The sequence of examining the abdomen changes according to the age and cooperativeness of the child. Often all four types of assessments (inspection, auscultation, percussion and palpation) are performed at dissimilar times. For example, the medical practitioner may auscultate for bowel sounds following estimate of heart and lung sounds at the beginning of the test when the child is quiet. Percussion usually follows lung percussion, and palpation may be done toward the end of the test when the child is relaxed and more trusting of the medical 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 across the abdomen straight through the umbilicus. This recipe of group admittedly 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, paralysis 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 usually in the rest of the abdomen. An unusually tympanitic sound, like the beating of a tight drum, usually breathing. However, it can also denote a pathoilogic health such as low intestinal obstruction or paralytic ileus. Lac of tympany may occur usually 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 doctor 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 attention 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 in any place in the abdomen during superficial palpation is all the time 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 usually dull, poorly localized, and difficult for the sick person to describe. Somatic pain is ordinarily sharp, well localized and more admittedly described. When assessing abdominal pain, it is foremost to remember that the child will often respond with an "all-or-none" reaction- whether there is no pain or great pain. Therefore all aspects of the test must be carefully carefully when ruling out conditions such as appendicitis.
A special 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 during 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 doctor 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, thriving identification of other organs, such as the spleen, kidney, and part of the colon, requires indispensable practice 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 length 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 looking is referred to a physician. usually the liver descends during inspiration as the diaphragm moves downward. This downward displacement should not be mistaken for a sign of hepatomegaly. In older children the liver Often is not palpable, although its lower edge can be estimated by percussing paralysis 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 usually felt during 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 all the time reported for additional medical investigation.
Other anatomical structures that are sometimes palpable in children include 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 usually 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 tasteless 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 associated with appendicitis.
Special methods of investigation
Laboratory examination
1. Habit 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. test 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 discrepancy 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 number of gastrointestinal disorders are caused by disturbances in motor function. Some such as Hirschsprung's disease, produce typical signs of obstruction and are alternately classified as obstructive disorders.
