - delayed passage of meconium (>48 hrs), abdominal distension, empty rectum on PR
  • Hypothyroidism, hypercalcaemia, coeliac disease, anal stenosis

5. Rectal Bleeding (Haematochezia / PR Bleeding)

6. Jaundice

• Neonatal jaundice - physiological (day 2-14), haemolytic (unconjugated), biliary atresia (conjugated - always pathological), neonatal hepatitis
• Conjugated (direct) hyperbilirubinaemia - always pathological; causes include biliary atresia, choledochal cyst, neonatal hepatitis, alpha-1-antitrypsin deficiency
• Unconjugated - haemolysis (spherocytosis, G6PD deficiency), Gilbert's syndrome (adolescents)
• Associated features: pale/acholic stools (biliary obstruction), dark urine, pruritus

7. Other Key Symptoms

• Dysphagia - oesophageal atresia (neonate), oesophagitis, eosinophilic oesophagitis
• Haematemesis - varices (portal hypertension in chronic liver disease), peptic ulcer, Mallory-Weiss tear
• Abdominal distension - organomegaly, ascites, obstruction, massive constipation, abdominal tumour (Wilms', neuroblastoma)
• Failure to thrive / poor weight gain - a crucial feature linking GI pathology (coeliac, IBD, CF, malabsorption) with systemic impact
• Infant regurgitation vs. GORD - regurgitation is common and benign; GORD implies complications (oesophagitis, aspiration, FTT, apnoea)

Part 2: Examination of the GI System in Children

General Approach

• Build rapport first - introduce yourself to both child and parent/carer
• Use distraction (toys, stories, asking the child to "help" examine them)
• In uncooperative toddlers, examine the child on the parent's lap, palpating the abdomen from behind
• Watch the child's face for pain during palpation - not just their abdomen
• Always start examination away from the area of pain

Step 1: General Inspection (Around the Bed)

• Nasogastric tube (feeding difficulties, obstruction, liver disease)
• IV fluids (dehydration, GI disease)
• Medications by bedside (e.g. PPIs, steroids, immunosuppressants - suggest IBD/liver disease)
• Stoma bag

• Distressed vs. comfortable at rest
• Motionless - peritonitis, appendicitis (splinting)
• Writhing/restless - colicky pain (intussusception, renal colic, intestinal obstruction)
• Dysmorphic features (Down's syndrome - duodenal atresia, Hirschsprung's)
• Growth parameters on admission: height, weight, BMI, head circumference (infants) - plot on centile chart; poor growth suggests chronic disease

Step 2: Hands

• Assess pulse - tachycardia suggests pain, dehydration, sepsis (e.g. appendicitis, IBD flare)

Step 3: Face, Eyes, Mouth

• Conjunctival pallor - anaemia (IBD, coeliac, GI blood loss)
• Scleral jaundice - liver disease, haemolytic anaemia
• Periorbital oedema - hypoalbuminaemia (liver disease, protein-losing enteropathy)
• Kayser-Fleischer ring - Wilson's disease (slit-lamp)
• Xanthelasma - primary biliary cirrhosis

• Angular stomatitis / glossitis - iron, B12, folate deficiency
• Aphthous ulcers - Crohn's disease (oral Crohn's), IBD
• Oral candidiasis - immunosuppression (liver transplant, IBD treatment)
• Pigmented macules on lips/buccal mucosa - Peutz-Jeghers syndrome (hamartomatous polyps)
• Parotid swelling - chronic liver disease, malnutrition

Step 4: Abdomen - Inspection (Child Supine, Knees Slightly Flexed)

1. Contour/shape:
   • Normal - abdomen is protuberant in toddlers (normal finding, not to be confused with distension)
   • Distension - obstruction, ascites, organomegaly, mass, severe constipation
   • Scaphoid - malnutrition, diaphragmatic hernia (bowel in thorax)
2. Skin:
   • Scars - previous surgery (laparotomy, appendicectomy, Kasai portoenterostomy for biliary atresia)
   • Visible peristalsis - pyloric stenosis (left-to-right peristaltic wave across epigastrium), intestinal obstruction
   • Dilated veins (caput medusae) - portal hypertension
   • Ecchymosis / bruising - trauma, coagulopathy, non-accidental injury
   • Striae - Cushing's (steroid use in IBD)
3. Umbilicus:
   • Umbilical hernia - common in infants, associated with Down's syndrome, hypothyroidism
   • Discharge or redness - omphalitis, patent vitello-intestinal duct (Meckel's), urachal remnant
4. Respiratory movement - reduced abdominal movement with breathing suggests peritonism

Step 5: Auscultation (Before Palpation)

• Bowel sounds:
  • Normal - low-pitched gurgles every 5-10 seconds
  • Hyperactive - diarrhoea, gastroenteritis, early obstruction, hyperthyroidism
  • Absent - paralytic ileus (peritonitis, post-operative), late mechanical obstruction
  • High-pitched tinkling - mechanical obstruction (suggest auscultating for at least 1-2 minutes over all four quadrants; absence confirmed after 4 minutes)
• Liver bruit - hepatoma, arteriovenous malformation (rare in children)
• Succession splash - gastric outlet obstruction (pyloric stenosis in infants - shake the abdomen and listen over epigastrium > 3 hours post-feed)

Step 6: Percussion

• Start away from site of pain
• Liver: percuss upper border (resonant-to-dull) at midclavicular line from 2nd intercostal space downward; percuss lower border upward from RIF
  • Normal span: neonates ~4-5 cm, increases with age
  • Hepatomegaly: >2 cm below right costal margin in infants
• Spleen: left lateral percussion - dullness over 9th-11th rib in posterior axillary line = Traube's space (normally resonant)
• Shifting dullness / fluid thrill - to detect ascites (distension + bulging flanks)
  • Shifting dullness: percuss from midline to flank in supine position, note dull-to-resonant interface, roll patient to lateral - interface shifts if free fluid present
• Suprapubic dullness - full bladder, large pelvic mass
• Hepatic dullness is lost in pneumoperitoneum (perforated viscus)

Step 7: Palpation

• Warm hands; kneel to child's level
• Use flat of hand; watch child's face throughout
• Begin with light palpation - all four quadrants, systematically
• Then deep palpation
• Ask child to point to worst pain - palpate that area last

• Start from RIF with right hand, move upward on deep inspiration - the liver edge descends onto the examining hand
• Characterise: smooth/irregular, tender, pulsatile, firm/soft

• Start at RIF, move toward left costal margin; cannot get above the spleen, moves with respiration, overlying percussion note is dull (unlike a kidney)

Step 8: Special Tests

• Shifting dullness - ascites (liver cirrhosis, portal hypertension, nephrotic syndrome, peritoneal disease)
• Fluid thrill - large-volume ascites
• Succussion splash - gastric outlet obstruction
• Iliopsoas test - retrocaecal appendicitis
• Obturator sign - pelvic appendicitis

Step 9: Hernial Orifices and Genitalia

• Examine inguinal regions for:
  • Indirect inguinal hernia (most common paediatric hernia; more common in males, premature infants)
  • Incarcerated hernia - tender, non-reducible; may present as acute abdomen
• Umbilical hernia - confirm reducibility
• Scrotal examination in males - testicular torsion can present as acute abdominal pain with vomiting
• Perianal inspection - fissures (constipation, Crohn's), skin tags (Crohn's), perianal excoriation (threadworms), fistulae (Crohn's)

Step 10: Digital Rectal Examination (DRE)

• Suspected Hirschsprung's disease (empty rectum, explosive release of gas/stool on withdrawal = "squirt sign")
• Perianal disease (Crohn's)
• Suspected constipation/faecal impaction when imaging is not available
• Suspected intussusception (occasionally blood on finger)
• Always done in the presence of a chaperone; explain to parent and child

Summary: Age-Specific Examination Pitfalls

Sources

• GOLDMAN-CECIL MEDICINE (Abdominal Examination chapter)
• Bailey and Love's Short Practice of Surgery 28th Edition (Examination of the Abdomen)
• Geeky Medics - Paediatric Abdominal Examination OSCE Guide
• NSW Agency for Clinical Innovation - Paediatric Abdominal Assessment (Dec 2023)