Pediatric Abdominal Examination

Abdominal pain is a common paediatric ED presentation. A structured abdominal exam, combined with a good history, helps differentiate benign conditions from surgical emergencies (e.g. appendicitis, intussusception, volvulus).

Approach the exam gently, involve the caregiver, and examine the child in the least distressing way. Observing the child quietly before touching the abdomen often gives valuable clues.

Preparation

Ensure the child is as comfortable and relaxed as possible – allow them to sit on a parent’s lap initially.
Explain what you are doing in age-appropriate language; show your hands and stethoscope first.
Ideally lie the child supine with a slight pillow under the head and knees slightly flexed.
Ensure warmth and privacy; expose the abdomen from xiphisternum to pubic symphysis.
Wash hands, use gloves if needed, and warm your hands/stethoscope.

Inspection

Stand at the end of the bed and look first before touching.

Overall appearance: distress, lying still vs writhing, child guarding their own abdomen.
Abdominal shape: distension, asymmetry, visible masses, hernias, surgical scars.
Movement with respiration: reduced movement may suggest peritonitis.
Skin changes: bruising (e.g. seatbelt sign), striae, rashes, visible veins, erythema.
Visible peristalsis or pulsations (think obstruction or aneurysm in rare cases).

Auscultation

Ideally performed before palpation or percussion.

Listen in all quadrants for bowel sounds: present, absent, high-pitched, tinkling.
Hyperactive “tinkling” bowel sounds may suggest early obstruction; absent sounds may suggest ileus, late obstruction, or peritonitis.
In selected cases, listen over renal arteries or epigastrium for bruits (rare in ED practice).

Palpation

Start away from the area of maximal pain, and watch the child’s face. Use warm hands and a gentle approach.

Begin with light palpation in all quadrants to identify tenderness and voluntary guarding.
Progress to deep palpation to assess for masses, organomegaly, and localised tenderness.
Assess liver and spleen size by feeling for their edges below costal margins.
Identify signs of peritonism: involuntary guarding, rigidity, rebound tenderness.
Check for hernias (inguinal, umbilical) and testicular exam in boys with lower abdominal pain.

Any child lying still, resisting movement, with rigid abdomen and marked tenderness = suspect surgical abdomen and escalate early (surgery/paediatrics).

Percussion

Percuss across the abdomen to identify areas of tympany (gas) vs dullness (solid organ, mass, fluid).
Shifting dullness may suggest ascites (chronic liver disease, nephrotic syndrome, etc.).
Localized dullness over a mass or organomegaly adds to palpation findings.

Differential Diagnosis by Pain Location

Location is helpful but not absolute – children often give poor localisation, and serious pathology can present atypically.

Right Upper Quadrant (RUQ)

Biliary disease (cholecystitis, gallstones): post-prandial pain, colicky, may radiate to back; nausea/vomiting.
Hepatitis: RUQ discomfort, jaundice, dark urine, pale stools, fatigue.
Pancreatitis: epigastric/RUQ pain radiating to back, vomiting, child often looks quite ill.
Right lower lobe pneumonia: may present with RUQ or upper abdominal pain ± cough, fever.

Left Upper Quadrant (LUQ)

Splenomegaly / splenic infarct or rupture: LUQ pain, tenderness, sometimes referred to left shoulder.
Gastritis / peptic ulcer disease: epigastric/LUQ burning, worse after meals, possible haematemesis/melaena.
Left lower lobe pneumonia: may cause referred LUQ pain.
Renal causes (left kidney): flank pain, fever, urinary symptoms (UTI/pyelonephritis, stones – stones less common in younger children).

Right Lower Quadrant (RLQ)

Appendicitis: classically periumbilical pain migrating to RLQ, anorexia, fever, localised tenderness/guarding.
Mesenteric adenitis: RLQ pain, often post-viral, may mimic appendicitis but child often looks less toxic.
Constipation: diffuse or lower abdominal pain with palpable faecal mass, stool history.
Ovarian torsion/cyst, PID (adolescent females): lower abdominal/pelvic pain, consider pregnancy test and gynaecological causes.
Right lower lobe pneumonia: referred pain with respiratory signs.

Left Lower Quadrant (LLQ)

Constipation: very common; LLQ fullness, pain, stool history, palpable stool.
Inflammatory bowel disease (Crohn’s / UC): chronic pain, diarrhoea, weight loss, growth faltering.
Renal/ureteric pathology: flank/LLQ pain, urinary symptoms.
Ovarian torsion/cyst, PID: in adolescent girls – lower abdominal/pelvic pain ± menstrual/sexual history.

Central / Diffuse Pain

Gastroenteritis: crampy pain, vomiting, diarrhoea, usually well child between episodes.
Intussusception: intermittent colicky pain, drawing up of legs, vomiting; later “red currant jelly” stool, sausage-shaped mass.
Malrotation with volvulus: bilious vomiting, acute abdomen, rapid deterioration (surgical emergency).
Functional abdominal pain: recurrent pain, normal exam, normal growth; diagnosis of exclusion.

Red flag abdominal pain: bilious vomiting, severe pain with silent child, peritonism, shock, GI bleeding, scrotal pain/swelling, or any sudden severe testicular pain (testicular torsion) – escalate urgently.

Common Pediatric Abdominal Conditions

Causes of Pediatric Hepatomegaly

Cause	Clinical Features
Non-alcoholic fatty liver disease (NAFLD)	Often overweight/obese child, elevated liver enzymes, hepatomegaly, usually asymptomatic or vague fatigue.
Viral hepatitis (A, B, others)	Jaundice, dark urine, pale stools, RUQ discomfort, fatigue, raised transaminases.
Metabolic liver disease	Failure to thrive, recurrent hypoglycaemia, hepatomegaly ± other systemic features.
Wilson disease	Hepatomegaly, abnormal LFTs, possible neuropsychiatric signs, Kayser-Fleischer rings.

Causes of Pediatric Splenomegaly / Hepatosplenomegaly

Cause	Clinical Features
Infectious mononucleosis	Fever, sore throat, cervical lymphadenopathy, fatigue, splenomegaly (risk of splenic rupture).
Haemolytic anaemia	Pallor, jaundice, fatigue, splenomegaly, sometimes gallstones.
Sickle cell disease	Pain crises, anaemia; early splenomegaly then possible autosplenectomy later.
Thalassaemia major	Marked hepatosplenomegaly, anaemia, skeletal changes, growth delay.
Leukaemia / lymphoma	Fatigue, weight loss, fevers, bruising, lymphadenopathy, hepatosplenomegaly.

Appendicitis – Key Features

Clinical Feature	Description
Typical pain pattern	Periumbilical or central pain migrating to RLQ over hours; may be less clear in younger children.
Nausea/vomiting & anorexia	Often follows onset of pain; loss of appetite is common.
Fever	Low-grade fever initially; higher fever and toxicity with perforation/peritonitis.
Localized tenderness	Maximal at McBurney’s point; may have guarding, rigidity, rebound tenderness.
Guarding	Involuntary tightening of abdominal muscles in response to palpation.
GI symptoms	May have diarrhoea or constipation; not specific.
Systemic features	Malaise, fatigue, child appears “unwell”, prefers to lie still.

Suspected appendicitis with peritonism or systemic toxicity = urgent surgical referral. Avoid repeated strong opiates & repeated deep palpation while awaiting review.

Hepatitis – Overview (Paediatric)

Most children with hepatitis in the ED will have non-specific symptoms and deranged LFTs; history and risk factors are key.

Type	Transmission	Incubation	Typical Features	Key Tests	General ED Management
Hepatitis A	Faeco-oral	≈ 15–50 days	Flu-like prodrome, jaundice, RUQ pain, dark urine, pale stools.	IgM anti-HAV, LFTs.	Supportive care, hydration; notify public health; vaccination for contacts per local policy.
Hepatitis B	Bloodborne, perinatal, sexual	≈ 45–180 days	Often asymptomatic; possible jaundice, abdominal pain, arthralgia.	HBsAg, anti-HBc IgM, LFTs.	Supportive in acute; ensure follow-up, consider antiviral therapy and family screening per guidelines.
Hepatitis C	Bloodborne (transfusion / needles)	≈ 14–180 days	Often silent; may have fatigue, mild RUQ discomfort, abnormal LFTs.	Anti-HCV, HCV RNA, LFTs.	Usually outpatient workup; chronic infection managed with antivirals via specialist clinic.
Hepatitis D	Bloodborne; requires HBV co-infection	≈ 21–56 days	Similar to HBV; may be more severe.	Anti-HDV, LFTs.	Treat as complicated HBV; refer to specialist.
Hepatitis E	Faeco-oral, contaminated water	≈ 15–60 days	Flu-like illness, jaundice, abdominal pain, nausea.	IgM anti-HEV, LFTs.	Supportive; usually self-limiting.

Conclusion

A structured abdominal exam in children, combined with age-appropriate observation and careful history, is crucial to identify those needing urgent surgical or medical intervention. When in doubt, reassess, observe trends, and escalate early.