The power of observation can be called the foundation of a successful diagnosis. In this article, Dr. YK Amdekar highlights the cues one should pick up on when faced with a patient complaint of abdominal distention.

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A normal infant has a protuberant abdomen as it partly accommodates the liver and spleen. As age advances and growth takes place, these organs are accommodated in the chest. A malnourished young child also has a protuberant abdomen due to hypotonia of the abdominal wall. In both these situations, abdominal distension is mild.  An obese child has protruding abdomen due to excess fat.

These three conditions do not represent any intra-abdominal pathology. However, significant abdominal distension, denotes an intra-abdominal pathology, the cause of which can be guessed on close observation.

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Observation of relevant facts

Sick or not sick?

1. A patient appears acutely sick when abdominal distension is due to intestinal obstruction – either mechanical (surgical) or paralytic ileus (sepsis, hypokalaemia) or capillary leak syndrome (due to ascites following dengue fever).
2. The patient looks to be chronically sick as in the case of chronic liver disease or malignancy.
3. The patient is comfortable in spite of abdominal distension in case of nephrotic syndrome or constipation.

Generalised or localised?

1. A large mass in the abdomen may result in generalised abdominal distension but such distension may be more central than in the flanks.
2. Generalised abdominal distension suggests accumulation of fluid (ascites), flatus or faeces (constipation). Flanks appear full in case of ascites while abdominal distension is waxing and waning if caused by flatus or constipation.
3. Localised abdominal distension to any quadrant is related to the organ situated in that particular area. Upper abdominal distension results in downward shifting of the umbilicus (normally umbilicus is at the centre of the abdomen) and is commonly a result of an enlarged liver with or without an enlarged spleen.
4. Initially localised hepatomegaly may lead to portal hypertension and ascites that result in ascites with generalised abdominal distension with the fullness of flanks. Isolated splenomegaly presents as a lump in the left hypochondrium as the spleen enlarges diagonally from the left hypochondrium to the right iliac fossa.
5. A large intra-abdominal mass may spread across the midline and occupy the central part of the abdomen. Fullness in the left side of the abdomen may denote a loaded descending colon due to constipation.

Visible peristalsis

Acute mechanical intestinal obstruction may reveal increased peristalsis. Reversed peristalsis in the epigastrium may suggest pyloric obstruction.

Other accompanying findings:

1. Oedema may suggest nephrotic syndrome (severe and generalised oedema) or pedal oedema (chronic liver disease).
2. Pallor, if significant denotes severe anaemia with enlarged liver and spleen.
3. Jaundice is a feature of liver disease.

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Importance of general observation

The following examples would reiterate the importance of general observation when a patient presents with abdominal distension.

Case 1

A 10-year-old, well-grown child had generalised abdominal distension without the fullness of flanks, peristalsis and looked acutely sick.

Diagnosis: It is most likely an intestinal obstruction. A similar presentation may be due to a paralytic ileus but peristalsis rules it out. However, peristalsis may not be present in an intestinal obstruction.

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Case 2

A 10-year-old child had generalised abdominal distension with flanks full, looked chronically sick and undernourished, and had oedema of feet.

Diagnosis: Flanks fullness suggests ascites and oedema of the feet indicate hypoproteinaemia. Chronically sick and undernourished appearance denotes chronic progressive disease. Hence, it is mostly cirrhosis of the liver. Compensated cirrhosis presents without jaundice that appears only when the liver starts failing.

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Case 3

A four-year-old child had upper abdominal distension with umbilicus shifted downwards and looked chronically sick and pale.

Diagnosis: It suggests probable hepatosplenomegaly, paleness denoting probable anaemia and sickness suggestive of severe illness. It is likely to be a disseminated malignant disorder. It may either be leukaemia or lymphoma.

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Case 4

A two-year-old child had generalised severe abdominal distension with flanks full, massive generalised oedema but looked very comfortable.

Diagnosis: This is a nephrotic syndrome with ascites.

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Case 5

A six-year-old child had mild generalised abdominal distension without the fullness of flanks. The child did not look sick but reported waxing and waning of abdominal distension.

Diagnosis: This is likely to be due to the accumulation of flatus or faeces as in the case of habitual constipation.

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In summary, a mere observation can make out the most likely cause of abdominal distension and it helps to fine-tune the diagnosis with the help of focussed history and physical examination.

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If you wish to read more interesting cases and practice pearls on abdominal distension, click here.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.