Abdominal distension

20 Abdominal distension




Case


A 32-year-old woman presents with a 6-day history of progressive abdominal distension and nausea. She had recently been an inpatient with an episode of acute pancreatitis. The aetiology of the pancreatitis was familial pancreatitis, with her grandmother, father and one brother having episodes of recurrent pancreatitis. She looked well, was afebrile and was not jaundiced or pale. Abdominal examination revealed a moderately distended abdomen that was tense but not tender. The bowel sounds were normal. There was evidence of shifting dullness and a fluid thrill. A provisional diagnosis of ascites was made.


Laboratory blood tests were all normal in particular the amylase, lipase, liver function tests and albumin. A CT scan confirmed marked ascites. The pancreas was slightly enlarged but well perfused with a slightly prominent pancreatic duct. There were no loculated fluid collections or evidence of pseudocyst formation. A diagnostic aspiration of the fluid revealed it was straw-coloured. Analysis confirmed it was an exudate with no cells and an amylase of over 100 000 I/U (serum ascites–albumin gradient < 11 g/L). This confirmed the clinical suspicion of pancreatic ascites.


The following day an ERCP was performed. The pancreatic duct was dilated at 4 mm with no obvious stricture. There was a leak of contrast from the region of the distal body into the peritoneal cavity. An endoscopic pancreatic stent was inserted with good drainage noted. Over the next 3 days the abdominal distension resolved and she was discharged home. Three weeks later a follow-up CT scan confirmed complete resolution of the ascites and a relatively normal pancreas with the stent in situ. She remained well and the stent was removed after 6 months. Unfortunately, she had further episodes of recurrent acute pancreatitis over the next 4 years and is likely to develop chronic pancreatitis.



Preliminary Examination of the Abdomen


The traditionally taught five causes of generalised abdominal distension (the ‘five Fs’) are: flatus, fluid, faeces, fetus and fat. To this list should be added a sixth: massive organomegaly or ‘filthy big tumour’.


For the patient presenting with generalised abdominal distension, a preliminary abdominal examination is worthwhile before a detailed history is taken to determine which of the ‘six Fs’ is the most likely cause. The reason for this departure from the usual sequence of history followed by examination is that history taking can be greatly simplified if the clinician has some prior idea of the underlying problem.









History and Further Examination


A classification of the causes of abdominal distension is presented in Table 20.1 and relevant symptoms are listed in Table 20.2. The duration of abdominal distension and its association with abdominal pain are key questions. Thus, abdominal pain should not usually be expected to be a feature, except with abdominal distension due to gas in bowel obstruction; with the other causes, there may be milder discomfort due to stretching of the parietal peritoneum or the capsule of an organ. Localised pain can occur with organ swelling. Similarly, the speed of development for most causes is slow, except with abdominal distension from gas, in which case it can be fast. Tense swelling of the abdomen due to fluid or a large tumour can cause increased intraabdominal pressure leading to heartburn, nausea, vomiting or dyspnoea (from elevation of the diaphragm). The specific clinical features for each cause are described below.


Table 20.1 Classification of causes of abdominal distension: the ‘six Fs’











































































































Cause Example Distension
1. Flatus (gaseous distension)    
Bowel obstructed    
Open   Generalised
Closed Sigmoid volvulus Localised
  Caecal volvulus Localised
Bowel not obstructed    
  Paralytic ileus Generalised
  Pseudo-obstruction Generalised
  Irritable bowel syndrome Generalised
  Acute gastric dilatation Localised
  Gas bloat Generalised
2. Fluid (ascites) See Table 20.3 for detail Generalised
3. Faeces   Localised
4. Fat   Generalised
5. Fetus   Localised
6. Filthy big tumour (organomegaly)    
Liver See Chapter 19 Localised
Spleen See Chapter 19 Localised
Ovary Ovarian cyst Localised
Uterus Fibroids Localised
Kidney Polycystic kidney Localised
Hydronephrosis Localised
Bladder Obstructed bladder Localised
Mesentery Tumour Localised
Retroperitoneum Tumour Localised or generalised

Table 20.2 Possible symptoms with abdominal distension
































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May 30, 2016 | Posted by in GASTROENTEROLOGY | Comments Off on Abdominal distension

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Symptom Relevance/significance
Abdominal pain:



Nausea/vomiting Bowel obstruction
Anorexia Non-specific, malignancy, cirrhosis
Loss of weight Non-specific, malignancy, cirrhosis
Bowel habit (recent and usual) Bowel obstruction, constipation
Respiratory symptoms Secondary to elevation of the diaphragm
Previous history of malignant disease As a possible cause of ascites
Alcohol or drug abuse As a cause of liver disease and ascites
Jaundice