Abdominal Distension

Differential Overview

Ascites

❑ Right-sided heart failure

❑ Cirrhosis

❑ Hypoalbuminemia

❑ Ovarian cancer

❑ Portal vein thrombosis

❑ Hepatic vein thrombosis

❑ Intra-abdominal metastases

❑ Tuberculous peritonitis

❑ Chylous effusion

Gas/Bloating

❑ Aerophagia

❑ Irritable bowel syndrome

❑ Acquired lactase deficiency

❑ Carbonated beverages

❑ Nonabsorbable carbohydrates

❑ Fatty food intolerance

❑ Small bowel obstruction

❑ Gastric dilation

Other

❑ Obesity

❑ Distended bladder

❑ Gravid uterus

Diagnostic Approach

In ascites, the abdomen is globular, the skin is tense and shiny, and the umbilicus is flush. The most reliable signs of ascites are bulging flanks, transmitted fluid wave, and shifting dullness to percussion. Ascitic fluid in the bulging flanks is best appreciated by a heaviness when the examiner lifts from below.

Venous dilation on the abdominal wall can be used as a differentiating feature. As determined by stripping veins, flow below the umbilicus is normally downward, and above the umbilicus, upward. In portal vein obstruction, the direction of flow is normal. In inferior vena cava obstruction, flow below the umbilicus is reversed as blood is shunted to the superior vena cava.

With portal hypertension, a soft liver suggests extrahepatic obstruction, a firm liver, cirrhosis, and a very hard or nodular liver, cancer. Portal hypertension alone does not produce ascites unless there is hypoalbuminemia or increased hepatic lymphatic pressure.

Look for signs of systemic disease such as weight loss or abdominal pain. For example, gluten-induced enteropathy may present with bloating and distension, but will also manifest prominent weight loss, steatorrhea, and diarrhea.

Clinical Findings

Right-sided heart failure  Dilated jugular veins and edema usually precede the ascites. In constrictive pericarditis, there is jugular distension, a quiet precordium, ascites, and hepatomegaly.

Cirrhosis  A history of chronic alcoholism or hepatitis is usually present. Other stigmata include dilated veins on the abdominal wall, spider angiomata, testicular atrophy, gynecomastia, hemorrhoids, and palmar erythema.

Hypoalbuminemia  Common causes include nephrotic syndrome, malabsorption, and protein-calorie malnutrition.

Ovarian cancer  Nearly two-thirds of cases present with ascites and a palpable pelvic mass. A gastric tumor with dropped implants in the cul-de-sac could present in a similar manner.

Portal vein thrombosis  Thrombosis produces esophageal varices, often with upper gastrointestinal bleeding and splenomegaly.

Hepatic vein thrombosis  Thrombosis is characterized by hepatomegaly and ascites. If the inferior vena cava is also obstructed, there may be massive
leg edema and dilated veins on the surface of the abdomen. It most
often occurs in the setting of renal cell cancer, polycythemia, or migratory thrombophlebitis.

Intra-abdominal metastases  A known tumor at an intra-abdominal site, palpable nodules especially in the liver or around the umbilicus, left supraclavicular adenopathy, and marked cachexia are clues.

Tuberculous peritonitis  Ascites without leg edema, loculation (no shifting dullness), night sweats, and evidence of extrapulmonary tuberculosis in other sites are important indicators of this unusual diagnosis.

Chylous effusion  Chyle is most commonly seen in association with trauma or tumor. In patients from endemic regions it may also be due to filariasis (elephantiasis).

Aerophagia  Eructation (belching) is the predominant phenomenon. It is caused by drinking carbonated beverages, air swallowing with excess saliva (e.g., gum or lozenges), chronic postnasal drainage, overly dry mouth (e.g., Sjogren or anticholinergics), or air swallowing with stress or habit, which can often be observed during the interview.

Irritable bowel syndrome  A sensation of abdominal bloating is common, despite little objective increase in gas formation. These symptoms will increase after a meal and are associated with cramping abdominal pain relieved by a bowel movement. Either constipation or loose stools can be present.

Acquired lactase deficiency  Milk, cheese, and ice cream produce loose stools, flatulence, abdominal cramps, bloating, or distension. Intolerance may be acquired as an adult, especially in patients of African or Asian descent (80% to 90%). It may also develop transiently following a viral gastroenteritis.

Carbonated beverages  Carbonated soft drinks, beer, and effervescent medications produce belching, especially when gulped, but seldom increase flatus.

Nonabsorbable carbohydrate  Baked beans, soybeans, broccoli, and cabbage contain a nonabsorbable complex carbohydrate that may be broken down into carbon dioxide, hydrogen, and methane by colonic bacteria. Saccharin and sorbitol (in sugarless gum) and fructose, in dates, prunes, grapes and fruit juices, may also be incompletely absorbed.

Fatty food intolerance  Carbon dioxide is produced in the duodenum, eliciting a sensation of postprandial bloating.

Small bowel obstruction  Poorly localized, cramping visceral pain, bilious vomiting, and swelling with tympanitic distension are typical. High-pitched rushes are heard on auscultation. Distended coils of intestine with visible peristalsis may be seen when abdominal musculature is lax.

Gastric dilation  Upper abdominal distension, tympany, and a succussion splash are the usual signs. Delayed gastric emptying may be the result of abdominal pain, peptic ulcer, paraplegia, diabetes (ketoacidosis or autonomic neuropathy), hypocalcemia, hypercalcemia, hypokalemia, uremia, or drugs (morphine, anticholinergics).

Obesity  There is an overhanging pannus, the skin is not stretched and shiny as in ascites, and the umbilicus is a deep pit rather than protruding as in ascites.

Distended bladder  A globular mass arises from the pelvis and is dull to percussion. There is usually a strong cramping pain referred to the urethra.

Gravid uterus  Pregnancy should be evident with amenorrhea and a central pelvic mass.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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