Abdominal distention

Abdominal distention: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

Abdominal distention refers to increased abdominal girth—the result of increased intra-abdominal pressure forcing the abdominal wall outward. Distention may be mild or severe, depending on the amount of pressure. It may be localized or diffuse and may occur gradually or suddenly. Acute abdominal distention may signal life-threatening peritonitis or acute bowel obstruction.

Abdominal distention may result from fat, flatus, a fetus (pregnancy or intra-abdominal mass [ectopic pregnancy]), or fluid. Fluid and gas are normally present in the GI tract but not in the peritoneal cavity. However, if fluid and gas are unable to pass freely through the GI tract, abdominal distention occurs. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid, or air from perforation of an abdominal organ.

Abdominal distention doesn’t always signal pathology. For example, in anxious patients or those with digestive distress, localized distention in the left upper quadrant can result from aerophagia—the unconscious swallowing of air. Generalized distention can result from ingestion of fruits or vegetables with large quantities of unabsorbable carbohydrates, such as legumes, or from abnormal food fermentation by microbes. Don’t forget to rule out pregnancy in all females with abdominal distention.

Emergency interventions

If you detect abdominal distention and rigidity along with abnormal bowel sounds, and the patient complains of pain, begin emergency interventions. Place the patient in the supine position, administer oxygen, and insert an I.V. line for fluid replacement. Prepare to insert a nasogastric tube to relieve acute intraluminal distention. Reassure the patient and prepare him for surgery.

History and physical examination

If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heartbeat, and difficulty breathing deeply or breathing when lying flat. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.

Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.

Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, glistening skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or an umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obese individuals. Inspect the abdomen for signs of an inguinal or femoral hernia and for incisions that may point to adhesions; both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for a succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.

Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally when the patient is in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen with generalized rather then localized dullness and without shifting dullness, prominent tympany, or palpable bowel or other masses.

Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference point for subsequent measurements. (See Abdominal distention: Causes and associated findings, pages 6 and 7.)

Medical causes

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.

Special considerations

Position the patient comfortably, using pillows for support. Place him on his left side to help flatus escape or, if he has ascites, elevate the head of the bed to ease his breathing. Administer drugs to relieve pain, and offer emotional support.

Prepare the patient for diagnostic tests, such as abdominal X-rays, endoscopy, laparoscopy, ultrasonography, computed tomography scan, or possibly paracentesis.

Pediatric pointers

Because a young child’s abdomen is normally rounded, distention may be difficult to observe. However, a child’s abdominal wall is less well developed than an adult’s, so palpation is easier. When percussing the abdomen, remember that children normally swallow air when eating and crying, resulting in louder-than-normal tympany. Minimal tympany with abdominal distention may result from fluid accumulation or solid masses. To check for abdominal fluid, test for shifting dullness instead of for a fluid wave. (In a child, air swallowing and incomplete abdominal muscle development make the fluid wave difficult to interpret.)

Some children won’t cooperate with a physical examination. Try to gain the child’s confidence, and consider allowing him to remain in the parent’s or caregiver’s lap. You can gather clues by observing the child while he’s coughing, walking, or even climbing on office furniture. Remove all the child’s clothing to avoid missing any diagnostic clues. Also, perform a gentle rectal examination.

In neonates, ascites usually results from GI or urinary perforation; in older children, from heart failure, cirrhosis, or nephrosis. Besides ascites, congenital malformations of the GI tract (such as intussusception and volvulus) may cause abdominal distention. A hernia may cause distention if it produces an intestinal obstruction. In addition, overeating and constipation can cause distention.

Geriatric pointers

As people age, fat tends to accumulate in the lower abdomen and near the hips, even when body weight is stable. This accumulation, together with weakening abdominal muscles, commonly produces a potbelly, which some elderly patients interpret as fluid collection or evidence of disease.

Patient counseling

If the patient’s anxiety triggers air swallowing or deep breathing that causes discomfort, advise him to take slow breaths. If the patient has an obstruction or ascites, explain food and fluid restrictions. Stress good oral hygiene to prevent dry mouth.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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