Management and Determining the Cause

Chief Complaint: Abdominal Distention

Step 1: Initial Rapid Assessment

  • Check vital signs and hemodynamic stability
  • Unstable Patient versus Stable Patient
  • Brief focused history: onset, pain, vomiting, last bowel movement
  • Quick abdominal inspection for obvious distension pattern
  • Listen for bowel sounds while obtaining history

Decision point: Is the patient hemodynamically unstable or showing signs of peritonitis? If yes → immediate surgical consultation and resuscitation.

Step 2: Systematic History and Physical (Next 10-15 minutes)

Structured history:

  1. Onset and progression (hours vs days)
  2. Associated symptoms (pain location/character, nausea, vomiting, fever)
  3. Bowel and bladder function
  4. Recent procedures, medications, medical history
  5. Previous abdominal surgeries

Systematic physical examination:

  1. Inspection: distension pattern, visible peristalsis, surgical scars
  2. Auscultation: bowel sounds (absent, hypoactive, hyperactive, high-pitched)
  3. Percussion: tympany vs dullness (gas vs fluid vs mass)
  4. Palpation: tenderness, guarding, masses, organomegaly
  5. Digital rectal exam if indicated

Step 3: Initial Diagnostic Testing (Parallel with assessment)

Laboratory orders:

  • CBC with differential
  • Basic metabolic panel
  • Lactate level
  • Consider: lipase, liver enzymes, urinalysis based on clinical suspicion

Initial imaging:

  • Upright chest X-ray (free air under diaphragm)
  • Supine and upright abdominal X-rays

Step 4: Clinical Decision Making (After initial results)

Pattern recognition:

  • Bowel obstruction: crampy pain, distension, vomiting, abnormal bowel sounds
  • Perforation: sudden onset, severe pain, rigid abdomen, free air
  • Ascites: gradual onset, shifting dullness, fluid wave
  • Ileus: recent surgery/medications, absent bowel sounds, uniform distension

Imaging decision:

  • If X-rays are diagnostic → proceed with management
  • If unclear or high suspicion for serious pathology → CT scan
  • If unstable and obvious surgical emergency → operating room

Step 5: Advanced Imaging and Consultation

CT abdomen/pelvis with contrast (unless contraindicated):

  • Identifies level and cause of obstruction
  • Detects perforation, ischemia, masses
  • Quantifies ascites
  • Evaluates vascular supply

Consultation timing:

  • Immediate: Hemodynamic instability, peritonitis, free air
  • Urgent: Complete bowel obstruction, suspected volvulus
  • Non-urgent: Partial obstruction, ascites evaluation

Step 6: Management Decision Tree

Based on findings:

  1. Surgical emergency → Operating room
  2. Complete bowel obstruction → NPO, NG decompression, surgical evaluation
  3. Partial obstruction → Conservative management with monitoring
  4. Ascites → Diagnostic paracentesis if new or clinical deterioration
  5. Ileus → Treat underlying cause, supportive care

Implementation Tips

Time-sensitive red flags that require immediate escalation:

  • Hypotension with abdominal distension
  • Severe abdominal pain with rigidity
  • Absent bowel sounds with tympany
  • Lactate >4 or signs of sepsis

Documentation checklist:

  • Time of onset and progression
  • Examination findings in all four quadrants
  • Imaging findings and interpretation
  • Consultant discussions and recommendations

This systematic approach ensures nothing critical is missed while efficiently moving toward diagnosis and treatment. The key is parallel processing of history, examination, and initial testing while maintaining awareness of time-sensitive conditions that require immediate intervention.

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Chronic Abdominal Distention (weeks to months)

Chronic distention suggests gradual processes, functional disorders, or progressive conditions:

Functional disorders like irritable bowel syndrome, chronic constipation, or gastroparesis develop slowly and often fluctuate with symptoms. Patients may report bloating that worsens throughout the day.

Malignancy including ovarian tumors, hepatic masses, or peritoneal carcinomatosis causes gradual abdominal enlargement. Associated symptoms might include weight loss, early satiety, or pelvic pressure.

Ascites from liver disease, heart failure, or malignancy accumulates over weeks to months. The distention is typically diffuse and may be accompanied by peripheral edema.

Organomegaly such as hepatosplenomegaly from various causes creates gradual, localized distention that patients may notice as increasing abdominal girth.

Chronic with Acute Exacerbations

Some conditions present as chronic issues with acute worsening, such as inflammatory bowel disease flares, partial bowel obstruction becoming complete, or worsening ascites in cirrhotic patients.

The temporal pattern, combined with associated symptoms, physical examination findings, and patient history, helps physicians prioritize diagnostic testing and determine the urgency of intervention. Acute distention generally warrants immediate evaluation and often imaging studies, while chronic distention may allow for more methodical workup including laboratory tests and outpatient imaging.

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Clinical History

The evaluation begins with a detailed history focusing on:

  • Onset and duration (acute vs. chronic)
  • Associated symptoms (pain, nausea, vomiting, changes in bowel habits)
  • Dietary factors and recent changes
  • Medical history including surgeries, medications, and underlying conditions
  • Family history of gastrointestinal or genetic disorders

Physical Examination

A thorough abdominal examination includes:

  • Inspection: Looking for asymmetry, visible peristalsis, or hernias
  • Palpation: Assessing for masses, organomegaly, or tenderness
  • Percussion: Distinguishing between gas, fluid, or solid masses (different sounds)
  • Auscultation: Listening for bowel sounds (absent, hyperactive, or normal)

Common Causes to Consider

The differential diagnosis typically includes:

  • Gastrointestinal: Bowel obstruction, constipation, inflammatory bowel disease, irritable bowel syndrome
  • Hepatic: Hepatomegaly, cirrhosis with ascites
  • Gynecologic: Ovarian masses, uterine enlargement, pregnancy
  • Urologic: Bladder distention, kidney masses
  • Other: Ascites from various causes, abdominal masses, hernias

Diagnostic Tests

Based on clinical findings, providers may order:

  • Laboratory tests: Complete blood count, comprehensive metabolic panel, liver function tests
  • Imaging: Abdominal X-rays, ultrasound, CT scan, or MRI depending on suspected cause
  • Specialized tests: Endoscopy, paracentesis (if ascites suspected), or specific tumor markers

The key is correlating symptoms with physical findings to guide appropriate testing and avoid unnecessary procedures. Acute distention with pain often requires urgent evaluation, while chronic distention may allow for a more measured diagnostic approach.

If you're experiencing concerning abdominal distention, it's important to consult with a healthcare provider for proper evaluation and diagnosis.

 

Abdominal Swelling

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