Abdominal assessment

Look

• Position the patient comfortably, so that the abdomen is relaxed. Supine with an exposed abdomen is best.
• In young uncooperative children, examination may be easier with the child cuddling the carer, then palpate the abdomen from behind. Alternatively, have the child lie on the carer's lap.
• Maintain privacy and dignity.
• Look at all four abdominal quadrants for:
• skin colour or discolouration
• scars
• masses
• prominent veins
• tension, rigid or soft
• distension (contour)
• bruising and/or signs of injury
• pulsations.
• Look at the umbilicus, observing redness, discharge or inflammation.
• Look for inguinal hernia (lump).
• Look at the patient’s activity level and movements. Decreased activity in a child that is usually very active may indicate serious illness or pain.

Listen

• Listen for bowel sounds:
  • hyperactive – increased gastrointestinal activity, such as diarrhoea
  • reduced – decreased intestinal activity, such as an early obstruction
  • absent over four quadrants – bowel sounds absent over 4 minutes may indicate an obstruction.

Feel

• With finger pads, palpate the area of least pain first.
• Palpation is best performed when the patient's attention is diverted away from the examination. e.g. use distraction techniques.
• Start with light palpation, followed by deep palpation and then organ palpation, if within scope.
• Note the level of pressure it takes to produce pain.
• Palpate each region for:
• tenderness
• pain (if present, is it referred, focal or generalised)
• guarding
• rebound tenderness
• masses
• pulses.
• Palpate the bladder. A full bladder:
• Is a pelvis mass that is typically regular, smooth, firm, and oval-shaped
• arises in the midline
• lower border cannot be felt
• upper border may reach as high as the umbilicus
• palpation typically worsens the urge to urinate.
• If appropriate, ask the patient to jump or hop, as this can produce pain caused by an inflamed appendix.
• Check that the patient can walk or mobilise as usual. Note: non-weight bearing is a red flag in children with abdominal pain. Assess the patient's gait.

Testicular exam

• Suspected testicular torsion requires urgent escalation of care.
• Testicular torsion can present as abdominal pain.
• Complete testicular exam:
• Explain the reason for the examination and what it will involve.
• Gain consent and confirm if the patient and/or parent understand the examination.
• Involve a chaperone.
• Allow the patient privacy to remove their underwear and provide a sheet to cover themselves.
• Inspect the penis, testicles and around the groin for bruising, swelling, erythema, lesions or scars.
• Move the penis and carefully examine the scrotum. Look for skin changes, scars, masses, swelling, erythema or bruising.
• If there is pain in a single testicle, palpate the opposite one first.
• Use your thumb and index finger to palpate the whole body of the testicle, feeling for a mass and pain.
• Typical clinical findings for a testicular torsion may include:
• sudden onset of pain that may radiate to the right iliac fossa or thigh
• pain that is generally localised to the upper pole of the testis and tender on palpation
• a palpable mass in the area of maximal tenderness
• the testis 'high riding' in the neck of the scrotum
• red or blue discolouration
• nausea and/or vomiting
• blue dot sign, i.e. a tender nodule with blue discolouration on the upper pole of the testis.
• Bruising to the genitals is uncommon and should raise suspicion of non-accidental injury.

Paediatric abdominal pain differentials

Differential	Description
Constipation	Generalised abdominal pain, rectal pain, abdominal mass or firm stools
Ovarian torsion	Lower abdominal pain associated with nausea and vomiting
Testicular torsion	Sudden onset pain that may radiate to thigh/iliac fossa, swelling of the testis, nausea and/or vomiting or impaired gait
Gastroenteritis	Generalised or cramping abdominal pain, loose stools and/or vomiting
Diabetic ketoacidosis (DKA)	Generalised abdominal pain, dehydration, nausea/vomiting, polyuria, polydipsia or altered conscious state
Appendicitis	Dull pain, increasing in severity, usually localised to the right iliac fossa, rebound tenderness, can be difficult to identify in young children and may present as sepsis
Pneumonia	Often associated with fever and cough
Intussusception	Intermittent episodic abdominal pain, abdominal mass, associated pallor, may appear well between episodes, isolated lethargy, vomiting, red currant jelly stool or rectal bleeding or diarrhoea
Gynaecological	Cyclical lower abdominal or pelvic pain, nausea and/or vomiting, amenorrhoea, abnormal bleeding, heavy menstrual bleeding, vaginal discharge or fever
Urinary tract infection	Lower abdominal pain or discomfort, loin pain, dysuria, frequency, urgency, non-specific symptoms in young children, fever, vomiting, poor feeding, lethargy or irritability

Suspected urinary tract infection

• If there is localised pain or irritation to the genitals, complete a brief inspection.
• Vulvovaginitis or balanitis can present with localised pain or discomfort to the genitals, particularly in prepubertal children.
• A vaginal exam is rarely required. If indicated, an examination should only be performed once by a senior clinician.
• Consider urinary tract infection (suspected) protocol.