The sequence of examining the abdomen changes according to the age and cooperativeness of the child. Frequently all four types of assessments (inspection, auscultation, percussion and palpation) are performed at dissimilar times. For example, the curative practitioner may auscultate for bowel sounds following estimate of heart and lung sounds at the beginning of the examination when the child is quiet. Percussion commonly follows lung percussion, and palpation may be done toward the end of the examination when the child is relaxed and more trusting of the curative practitional.
For descriptive purposes the abdominal cavity is divided into four compartments or quadrants by drawing a vertical line midway from the sternum to the pubic symphysis and a horizontal line over the abdomen through the umbilicus. This recipe of division unmistakably includes the pelvic cavity. Each section is designated as follows: Right upper quadrant (Ruq), Right lower quadrant (Rlq), Left upper quadrant (Luq), Left lower quadrant (Llq).
Percussion
Percussion of the abdomen is performed in the same manner as percussion of the lungs and heart. Normally, deadness or flatness is heard on the right side at the lower costal margin because of the location of the Liver. Tympany is typically heard over the stomach on the left side and commonly in the rest of the abdomen. An unusually tympanitic sound, like the beating of a tight drum, commonly breathing. However, it can also denote a pathoilogic condition such as low intestinal obstruction or paralytic ileus. Lac of tympany may occur commonly when the stomach is full after a meal, but in other situations it may denote the presence of fluid or solid masses.
Palpation
Two types of palpation are performed, superficial and deep. In superficial palpation a physician lightly places the hand against the skin and feels each quadrant, noting any areas of tenderness, muscle tone, and superficial lesions, such as cysts. Superficial palpation is often perceived as "tickling" by the child. Which can interfere with its effectiveness, The nurse can avoid this qoute by having the child "help" with the palpation by placing him with statements such as, "I am trying to feel what you had for lunch". Admonishing the child to stop laughing only draws concentration to the sensation and decreases cooperation. Positioning the child in supinated position with the legs flexed at the hips and knees helps relax the abdominal muscles.
Tenderness everywhere in the abdomen while superficial palpation is always noted. There are two types of abdominal pain:
1. Visceral, which arises from the viscera or internal organs such as the intestines, and
2. Somatic, which arises from the walls or linings of the abdominal cavity such as the peritoneum.
Visceral pain is commonly dull, poorly localized, and difficult for the sick person to describe. Somatic pain is generally sharp, well localized and more unmistakably described. When assessing abdominal pain, it is leading to remember that the child will often write back with an "all-or-none" reaction- whether there is no pain or great pain. Therefore all aspects of the examination must be carefully carefully when ruling out conditions such as appendicitis.
A extra phenomenon called rebound tenderness, or Blumberg's sign, may be performed if the child complains of abdominal pain. It is performed by pressing firmly over the part of the abdomen distal to the area of tenderness. When the pressure is suddenly released, the child feels pain in the former area of tenderness. This response is only found when the peritoneum overlying a diseased visceral or organ is inflamed, such as in appendicitis.
Deep palpation is used for palpating organs and large blood vessels and for detecting masses and tenderness that were not discovered while superficial palpation. If the child complains of abdominal pain, the area of the abdomen is palpated last. Normally, palpation of the mid-epigastrium causes pain as pressure is exerted over the aorta, but this should not be confused with visceral or somatic tenderness.
The physician palpates the abdominal organs by pressing them with a free hand, which is placed on the child's back. Palpation begins in the lower quadrants and proceeds upwards. In this way, the edge of an enlarged liver or spleen is not missed. Except for palpating the liver, prosperous identification of other organs, such as the spleen, kidney, and part of the colon, requires essential custom with tutored supervision.
The lower edge of the liver is sometimes palpable in infants and young children as a superficial mass 1 to 2cm (1/2 to inch) below the right costal margin (the distance is sometimes measured in fingerbreadths). If the liver is palpable 3cm (1/4 inches) or 2 fingerbreadths below the costal margin, It is carefully enlarged and this finding is referred to a physician. commonly the liver descends while inspiration as the diaphragm moves downward. This downward displacement should not be mistaken for a sign of hepatomegaly. In older children the liver Frequently is not palpable, although its lower edge can be estimated by percussing deadness at the costal margin.
The spleen is palpated by feeling it between the hand placed against the back and the one palpating the left upper quadrant. The spleen is much smaller than the liver and positioned behind the fundus of the stomach. The tip of the spleen is commonly felt while inspiration as it descends within the abdominal cavity. It is sometimes palpable 1 to 2 cm below the left costal margin in infants and young children. A spleen that is facilely palpated more than 2cm below the right costal margin is enlarged and is always reported for added curative investigation.
Other anatomical structures that are sometimes palpable in children comprise the cecum, and sigmoid colon. The cecum is a soft, gas-filled mass in the right lower quadran. The sigmoid colon is left as a sausage-shaped mass that is freely movable over the pelvic brim in the left lower quadrant and is commonly tender.
Although most of these structures are not routinely felt, one should be aware of their relative location and characteristics in order not to mistake them for abnormal masses. The most coarse palpable lower quadrant because with constipation the left colon fills with stool and gas until the ileocecal valve is reached. The the cecum becomes distended, causing pain, which may be erroneously linked with appendicitis.
Special methods of investigation
Laboratory examination
1. Routine blood examination
2. Urine tests (bile pigments, ketonuria)
3. Biochemical determination (bilirubin total, unconjugated and conjugated bilirubin, protein, cholesterol, AlAt, AsAt, amylase, trypsin and lipase)
4. Biochemical determination of Urine for diastase.
Disorders
1. Syndrome of cholistasis increased level of total and conjugated bilirubin and cholesterol).
2. Syndrome of cytolysis (increased level of AsAt, AlAt, Ldg)
3. Syndrome of dysfunction of pancreas (increased level of amylase, trypsin, lipase)
4. Chain polymerizes reaction for virus of hepatitis A, B, C
5. examination of feces for intestinal parasites (ascarides, lamblia cysts, enterobiosis)
6. Copogram
• Indigested muscular fibers
• Steatorrhea
• Lientery
• Bacteria in the feces
Instrumental methods of examination
1. Esophagogastroduodenoscpy
2. Ultrasound investigation
3. Intragastric pH-metry
4. Colonoscopy
5. Procto(sigmoido)scopy
6. Artificial variation study of gastrointestinal system
7. Laparoscopy
8. Irrigoscopy and irrigography
Normal laboratory values of biochemical determination of blood
Glucose 3.33-5.55 mmol/L
Bilirubin total 8.5-2.0 mcmol/L
Unconjugated 2/3 of total
Conjugated 1/3 of total
Protein total 60.0-80.0g/L
Alt 0.1-0.75 mcmol/g/L
Ast 0.1-0.45 mcmol/g/L
Amylase 16-32 dye units/L
A amount of gastrointestinal disorders are caused by disturbances in motor function. Some such as Hirschsprung's disease, furnish typical signs of obstruction and are alternately classified as obstructive disorders.
