Medical symptom checker - swollen stomach /abdominal distention causes- General overview
Medical symptom checker - swollen stomach / abdominal distention - general overview
Abdomen distention is also known as “swollen stomach “. It caused by an increase in the intra abdominal pressure which pushes the abdomen outwards. This condition will lead to an increase in the abdominal girth.
The onset is mild to moderate (depends on pressure), slow or progressive, and acute or chronic as well as localized or generalized. Acute cases of abdominal distention are associated with peritonitis or acute bowel obstruction which is life threatening.
Pregnancy should be ruled out in any childbearing women with abdominal distention. The anxious and stressful patient may lead to localized distention in the lower quadrant as a result of swallowing of the air unconsciously ( aerophagia ) .Consuming vegetables and fruits may lead to abdominal distention as a result of fermentation of the food by microbes or the ingestion of vegetables and fruit with legumes ( unabsorbed vegetables ).
The most common causes of abdominal distention may include fluid, fat, fetus and flatus. Fluid and flatus which are unable to pass the gastrointestinal tract will lead to abdominal distention. The fetus is associated with intrauterine or ectopic pregnancy. Distention may originate from the peritoneal cavity in case of perforation of abdominal organs, acute bleeding and accumulation of ascitic fluid.
General approach to an abdominal distention patient
History and examination are important to assess the patient‘s abdomen. The most important questions include site, onset, characteristic, nature, radiation, associated factors, time, exaggerating factors and severity.
Typically the patient with generalized abdomen distention may present with pounding heartbeat, shortness of breath and bloated feeling while lying flat.
The patient with localized abdominal distention may present with localized pressure, tenderness and fullness in that specific area.
The associated features of abdominal distention may include fever, nausea, vomiting, anorexia and weight loss or weight gain.
After focusing on the history of the presenting complains (site, nature, radiation...) It is worth asking about any significant medical history or surgical history which may lead to peritonitis, associates, hepatitis, cirrhosis or inflammatory bowel disease (common causes of abdominal distention). Questions regarding recent abdominal trauma due to an accident is also important. A patient with chronic constipation may also present with abdominal distention.
The physical examination is performed by focusing on entire well being of the patient and not just examining the abdomen. Doctors are required to stand at the foot of the bed and observe the patient in a recumbent position. Any swelling is noted. Notice if the swelling is localized or generalized, symmetrical or asymmetrical. Then look for any evidence of visible peristalsis which indicates bowel obstruction. The abdominal contour is observed by stooping at the patient’s sides. The abdominal contour that is tense, glistening as well as bulging in the flank region may indicate ascites (signs of cirrhosis).
Besides inspection of the abdominal contour, the patient umbilicus needs to be inspected. The everted umbilicus is highly suggestive of umbilical hernia or ascites while the inverted umbilicus may suggest obesity and gas related distention. Any femoral or inguinal hernias also need to be inspected as well as any surgical scars in case of adhesion. All these conditions may lead to intestinal obstruction.
Auscultation of the abdomen is also important. Listen for any friction rub, which indicates peritoneal inflammation and any bruit which indicates pulsatile abdominal aortic aneurysm. Listen for succussion splash which is a splashing sound that is audible while palpating the abdominal viscera or heard in the stomach while the patient is moving. Gastric dilation or obstruction is an indicated by abnormal loud splashing sounds.
The next steps involved palpation and percussion of the abdomen. The aim of this action is to differentiate between air filled and fluid filled abdominal distention. Generalized abdominal distention with tympanic note on percussion may indicate air filled peritoneal cavity abdominal distention. Localized abdominal distention as in left lower quadrant may indicate air filled the sigmoid colon or descending colon.
Dullness on the percussion note of the generalized abdominal distention may indicate fluid filled peritoneal cavity. Patient that present with shifting dullness while the patient in lateral decubitus position may indicate fluid filled abdominal cavity. The presence if any intra abdominal mass and pelvic mass may present with localized dullness. Obese patient may present with generalized dullness without shifting dullness and no palpable masses, bowel or organs.
Tenderness either localized or generalized may be detected by palpating the abdomen. Do not forget to watch any signs such as McBurney ‘sign, psoas signs or obturator signs and other peritoneal signs such as guarding, rebound tenderness and rigidity.
Measurement of the abdominal girth is also important for comparison of the baseline value and to detect any increase or decrease in the abdominal girth
All the patient with abdominal distention may also require a digital rectal exam and faecal occult blood test to detect any risk of colon cancer. Pelvic exam requires for women while the external genital exam in men.
The most common causes of abdominal distention include irritable bowel syndrome, large bowel obstruction, small bowel obstruction, paralytic ileus, toxic megacolon, peritonitis, heart failure, cirrhosis and abdominal trauma.
Common causes of abdominal distention
Irritable bowel syndrome
It is a condition that characterized by periodic intestinal spasm with intermittent localized distention that may associate with cramping and lower abdominal pain/discomfort. It may also present with nausea, dyspepsia, diarrhoea and constipation alternately, feeling of incomplete evacuation of stool, straining or urgency at defecation and production of small mucus streaked stool. Irritable bowel syndrome may be relieved by passing of the gas (flatulence) and make worse with stress.
Large bowel obstruction
It is a life threatening condition. In severe cases it may present with a visible loop of bowels on examination. Constipation may only be the presenting complaint and preceding any cases of large bowel obstruction. On physical finding, the patient may present with sudden onset of colicky lower abdominal pain with faecal vomiting and diminished peristalsis wave and tympanic notes as well as high pitched bowel sound on auscultation. Faecal vomiting diminished peristalsis and bowel sounds are the late signs.
Small bowel obstruction
Small bowel obstruction is a life threatening bowel obstruction that may present with constipation, colicky peri umbilical pain and nausea and vomiting, the higher degree of obstruction, the severe and the earlier the onset of vomiting. On examination the patient may present with hyperactive and hypoactive bowel sounds and tympanic note on percussion. The patient may also present with drowsiness and malaise. Signs of dehydration which may later develop to hypovolaemic shock as a result of plasma loss and progressive dehydration. Small bowel obstruction may appear with tenderness as a result of strangulated intestine and ischaemia.
Patient with paralytic ileus may present with generalized distention. They may also present with constipation, mild abdominal pain and vomiting. A tympanic note may also present on percussion. The patient may present with small and liquid form stools and flatus. Absent / hypoactive bowel sound may indicate the present of paralytic ileus.
It is a localized or generalized abdominal distention which is air or fluid filled. Peritonitis is a life threatening condition. It may present with accumulation of fluid first within the peritoneal cavity which later accumulates the lumen of the bowel which shows a shifting dullness/movement of fluid waves. Patient with peritonitis may not just present with abdominal distention but also abdominal pain that is sudden and severe and worse with movement. Patient may also develop other peritonitis signs such as guarding, rebound tenderness and abdominal rigidity. Patient‘s skin may appear taut. Signs of shock such as nausea, vomiting, fever chills, hyperalgesia and hypoactive or absent of bowel sounds.
Acute toxic megacolon
It is a life threatening condition that is presented with dramatic abdominal distention that develops progressively. The patient presents with abdominal pain, fever, tachycardia and tenderness. On examination, tympanic note is heard on percussion and reduce or absent bowel sounds are heard on auscultation with mild rebound tenderness. Acute toxic megacolon is associated with complications of ulcerative colitis and infectious colitis.
Heart failure is associated with severe cardiovascular symptoms and signs, Beside that, it may also present with generalized abdominal distention ( ascites ) that is presented with the shifting dullness and a fluid wave. The most common signs and symptoms of heart failure may include, dyspnea, peripheral edema, distention of jugular veins and tachycardia. Other signs and symptoms are nausea, vomiting, hepatomegaly at the right upper quadrant, coughing, crackles, cyanotic nail bed, nocturnal wheezing, nocturia as well as cardiomegaly.
Cirrhosis is presented with generalized abdominal distention in the form of ascites which is characterized by everted umbilicus, shifting dullness and fluid waves. Caput Medusa may also be observed on the abdomen. (Dilated vein on the umbilicus) . The patient typically complains of vague abdominal pain, feeling of abdominal fullness, bloating, weight gain,
Nausea, vomiting, fever, spider angioma, Palmar erythema, increase in bleeding tendency, severe pruritus, leg edema, splenomegaly, constipation and diarrhoea. Other signs may include enlargement of the liver and spleen ( hepato splenomegaly ) which is initially palpable but is not palpable in later stages. Complication of cirrhosis such as encephalopathy, gynecomastia, testicular atrophy and haematemesis are present. Jaundice is common but late signs.
Abdominal trauma may be presented with brisk internal bleeding that may present with signs and symptoms of hypovolemic shock such as tachycardia and hypotension. Beside that abdominal distention may also present as a result of accumulation of blood. The patient may also complain of abdominal pain over the sited of trauma or over the scapula if any irritation of the phrenic nerve happens. Abdominal bruising and tenderness may present in patient with abdominal trauma. Other abdominal signs may include reduction of the vowel sound, rebound guarding, abdominal rigidity and vomiting.
Patient with abdominal distention may require special consideration such as preparing the patient for diagnostic test which includes abdominal x ray, laparoscopy, endoscopy, ultrasounds, CT - scan and in certain case paracentesis.
In any geriatric setting potbelly is common and often misinterpreted as ascites/ fluid collection. Potbelly typically presents in elderly due to accumulation of fat in the lower abdomen near the hip that will weaken the abdominal muscle.
In pediatric setting, (neonates) fluid accumulation or ascites are common mostly resulted from urinary perforation or gastrointestinal disorder. Heart failure, nephrosis and cirrhosis may also present in children. Other disorder such as intussuception and volvulus which are congenital gastrointestinal tract malformation may also present with abdominal distention. Hernia which leads to intestinal obstruction may also present with abdominal distention. Constipation and overeating are also the most common causes of abdominal distention. Tympany which is louder than normal while percussing the abdomen indicates the swallowing of the air when the child cries or eating. While tympany note that is minimal indicates solid mass or fluid accumulation that leads to abdominal distention.
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