ORGANUM
After identifying the major GI symptom, onset and progression should be determine (improved, unchanged, worsening). Characterisation of signs and symptoms should identify factors such as:
Triggers
Actions that elevate the symptoms
Timing, frequency and duration of the symptoms
Relationship to meals and defecation
Associated symptoms - fever and weight loss
Other key history includes exposure to others (family, school contacts), travel, environmental exposure, and impact of illness on the child (school absences).
History may suggest a diagnosis and thus direct the investigations needed, but a full examination as well as thorough abdominal examination. Extra-intestinal disorders may produce GI manifestations (emesis with group A streptococcal pharyngitis, abdominal pain with lower lobe pneumonia).
The examination should begin with a careful external inspection for abdominal distention, bruising, or discolouration, abnormal veins, jaundice, surgical scars, and ostomies. Abnormalities of intensity and pitch of bowel sounds can occur with bowel obstruction. When palpating for tenderness, the examiner should note location, facial expression, guarding, and rebound tenderness. Palpation can also detect enlargement of the liver or spleen as well as feces and masses. If detected, organomegaly should be measured with a tape measure, noting abnormal firmness or contour. A rectal examination, including inspection for fissures, skin tags, abscesses, and fistulous openings should be performed for children with history suggesting constipation, GI bleeding, abdominal pain, chronic diarrhoea, and suspicion of IBD. Digital rectal examination should include assessment of anal sphincter tone, anal canal size and elasticity, tenderness, extrinsic masses, presence of fecal impaction, and caliber of the rectum. Stool should be tested for occult blood.
A FBC may provide evidence for inflammation (WBC and platelet count), poor nutrition or bleeding (anaemia, red blood cell volume, reticulocyte count), and infection (WBC number and differential, presence of toxic granulation). Serum electrolytes, blood urea nitrogen (BUN), and creatinine help define hydration status. Tests of liver dysfunction includes LFTs. Bilirubin, AST and ALT indicate hepatocellular injury while ALP and y-GGT indicate bile duct injury. Hepatic synthetic function can be assessed by coagulation factor levels, prothrombin time, and albumin levels. Pancreatic enzyme tests (amylase, lipase) provide evidence of pancreatic injury or inflammation. Urinanalysis can gauge dehydration and identify a possible source of protein loss.
Consultation with a radiologist is often advisable to discuss appropriate imaging, decide what variants of the technique to use, and learn how to prepare the patient for the study. A plain AXR to document excessive retaiend stool when history is consistent with constipation and encopresis is not necessary, as examination alone can confirm the diagnosis.
Endoscopy permits the direct visualisation of the inferior of the gut. Video endoscopes may be used veem in veru small infants by pediatric gastroentrelogists.