Interexaminer reliability in physical examination of pediatric patients with abdominal pain

OBJECTIVE: To test the interexaminer reliability of abdominal examinations performed by pediatric emergency medicine physicians and surgeons in an emergency department. METHODS: A prospective cross-sectional study in which 3 different types of physicians (pediatric emergency department residents, pediatric emergency department attending physicians, and pediatric surgeons in training) independently examined a convenience sample of children (aged 3-19 years) with initial complaint of abdominal pain. The interexaminer reliability of 6 components of the abdominal examination (the presence or absence of abdominal distension, abdominal tenderness to percussion, abdominal tenderness to palpation, abdominal guarding, rebound tenderness, and bowel sounds) and the clinical diagnosis of peritonitis was tested. RESULTS: Sixty-eight patients were examined by pediatric emergency department residents and pediatric emergency department attending physicians. All 3 physician types examined 46 of these 68 patients. When comparing residents and attending physicians, the components of the abdominal examination showed less than moderate chance-adjusted agreement (kappa range, -0.04 to 0.38). When comparing attending physicians and surgeons, the presence of rebound tenderness showed moderate agreement (kappa = 0.54). The rest of the components demonstrated less than moderate chance-adjusted agreement (kappa range, -0.04 to 0.34). CONCLUSIONS: The components of the abdominal examination are poorly reliable between physician types. Only the "rebound tenderness" component of the abdominal examination shows moderate agreement between the pediatric emergency department attending physicians and the surgeon. No component of the abdominal examination appears to be consistently reliable. Interexaminer agreement must be considered when developing management strategies for acute abdomen. Interventions to improve reliability should be developed.