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GI Examination Becky Ollerenshaw - Paediatrics Society 18.04.15

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Introduction To Mum/Dad and to child If parents are on your side things are easier! Explain what you're going to do

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General Inspection Observe Observe! Observe!!!

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General inspection Well or ill? Appearance Nutritional status Behaviour Cannulae, creon, inhalers, wiggly bags (cartoon bags for central lines),walking aids etc.

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Rapport Depends on age of child Get mum/dad involved Explain with detail appropriate to age of child

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Positioning On parents lap for wiggly/scared toddlers and small children

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Hands Leukonychia, Koilonychia, Clubbing Crohns, UC, coeliacs Beaus lines horizontal white lines caused by any acute severe illness grow out in 12 weeks Asterixis realistically only in older children

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Hands Pulse, perfusion (cap refill on sternum) Colour, skin Single palmar crease - thyroid problems, small bowel obstruction Bruising liver failure / vitamin K deficiency (in neonates)

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Face Sunken fontanelle - dehydration Yellow sclera - jaundice Pale conjunctiva - anaemia Keyser-Fleischer rings Wilsons disease (mean age of presentation 6-20)

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Face Ulceration Crohns, Angular stomatitis, Glossitis Gum hypertrophy leukaemia, anti-epileptics (phenytoin) Candida immunodeficiency (AIDs, leukaemia) Freckling around the mouth Putz-Jehgers syndrome associated with polyps in the bowel. High risk of cancer / obstruction

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Warm hands! And stethoscopes!!!

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Tummy! Can be tickley Get down to their level Get them to move before you touch- Puff out tummy = rebound tenderness Pain less localised than in adults (abdo pain can be pneumonia!) Normal to be rounded Normal to be rounded and feel up to 2 finger widths of liver and spleen in babies and toddlers.

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Abdomen Inspection - peristalsis, 4 Fs (not 5!), bruises, scars, etc. Pyloric stenosis visible peristalsis Palpate as for adult in older child Check for pain and distension in babies (& toddlers if unco-operative) Hydration status (skin pinch) Percussion and auscultation technique as for adult

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Abdomen Listen for cornflakes!!!

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Don't forget!! Dipstick the urine Plot a growth chart PR not routinely done

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Case 1 Creon by bed, small for age, patient comfortable at rest. Old laporotomy scar No tenderness, no organomegaly

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Cystic Fibrosis Creon by bed exocrine pancreatic insufficiency Small for age - malabsorption Old laporotomy scar may be due to neonatal complicated meconium ileus No tenderness, no organomegaly

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Case 2 Young child of afro-caribbean ethnicity, patient comfortable at rest. No jaundice, some conjunctival pallor No scars No tenderness, splenomegaly

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Early Sickle cell/ Thalassaemia Young child of afro-carribean ethnicity not likely spherocytosis/eliptocytosis No jaundice, some conjunctival pallor - Anaemia No tenderness, splenomegaly Late SC anaemia spleen would be infarcted (not palpable)

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Congenital Abnormalities requiring surgery Congenital abnormalities which require abdominal surgery but leave the child well: Omphalacele, Gastroschisis, Meconium ileus, NEC (necrotising enterocolitis usually premies), Malformations of gut (eg duodenal atresia, biliary atresia- livertransplant etc.) Its worth making a short list of what you would expect to find dont spend too much time doing this though (they dont expect you to be paediatrician just yet!!)