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Abdominal distension

Medicine > Gastrointestinal

Differential Diagnosis Schema 🧠

Gastrointestinal Causes

  • Ascites: Often due to cirrhosis, malignancy, or heart failure.
  • Bowel Obstruction: Can be mechanical (e.g., hernias, tumours) or functional (e.g., ileus).
  • Colorectal Cancer: Persistent change in bowel habit, rectal bleeding, weight loss.
  • Inflammatory Bowel Disease: Abdominal pain, diarrhoea, weight loss, extra-intestinal manifestations.
  • Coeliac Disease: Diarrhoea, weight loss, bloating, and malabsorption.

Hepatobiliary Causes

  • Hepatomegaly: Commonly seen in cirrhosis, liver metastases, and right heart failure.
  • Cholecystitis: RUQ pain, fever, Murphy’s sign, history of gallstones.
  • Pancreatitis: Epigastric pain radiating to back, associated with nausea and vomiting.
  • Liver Abscess: Fever, right upper quadrant pain, hepatomegaly.

Cardiovascular Causes

  • Heart Failure: Hepatic congestion leading to ascites.
  • Pericarditis: Associated with pericardial effusion, causing ascites and pleural effusion.
  • Portal Hypertension: Commonly secondary to cirrhosis, leading to ascites.
  • Budd-Chiari Syndrome: Hepatic vein obstruction causing hepatomegaly, ascites, and abdominal pain.

Renal Causes

  • Polycystic Kidney Disease: Abdominal mass, hypertension, haematuria, family history.
  • Nephrotic Syndrome: Generalised oedema, proteinuria, hypoalbuminemia.
  • Acute Kidney Injury: Can lead to fluid overload and ascites.
  • Hydronephrosis: Flank pain, UTI symptoms, possible mass in the flank region.

Endocrine and Metabolic Causes

  • Hypothyroidism: Can cause a generalised myxoedema, contributing to ascites.
  • Cushing’s Syndrome: Central obesity, striae, hypertension, and oedema.
  • Diabetes Mellitus: Can be associated with gastroparesis, leading to bloating and distension.
  • Obesity: Abdominal distension due to adiposity, often with co-existing conditions.

Key Points in History 🥼

Onset and Duration

  • Sudden Onset: Suggests bowel obstruction, perforation, or acute pancreatitis.
  • Chronic Onset: Points to chronic liver disease, malignancy, or ascites.
  • Intermittent: May indicate IBS or functional bowel disorders.

Pain Characteristics

  • Colicky Pain: Often associated with bowel obstruction or biliary colic.
  • Continuous Pain: Suggests inflammatory conditions such as pancreatitis or peritonitis.
  • Referred Pain: Shoulder pain can indicate diaphragmatic irritation, common in biliary colic.

Associated Symptoms

  • Nausea and Vomiting: Strongly associated with bowel obstruction, gastroparesis, or pancreatitis.
  • Weight Loss: Raises suspicion of malignancy, chronic infection, or chronic disease.
  • Fever: Points to an infectious or inflammatory cause, such as diverticulitis or cholangitis.
  • Diarrhoea: Associated with IBS, IBD, or infection; can contribute to distension.

Background

  • Past Medical History: Previous surgeries (adhesions causing obstruction), chronic liver disease (ascites), or cancer (metastasis).
  • Drug History: NSAIDs (risk of peptic ulcer), steroids (Cushing’s), diuretics (hypokalaemia and ileus).
  • Family History: Consider genetic conditions like polycystic kidney disease or hereditary cancer syndromes.
  • Social History: Alcohol use (cirrhosis), smoking (cancer risk), recent travel (infectious causes).

Possible Investigations 🌡️

Blood Tests

  • Full Blood Count (FBC): Anaemia may indicate GI bleeding or chronic disease.
  • Liver Function Tests (LFTs): Abnormalities can point to liver disease, hepatitis, or biliary obstruction.
  • C-Reactive Protein (CRP) and ESR: Elevated in inflammatory and infectious conditions.
  • Electrolytes: Important in assessing fluid balance, especially in cases of ascites or vomiting.

Imaging Studies

  • Abdominal X-Ray: Useful for identifying bowel obstruction, perforation (free air), or calcifications (e.g., gallstones).
  • Ultrasound: First-line for assessing liver, gallbladder, and ascites. Can guide paracentesis.
  • CT Scan: Provides detailed images of abdominal organs, essential for diagnosing tumours, abscesses, or vascular conditions.
  • MRI: Useful in complex cases, especially for liver and pancreas assessment, or when radiation exposure is a concern.
  • Endoscopy: Upper or lower GI endoscopy indicated if malignancy, bleeding, or obstruction is suspected.

Special Tests

  • Ascitic Fluid Analysis: Important in evaluating the cause of ascites; includes cell count, culture, and albumin gradient.
  • Liver Biopsy: May be required for definitive diagnosis of liver conditions like cirrhosis or hepatitis.
  • Laparoscopy: Direct visualisation and biopsy in cases of undiagnosed abdominal masses or ascites.
  • Stool Studies: Useful in cases with diarrhoea, assessing for infections, malabsorption, or inflammatory conditions.

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Gastrointestinal