Causes of Ascites

• Bile ascites (bile peritonitis): Spontaneous rupture of the common bile duct
• Renal
  –Nephrotic syndrome
  –Urinary ascites (due to bladder rupture)
  –Obstructive uropathy: Congenital ascites may be seen with bilateral hydronephrosis
• Peritoneal dialysis
• Cardiac
  –Congestive heart failure
  –Chronic constrictive pericarditis
  –Inferior vena cava web
  –Erythroblastosis fetalis
• Peritonitis
  –Tuberculous peritonitis
  –Schistosomiasis (Mansoni)
  –Tularemia
  –Abscess
• Gastrointestinal disorders
  –Infarcted bowel
  –Bowel perforation
  –Pancreatitis, ruptured pancreatic duct
  –Protein-losing gastroenteropathy
• Chylous ascites
  –Collection of lymph within the abdominal cavity; secondary to lymphatic obstruction from trauma, surgery, tumor, tuberculosis, or filariasis
• Gynecologic
  –Ovarian tumors, cyst torsion or rupture
• Malignancy
  –Leukemia, lymphoma, neuroblastoma
• Systemic lupus erythromatosus
• Ventriculoperitoneal shunt
• Hypothyroidism

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Abdominal Masses: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Wilms tumor
  –More common in younger children
• Neuroblastoma
  –More common in younger children
• Leukemia/lymphoma
  –Involvement of retroperitoneal nodes, liver, or spleen
• Hepatic tumors
  –Hepatoblastoma, hepatocellular carcinoma, angiosarcoma, rhabdomyosarcoma of the liver, metastatic disease
• Germ cell tumors
  –Ovarian, teratoma
• Soft tissue sarcoma
  –Rhabdomyosarcoma
• Rare malignancies in children
  –Carcinoid tumors, adrenocortical carcinoma, pancreatoblastoma, malignant rhabdoid tumor
• Cystic masses
  –Ovary, renal, mesenteric
• Benign tumors
  –Adenomas (especially of liver), hamartomas, pheochromocytoma
• Vascular lesions (e.g., hemangioma)
• Renal etiologies
  –Distended, nonemptying bladder, bladder outlet obstruction
  –Congenital mesoblastic nephroma
  –Severe hydronephrosis
• Gynecologic
  –Ovarian torsion, endometriosis, pelvic inflammatory disease
• Gastrointestinal
  –Constipation/stool impaction, intestinal obstruction (e.g., Hirschsprung), GI duplication, incarcerated hernia
• Pancreatic pseudocyst
• Infectious
  –Abscess, hepatitis, virus (EBV, CMV) causing splenomegaly or hepatomegaly
• Structures normally palpable in small children are liver edge, spleen tip (especially with viral illness), aorta, sigmoid colon, and spine

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Abdominal distention: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal cancer.Generalized abdominal distention may occur when the cancer — most commonly ovarian, hepatic, or pancreatic — produces ascites (usually in a patient with a known tumor). It’s an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

❑ Abdominal trauma.When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. Pain may occur over the trauma site, or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

❑ Cirrhosis. In cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave, shifting dullness, and a puddle sign. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The patient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema, and possibly splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also be seen. Jaundice is usually a late sign. Hepatomegaly occurs initially, but the liver may not be palpable if the patient has advanced disease.

❑ Heart failure. Generalized abdominal distention due to ascites typically accompanies severe cardiovascular impairment and is confirmed by shifting dullness and a fluid wave. Signs and symptoms of heart failure are numerous and depend on the disease stage and degree of cardiovascular impairment. Hallmarks include peripheral edema, jugular vein distention, dyspnea, and tachycardia. Common associated signs and symptoms include hepatomegaly (which may cause right upper quadrant pain), nausea, vomiting, a productive cough, crackles, cool extremities, cyanotic nail beds, nocturia, exercise intolerance, nocturnal wheezing, diastolic hypertension, and cardiomegaly.

❑ Irritable bowel syndrome. Irritable bowel syndrome may produce intermittent, localized distention — the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function, nausea, dyspepsia, straining and urgency at defecation, a feeling of incomplete evacuation, and small, mucus-streaked stools.

❑ Large-bowel obstruction. Dramatic abdominal distention is characteristic in this life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and the sudden onset of colicky lower abdominal pain that becomes persistent. Fecal vomiting and diminished peristaltic waves and bowel sounds are late signs.

❑ Mesenteric artery occlusion (acute). In this life-threatening disorder, abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

❑ Paralytic ileus. Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, mild abdominal pain and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

❑ Peritonitis. Peritonitis is a life-threatening disorder in which abdominal distention may be localized or generalized, depending on the extent of the inflammation. Fluid accumulates within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by sudden and severe abdominal pain that worsens with movement, rebound tenderness, and abdominal rigidity.

The skin over the patient’s abdomen may appear taut. Associated signs and symptoms usually include hypoactive or absent bowel sounds, fever, chills, hyperalgesia, nausea, and vomiting. Signs of shock, such as tachycardia and hypotension, appear with significant fluid loss into the abdomen.

❑ Small-bowel obstruction. Abdominal distention is characteristic in small-bowel obstruction, a life-threatening disorder, and is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

❑ Toxic megacolon (acute).Toxic megacolon is a life-threatening complication of infectious or ulcerative colitis.  It produces dramatic abdominal distention that usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also presents with abdominal pain and tenderness, fever, tachycardia, and dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal mass: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm. Abdominal aortic aneurysm may persist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. However, it may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less commonly, low back or dull abdominal pain. If the aneurysm ruptures, he’ll report severe abdominal and back pain. After rupture, the aneurysm no longer pulsates.

Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock — such as tachycardia and cool, clammy skin — appear with significant blood loss.

❑ Cholecystitis.Deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. However, with acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right upper quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

❑ Colon cancer.A right lower quadrant mass may occur with cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Occasionally, cancer of the left colon also causes a palpable mass. It usually produces rectal bleeding, intermittent abdominal fullness or cramping, and rectal pressure. The patient may also report fremitus and pelvic discomfort. Later, he develops obstipation, diarrhea, or pencil-shaped, grossly bloody, or mucus-streaked stools. Typically, defecation relieves pain.

❑ Crohn’s disease. With Crohn’s disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right lower quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

❑ Diverticulitis. Most common in the sigmoid colon, diverticulitis may produce a left lower quadrant mass that’s usually tender, firm, and fixed. It also produces intermittent abdominal pain that’s relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, a low-grade fever, and a distended and tympanic abdomen.

❑ Gastric cancer.Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness after eating, fatigue and, occasionally, coffee-ground vomitus or melena.

❑ Hepatomegaly. Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right upper quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy and, possibly, splenomegaly.

❑ Hernia. The soft and typically tender bulge is usually an effect of prolonged, increased intra-abdominal pressure on weakened areas of the abdominal wall. An umbilical hernia is typically located around the umbilicus and an inguinal hernia in either the right or left groin. An incisional hernia can occur anywhere along a previous incision. Hernia may be the only sign until strangulation occurs.

❑ Hydronephrosis. Enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

❑ Ovarian cyst. A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.

❑ Splenomegaly. The lymphomas, leukemias, hemolytic anemias, and inflammatory diseases are among the many disorders that may cause splenomegaly. Typically, the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but usually include a feeling of abdominal fullness, left upper quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and a low-grade fever.

❑ Uterine leiomyomas (fibroids). If large enough, these common, benign uterine tumors produce a round, multinodular mass in the suprapubic region. The patient’s chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal distention: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal cancer

Generalized abdominal distention may occur when the cancer—most commonly ovarian, hepatic, or pancreatic cancer—produces ascites (usually in a patient with a known tumor). It’s an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

Abdominal trauma

When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. The patient may feel pain over the trauma site, or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

Bladder distention

Various disorders cause bladder distention, which in turn causes lower abdominal distention. Slight dullness on percussion above the symphysis indicates mild bladder distention. A palpable, smooth, rounded, fluctuant suprapubic mass suggests severe distention; a fluctuant mass extending to the umbilicus indicates extremely severe distention. Urinary dribbling, frequency, or urgency may occur with urinary obstruction. Suprapubic discomfort is also common.

Cirrhosis

In cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave, shifting dullness, and a puddle sign. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The patient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema, and possibly splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also occur. Jaundice is usually a late sign. Hepatomegaly occurs initially, but the liver may not be palpable in advanced disease.

Gastric dilation (acute)

Left-upper-quadrant distention is characteristic in acute gastric dilation, but the presentation varies. The patient usually complains of epigastric fullness or pain and nausea with or without vomiting. Physical examination reveals tympany, gastric tenderness, and a succussion splash. Initially, peristalsis may be visible. Later, hypoactive or absent bowel sounds confirm ileus. The patient may be pale and diaphoretic and may exhibit tachycardia or bradycardia.

Heart failure

Generalized abdominal distention due to ascites typically accompanies severe cardiovascular impairment and is confirmed by shifting dullness and a fluid wave. Signs and symptoms of heart failure are numerous and depend on the disease stage and degree of cardiovascular impairment. Hallmarks include peripheral edema, jugular vein distention, dyspnea, and tachycardia. Common associated signs and symptoms include hepatomegaly (which may cause right-upper-quadrant pain), nausea, vomiting, productive cough, crackles, cool extremities, cyanotic nail beds, nocturia, exercise intolerance, nocturnal wheezing, diastolic hypertension, and cardiomegaly.

Irritable bowel syndrome (IBS)

IBS may produce intermittent, localized distention—the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function; nausea; dyspepsia; straining and urgency at defecation; feeling of incomplete evacuation; and small, mucus-streaked stools.

Large-bowel obstruction

Dramatic abdominal distention is characteristic in large-bowel obstruction, a life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and sudden onset of colicky lower abdominal pain that becomes persistent. Fecal vomiting and diminished peristaltic waves and bowel sounds are late signs.

Mesenteric artery occlusion (acute)

In mesenteric artery occlusion—a life-threatening disorder—abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

Nephrotic syndrome

Nephrotic syndrome may produce massive edema, causing generalized abdominal distention with a fluid wave and shifting dullness. It may also produce elevated blood pressure, hematuria or oliguria, fatigue, anorexia, depression, pallor, periorbital edema, scrotal swelling, and skin striae.

Ovarian cysts

Typically, large ovarian cysts produce lower abdominal distention accompanied by umbilical eversion. Because they’re thin walled and fluid filled, these cysts produce a fluid wave and shifting dullness—signs that mimic ascites. Lower abdominal pain and a palpable mass may be present.

Paralytic ileus

Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, mild abdominal pain and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

Peritonitis

In peritonitis—a life-threatening disorder—abdominal distention may be localized or generalized, depending on the extent of peritonitis. Fluid accumulates first within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by rebound tenderness, abdominal rigidity, and sudden and severe abdominal pain that worsens with movement.

The skin over the patient’s abdomen may appear taut. Associated signs and symptoms usually include hypoactive or absent bowel sounds, fever, chills, hyperalgesia, nausea, and vomiting. Signs of shock, such as tachycardia and hypotension, appear with significant fluid loss into the abdomen.

Small-bowel obstruction

Abdominal distention, which is characteristic in small-bowel obstruction—a life-threatening disorder—is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

Toxic megacolon (acute)

Toxic megacolon is a life-threatening complication of infectious or ulcerative colitis that produces dramatic abdominal distention. The distention usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also experiences abdominal pain and tenderness, fever, tachycardia, and dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal mass: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm

An abdominal aortic aneurysm may persist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. However, it may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less often, low back or dull abdominal pain. If the aneurysm ruptures, he’ll report severe abdominal and back pain. And after rupture, the aneurysm no longer pulsates.

Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock—such as tachycardia and cool, clammy skin—appear with significant blood loss.

Bladder distention

A smooth, rounded, fluctuant suprapubic mass is characteristic. In extreme distention, the mass may extend to the umbilicus. Severe suprapubic pain and urinary frequency and urgency may also occur.

Cholecystitis

Deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. However, in acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right-upper-quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

A stone-filled gallbladder usually produces a painless right-upper-quadrant mass that’s smooth and sausage-shaped. However, passage of a stone through the bile or cystic duct may cause severe right-upper-quadrant pain that radiates to the epigastrium, back, or shoulder blades. Accompanying signs and symptoms include anorexia, nausea, vomiting, chills, diaphoresis, restlessness, and low-grade fever. Jaundice may occur with obstruction of the common bile duct. The patient may also experience intolerance of fatty foods and frequent indigestion.

Colon cancer

A right-lower-quadrant mass may occur in cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Occasionally, cancer of the left colon also causes a palpable mass. Usually though, it produces rectal bleeding, intermittent abdominal fullness or cramping, and rectal pressure. The patient may also report fremitus and pelvic discomfort. Later, he develops obstipation, diarrhea, or pencil-shaped, grossly bloody, or mucus-streaked stools. Typically, defecation relieves pain.

Crohn’s disease

In Crohn’s disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right-lower-quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

Diverticulitis

Most common in the sigmoid colon, diverticulitis may produce a left-lower-quadrant mass that’s usually tender, firm, and fixed. It also produces intermittent abdominal pain that’s relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, low-grade fever, and a distended and tympanic abdomen.

Gallbladder cancer

Gallbladder cancer may produce a moderately tender, irregular mass in the right upper quadrant. Accompanying it is chronic, progressively severe epigastric or right-upper-quadrant pain that may radiate to the right shoulder. Associated signs and symptoms include nausea, vomiting, anorexia, weight loss, jaundice, and possibly hepatosplenomegaly.

Gastric cancer

Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness after eating, fatigue, and occasionally coffee-ground vomitus or melena.

Hepatic cancer

Hepatic cancer produces a tender, nodular mass in the right upper quadrant or right epigastric area accompanied by severe pain that’s aggravated by jolting. Other effects include weight loss, weakness, anorexia, nausea, fever, dependent edema, and occasionally jaundice and ascites. A large tumor can also cause a bruit or hum.

Hepatomegaly

Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right-upper-quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy, and possibly splenomegaly.

Hydronephrosis

By enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

Ovarian cyst

A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.

Pancreatic abscess

Occasionally, pancreatic abscess may produce a palpable epigastric mass accompanied by epigastric pain and tenderness. The patient’s temperature usually rises abruptly but may climb steadily. Nausea, vomiting, diarrhea, tachycardia, and hypotension may also occur.

Pancreatic pseudocysts

After pancreatitis, pseudocysts may form on the pancreas, causing a palpable nodular mass in the epigastric area. Other findings include nausea, vomiting, diarrhea, abdominal pain and tenderness, low-grade fever, and tachycardia.

Renal cell carcinoma

Usually occurring in only one kidney, renal cell carcinoma produces a smooth, firm, nontender mass near the affected kidney. Accompanying it are dull, constant abdominal or flank pain and hematuria. Other signs and symptoms include elevated blood pressure, fever, and urine retention. Weight loss, nausea, vomiting, and leg edema occur in late stages.

Splenomegaly

Lymphomas, leukemias, hemolytic anemias, and inflammatory diseases are among the many disorders that may cause splenomegaly. Typically, the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but often include a feeling of abdominal fullness, left-upper-quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and low-grade fever.

Uterine leiomyomas (fibroids)

If large enough, these common, benign uterine tumors produce a round, multinodular mass in the suprapubic region. The patient’s chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Peritonitis: Causes
(Handbook of Diseases)

Although the GI tract normally contains bacteria, the peritoneum is sterile. In peritonitis, however, bacteria invade the peritoneum. Generally, such infection results from inflammation and perforation of the GI tract, allowing bacterial invasion. Usually, this is a result of appendicitis, diverticulitis, peptic ulcer, ulcerative colitis, volvulus, strangulated obstruction, perforated or ruptured gallbladder, gangrenous gallbladder, abdominal neoplasm, or a penetrating wound.

Peritonitis may also result from chemical inflammation, as in the rupture of a fallopian tube or the bladder, perforation of a gastric ulcer, or release of pancreatic enzymes.

With chemical and bacterial inflammation, accumulated fluids containing protein and electrolytes make the transparent peritoneum opaque, red, inflamed, and edematous. Because the peritoneal cavity is so resistant to contamination, such infection is often localized as an abscess instead of disseminated as a generalized infection.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Abdominal distention: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal cancer

Generalized abdominal distention may occur when the cancer — most commonly ovarian, hepatic, or pancreatic — produces ascites (usually in a patient with a known tumor). It’s an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

Abdominal trauma

When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. Pain may occur over the trauma site or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

Bladder distention

Various disorders cause bladder distention which, in turn, causes lower abdominal distention. Slight dullness on percussion above the symphysis pubis indicates mild bladder distention. A palpable, smooth, rounded, fluctuant suprapubic mass suggests severe bladder distention; a fluctuant mass extending to the umbilicus indicates extremely severe bladder distention. Urinary dribbling, frequency, or urgency may occur with urinary obstruction. Suprapubic discomfort is also common.

Cirrhosis

With cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave and shifting dullness. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The patient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema and, possibly, splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also be seen. Jaundice is usually a late sign. Hepatomegaly occurs initially; however, the liver may not be palpable if the patient has advanced disease.

Gastric dilation (acute)

Left-upper-quadrant distention is characteristic of acute gastric dilation, but the presentation varies. The patient usually complains of epigastric fullness or pain and nausea (with or without vomiting). Physical examination reveals tympany, gastric tenderness, and a succussion splash. Initially, visible peristalsis may occur. Later, hypoactive or absent bowel sounds confirm ileus. The patient may be pale and diaphoretic and may exhibit tachycardia or bradycardia.

Heart failure

Generalized abdominal distention due to ascites typically accompanies severe cardiovascular impairment and is confirmed by shifting dullness and a fluid wave. Signs and symptoms of heart failure are numerous and depend on the disease stage and degree of cardiovascular impairment. Hallmarks include peripheral edema, jugular vein distention, dyspnea, and tachycardia. Common associated signs and symptoms include hepatomegaly (which may cause right-upper-quadrant pain), nausea, vomiting, productive cough, crackles, cool extremities, cyanotic nail beds, nocturia, exercise intolerance, nocturnal wheezing, diastolic hypertension, and cardiomegaly.

Irritable bowel syndrome

Irritable bowel syndrome may produce intermittent, localized distention — the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function; nausea; dyspepsia; straining and urgency at defecation; feeling of incomplete evacuation; and small, mucus-streaked stools.

Large-bowel obstruction

Dramatic abdominal distention is characteristic of large-bowel obstruction, a life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and the sudden onset of colicky lower abdominal pain that becomes persistent. Fecal vomiting and diminished peristaltic waves and bowel sounds are late signs.

Mesenteric artery occlusion (acute)

In acute mesenteric artery occlusion, a life-threatening disorder, abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

Nephrotic syndrome

Nephrotic syndrome may produce massive edema, causing generalized abdominal distention with a fluid wave and shifting dullness. It may also produce elevated blood pressure, hematuria or oliguria, fatigue, anorexia, depression, pallor, periorbital edema, scrotal swelling, and skin striae.

Ovarian cysts

Typically, large ovarian cysts produce lower abdominal distention accompanied by umbilical eversion. Because they’re thin walled and fluid filled, these cysts produce a fluid wave and shifting dullness — signs that mimic ascites. Lower abdominal pain and a palpable mass may be present.

Paralytic ileus

Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, extreme distress and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

Peritonitis

In peritonitis, a life-threatening disorder, abdominal distention may be localized or generalized, depending on the extent of peritonitis. Fluid accumulates first within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by sudden and severe abdominal pain that worsens with movement. Rebound tenderness and abdominal rigidity may be present.

Associated signs and symptoms usually include hypoactive or absent bowel sounds, fever, chills, hyperalgesia, nausea, and vomiting. Also, the skin over the patient’s abdomen may appear taut. Signs of shock, such as tachycardia and hypotension, appear with significant fluid loss into the abdomen.

Small-bowel obstruction

Abdominal distention, which is characteristic of small-bowel obstruction, is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms of this life-threatening disorder include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

Toxic megacolon (acute)

Acute toxic megacolon is a life-threatening complication of infectious or ulcerative colitis. It produces dramatic abdominal distention that usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also presents with abdominal pain and tenderness, fever, tachycardia, and dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal mass: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal aortic aneurysm

An abdominal aortic aneurysm may persist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. However, it may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less often, low back or dull abdominal pain. If the aneurysm ruptures, he’ll report severe abdominal and back pain. After rupture, the aneurysm no longer pulsates.

Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock — such as tachycardia and cool, clammy skin — appear with significant blood loss.

Bladder distention

A smooth, rounded, fluctuant suprapubic mass is characteristic of bladder distention. With extreme distention, the mass may extend to the umbilicus. Severe suprapubic pain and urinary frequency and urgency may also occur.

Cholecystitis

With cholecystitis, deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. However, with acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right-upper-quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

With cholelithiasis, a stone-filled gallbladder usually produces a painless right-upper-quadrant mass that’s smooth and sausage-shaped. However, passage of a stone through the bile or cystic duct may cause severe right-upper-quadrant pain that radiates to the epigastrium, back, or shoulder blades. Accompanying signs and symptoms include anorexia, nausea, vomiting, chills, diaphoresis, restlessness, and low-grade fever. Jaundice may occur with obstruction of the common bile duct. The patient may also experience intolerance to fatty foods and frequent indigestion.

Colon cancer

A right-lower-quadrant mass may occur with cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Occasionally, cancer of the left colon also causes a palpable mass. Usually though, it produces rectal bleeding, intermittent abdominal fullness or cramping, and rectal pressure. The patient may also report fremitus and pelvic discomfort. Later, he develops obstipation, diarrhea, or pencil-shaped, grossly bloody, or mucus-streaked stools. Typically, defecation relieves pain.

Crohn’s disease

With Crohn’s disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right-lower-quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

Diverticulitis

Most common in the sigmoid colon, diverticulitis may produce a left-lower-
quadrant mass that’s usually tender, firm, and fixed. It also produces intermittent abdominal pain that’s relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, low-grade fever, and a distended and tympanic abdomen.

Gallbladder cancer

Gallbladder cancer may produce a moderately tender, irregular mass in the right upper quadrant. Accompanying it is chronic, progressively severe epigastric or right-upper-quadrant pain that may radiate to the right shoulder. Associated signs and symptoms include nausea, vomiting, anorexia, weight loss, jaundice and, at times, hepatosplenomegaly.

Gastric cancer

Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness, fatigue and, occasionally, coffee-ground vomitus or melena.

Hepatic cancer

Hepatic cancer produces a tender, nodular mass in the right upper quadrant or right epigastric area accompanied by severe pain that’s aggravated by jolting. Other effects include weight loss, weakness, anorexia, nausea, fever, dependent edema and, occasionally, jaundice and ascites. A large tumor can also cause a bruit or hum.

Hepatomegaly

Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right-upper-quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy and, possibly, splenomegaly.

Hydronephrosis

Enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

Ovarian cyst

A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.

Pancreatic abscess

Occasionally, pancreatic abscess may produce a palpable epigastric mass accompanied by epigastric pain and tenderness. The patient’s temperature usually rises abruptly but may climb steadily. Nausea, vomiting, diarrhea, tachycardia, and hypotension may also occur.

Renal cell cancer

Usually occurring in only one kidney, renal cell carcinoma produces a smooth, firm, nontender mass near the affected kidney. Accompanying it are dull, constant abdominal or flank pain and hematuria. Other signs and symptoms include elevated blood pressure, fever, and urine retention. Weight loss, nausea, vomiting, and leg edema occur in late stages.

Splenomegaly

The lymphomas, leukemias, hemolytic anemias, and inflammatory diseases are among the many disorders that may cause splenomegaly. Typically, the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but commonly include a feeling of abdominal fullness, left-upper-quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and low-grade fever.

Uterine leiomyomas (fibroids)

If large enough, a uterine leiomyoma (common, benign uterine tumor) can produce a round, multinodular mass in the suprapubic region. The patient’s chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal Masses: Principal Causes of Abdominal Masses
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Rightupper quadrant
   1. Liver
      1. Hepatomegaly
      2. Hepatic cyst
      3. Primary hepatic neoplasms
   2. Gallbladder
      1. Cholecystitis
      2. Hydrops of the gallbladder
   3. Biliary tree
      1. Choledochal cyst
   4. Intestine
      1. Pyloric stenosis
      2. Duodenal hematoma
      3. Duplication
2. Left upper quadrant
   1. Spleen
      1. Splenomegaly
      2. Splenic cyst
      3. Neoplasm
3. Epigastric
   1. Stomach
      1. Bezoar
      2. Duplication
   2. Pancreas
      1. Pancreatic cyst
      2. Pancreatic pseudocyst
      3. Neoplasm
4. Right/left mid-abdomen
   1. Kidney
      1. Unilateral
         1. Hydronephrosis
         2. Multicystic dysplastic kidney
         3. Renal vein thrombosis
         4. Congenital mesoblastic nephroma
         5. Wilms tumor
         6. Renal cyst
         7. Ectopic kidney
         8. Horseshoe kidney
         9. Renal or perinephric abscess
      2. Bilateral
         1. Hydronephrosis
         2. Multicystic dysplastic kidney
         3. Renal vein thrombosis
         4. Polycystic kidney disease
         5. Beckwith-Wiedemann syndrome
   2. Adrenal
      1. Neonatal adrenal hematoma
      2. Neuroblastoma
5. Periumbilical
   1. Intestine
      1. Mesenteric cyst
      2. Volvulus
      3. Duplication
      4. Neoplasm
6. Right lower quadrant
   1. Intestine
      1. Abscess
      2. Intussusception
      3. Lymphoma
   2. Ovary
      1. Cyst
      2. Torsion
      3. Neoplasm
7. Left lower quadrant
   1. Intestine
      1. Constipation
   2. Ovary (see right lower quadrant)
8. Hypogastrium
   1. Bladder
      1. Distension/obstruction
   2. Uterus
      1. Pregnancy
      2. Hydrometrocolpos

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Abdominal distention: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal cancer.Generalized abdominal distention may occur when the cancer—most commonly ovarian, hepatic, or pancreatic—produces ascites (usually in a patient with a known tumor). It's an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

Abdominal trauma.When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. Pain may occur over the trauma site, or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

Cirrhosis.In cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave, shifting dullness, and a puddle sign. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The pa-tient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema, and possibly splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also be seen. Jaundice is usually a late sign. Hepatomegaly occurs initially, but the liver may not be palpable if the patient has advanced disease.

Heart failure.Generalized abdominal distention due to ascites typically accompanies severe cardiovascular impairment and is confirmed by shifting dullness and a fluid wave. Signs and symptoms of heart failure are numerous and depend on the disease stage and degree of cardiovascular impairment. Hallmarks include peripheral edema, jugular vein distention, dyspnea, and tachycardia. Common associated signs and symptoms include hepatomegaly (which may cause right upper quadrant pain), nausea, vomiting, a productive cough, crackles, cool extremities, cyanotic nail beds, nocturia, exercise intolerance, nocturnal wheezing, diastolic hypertension, weight gain, and cardiomegaly.

Irritable bowel syndrome.Irritable bowel syndrome may produce intermittent, localized distention—the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function, nausea, dyspepsia, straining and urgency at defecation, a feeling of incomplete evacuation, and small, mucus-streaked stools.

Large-bowel obstruction.Dramatic abdominal distention is characteristic in this life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and the sudden onset of colicky lower abdominal pain that becomes persistent. Nausea, fecal vomiting, and diminished peristaltic waves and bowel sounds are late signs.

Mesenteric artery occlusion (acute). In this life-threatening disorder, abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

Paralytic ileus.Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, mild abdominal pain and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

Peritonitis.Peritonitis is a life-threatening disorder in which abdominal distention may be localized or generalized, depending on the extent of the inflammation. Fluid accumulates within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by sudden and severe abdominal pain that worsens with movement, rebound tenderness, and abdominal rigidity.

The skin over the patient's abdomen may appear taut. Associated signs and symptoms usually include hypoactive or absent bowel sounds, fever, chills, hyperalgesia, nausea, and vomiting. Signs of shock, such as tachycardia and hypotension, appear with significant fluid loss into the abdomen.

Small-bowel obstruction.Abdominal distention is characteristic in small-bowel obstruction, a life-threatening disorder, and is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

Toxic megacolon (acute).Toxic megacolon is a life-threatening complication of infectious or ulcerative colitis. It produces dramatic abdominal distention that usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also presents with abdominal pain and tenderness, fever, tachycardia, and dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal mass: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal aortic aneurysm.An abdominal aortic aneurysm may exist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. It may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less commonly, low back or dull abdominal pain. If the aneurysm ruptures, he'll report severe abdominal and back pain. After rupture, the aneurysm no longer pulsates.

Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock—such as altered mental status, tachycardia, and cool, clammy skin—appear with significant blood loss.

Cholecystitis.Deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. With acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right upper quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy's sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Colon cancer.A right lower quadrant mass may occur with cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Occasionally, cancer of the left colon also causes a palpable mass. It usually produces rectal bleeding, intermittent abdominal fullness or cramping, and rectal pressure. The patient may also report fremitus and pelvic discomfort. Later, he develops obstipation, diarrhea, or pencil-shaped, grossly bloody, or mucus-streaked stools. Typically, defecation relieves pain.

Crohn's disease.With Crohn's disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right lower quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

Diverticulitis.Most common in the sigmoid colon, diverticulitis may produce a left lower quadrant mass that's usually tender, firm, and fixed. It also produces intermittent abdominal pain that's relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, a low-grade fever, and a distended and tympanic abdomen.

Gastric cancer.Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness after eating, fatigue and, occasionally, coffee-ground vomitus or melena.

Hepatomegaly.Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right upper quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy and, possibly, splenomegaly.

Hernia.The soft and typically tender bulge is usually an effect of prolonged, increased intra-abdominal pressure on weakened areas of the abdominal wall. An umbilical hernia is typically located around the umbilicus and an inguinal hernia in either the right or left groin. An incisional hernia can occur anywhere along a previous incision. Hernia may be the only sign until strangulation occurs.

Hydronephrosis.Enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

Ovarian cyst.A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.

Splenomegaly.With splenomegaly,the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but usually include a feeling of abdominal fullness, left upper quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and a low-grade fever.

Uterine leiomyomas (fibroids).If large enough, these common, benign uterine tumors produce a round, multinodular mass in the suprapubic region. The patient's chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Ascites: Ascites - pathophysiology
(The 5-Minute Pediatric Consult)

• Development of ascitic fluid may be sudden or insidious, associated with nonhepatic etiologies, or secondary to acute reduction in hepatocellular function in a marginally compensated liver.
• Intra-abdominal factors (resulting in a net flow of fluid and protein out of the mesenteric capillary bed):
  • Decreased plasma colloid osmotic pressure
  • Increased capillary pressure
  • Increased ascitic colloid osmotic fluid pressure
  • Decreased ascitic fluid hydrostatic pressure
• Accumulation of fluid occurs with:
  • Inflammatory conditions (e.g., mesenteric adenitis, tuberculosis, pancreatitis, secondary to inflammation of visceral and/or parietal peritoneum)
  • Obstruction of portal vein flow and/or lymphatic flow by mass, tumor, or external pressure; tumors of abdominal viscera, retroperitoneum, thorax, or mediastinum (often characterized by chylous ascites)
  • Primary (congenital) abnormalities of the lymphatics (Milroy disease), congenital neonatal ascites, secondary to abdominal trauma (e.g. ureteral rupture), hematologic diseases (hydrops secondary to hemolysis), congestive heart disease; and lysosomal storage diseases including sialidosis (neuraminidase deficiency), Salla disease, GM1 gangliosidosis, Gaucher disease, and Niemann-Pick type C
  • Decreased plasma oncotic pressure secondary to hypoalbuminemia (increased losses: Renal, GI tract; decreased production: Hepatic failure)
  • Rupture of intra-abdominal viscus or peritoneal/mesenteric cyst

Ascites - etiology

• Hepatic: Liver cirrhosis, chronic liver failure, portal vein occlusion, Budd-Chiari syndrome, lysosomal storage disease
• Renal: Nephrotic syndrome, obstructive uropathy, perforated urinary tract, peritoneal dialysis
• Cardiac: CHF, constrictive pericarditis, inferior vena cava web
• Infectious: Abscess, tuberculosis, Chlamydia infection, schistosomiasis
• GI: Infarcted bowel, perforation
• Pancreatic: Pancreatitis, ruptured pancreatic duct
• Neoplastic: Lymphoma, neuroblastoma
• Gynecologic: Ovarian tumors, torsion, or rupture
• Miscellaneous: Systemic lupus erythematous, eosinophilic ascites, chylous ascites, hypothyroidism, ventriculoperitoneal shunt

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

Peritonitis: Peritonitis - risk factors
(The 5-Minute Pediatric Consult)

• Liver cirrhosis (10–30% of adults hospitalized with cirrhosis have SBP), nephrotic syndrome (staphylococcal species, streptococci, enteric organisms, and fungi)
• Splenectomy (encapsulated organisms: Group A streptococci, E. coli, Streptococcus pneumoniae, Bacteroides sp.)
• Decreased serum complement levels
• Decreased ascitic protein and complement levels
• Presence of gastrointestinal hemorrhage

Peritonitis - pathophysiology

• When bacteria or chemicals reach the peritoneal cavity, a local peritoneal and systemic response is initiated.
  • Hyperemia and exudation of fibrinogen, albumin, opsonins, and complement
  • Mesothelial cells secrete cytokines (interleukin [IL]-6, IL-8, tumor necrosis factor-α [TNF-α]). IL-6 stimulates T- and B-cell differentiation, and IL-8 is a selective chemoattractant for polymorphonuclear (PMN) leucocytes.
• In SBP, pathogenic bacteria are cultured from peritoneal fluid without any apparent intra-abdominal surgical treatable source of infection. Recognized as a complication in patients with ascites as a result of cirrhosis of any etiology:
  • Generalized bacteremia and translocation of organisms from the gut (E. coli, Klebsiella sp.) into the portal veins or lymphatics or, less likely, directly into the ascitic fluid may account for the source of the infection.
  • Clearance of bacteria from the bloodstream may be impaired in patients with cirrhosis and ascites because of diminished phagocytic activity of the hepatic reticulo-endothelial system secondary to cellular functional defects or shunting of blood away from the liver.
  • Complement, necessary for the opsonization of bacteria and ultimately clearance by phagocytes, is decreased in the ascitic fluid of patients with ascites.
• In secondary bacterial peritonitis, the underlying bacterial infection tends to be a complex polymicrobial infection with an average of 3 or 4 different isolates; the most common isolates are combinations of E. coli and Bacteroides fragilis, and the most common Gram-positive organisms are nonenterococcal streptococci and enterococci.

Peritonitis - etiology

• Primary peritonitis: Liver cirrhosis or other conditions associated with ascites, such as:
  • Budd-Chiari syndrome
  • CHF
  • Nephrotic syndrome
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
• The etiology of secondary peritonitis varies with age.
  • Neonate:
    • Necrotizing enterocolitis
    • Idiopathic gastrointestinal perforation
    • Perforation due to Hirschsprung disease
    • Spontaneous biliary perforation
    • Omphalitis
    • Perforation of an urachal cyst
  • Children and adolescents:
    • Secondary to appendicitis
    • Perforation of Meckel diverticulum
    • Gastric ulcer perforation
    • Pancreatitis
    • Traumatic perforation of the intestine
    • Intussusception
    • Neutropenic colitis (typhlitis)
    • Crohn disease with fistula and abscess formation
    • Toxic megacolon
    • Tuberculosis
    • Salpingitis

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

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