Abdominal distension and bloating

Abdominal distension may be generalised, or may be localised to a discrete mass or enlargement of an organ. The main causes of generalised abdominal distension are easily remembered by the five Fs:

• Fat (obesity).

• Faeces (constipation).

• Fetus (pregnancy).

• Flatus (gastrointestinal).

• Fluid (ascites).

Le cause più comuni sono:

• Obesità.

• Gravidanza.

• Sindrome dell'intestino irritabile.

• Costipazione.

• Fibromi.

• Enlarged bladder.

Causes of generalised abdominal distension

Non-obstructive causes

• Obesità.

• Gravidanza.

• Gas - eg, sindrome dell'intestino irritabile and other functional gut conditions.

• Ascites - eg, congestive cardiac failure, cirrosi, sindrome nefrotica, peritoneal carcinomatosis, peritoneal tuberculosis.

• Linfoadenopatia.

• Intra-abdominal bleeding - eg, rottura di aneurisma aortico.

Mechanical bowel obstruction

• Neoplasms: intraluminal, extraluminal.

• Infections: malattia diverticolare, intra-abdominal abscess, parasitic infections.

• Foreign bodies: bezoar, ingested foreign body.

• Miscellaneous: adhesions, endometriosi, pregnancy, strangulated hernia, volvolo, intussuscezione, calcoli biliari, faecalith/meconium ileus, haematoma, pneumatosis intestinalis (pneumatosis coli), superior mesenteric artery syndrome, annular pancreas, Malattia di Hirschsprung, stenosis (radiation, surgical anastomosis site, morbo di Crohn, tuberculous).

Non-mechanical bowel obstruction

• Vascular insufficiency: thrombosis, embolism.

• Retroperitoneal irritation: renal colic, neoplasm, infection.

• Extra-abdominal infection: sepsis, polmonite, empyema, spinal osteomielite.

• Metabolic/toxic: ipokaliemia, uraemia, avvelenamento cronico da piombo.

• Chemical irritation: perforated peptic ulcer, pancreatite, biliary peritonitis.

• Miscellaneous: excessive intraluminal gas, intra-abdominal infection, trauma, mechanical ventilation, other causes of peritoneal inflammation, severe pain and non-steroidal anti-inflammatory drugs (NSAIDs).

Right upper quadrant

• Hepatomegaly, hepatoma, liver cancer.

• Gallbladder - eg, mucocele, empyema, secondary to carcinoma of pancreas.

• Right colon - eg, colonic carcinoma, faeces, caecal volvulus, intussuscezione.

• Right kidney - eg, polycystic kidney, hydronephrosis, cyst, renal tumour, tubercolosi.

Left upper quadrant

• Splenomegalia.

• Stomach: cancro allo stomaco, gastric distension (eg, stenosi pilorica).

• Pancreas - eg, pseudocyst, carcinoma.

• Left kidney - eg, polycystic kidney, hydronephrosis, cyst, tumour, tubercolosi.

• Colon - eg, carcinoma, faeces, diverticular mass.

Vedi il Dolore nel Quadrante Superiore Sinistro article for further detail.

Epigastrium

• Abdominal wall - eg, lipoma, ernia.

• Stomach - eg, carcinoma, distension due to pyloric stenosis.

• Pancreas - eg, pseudocyst, carcinoma.

• Transverse colon - eg, carcinoma, faeces, diverticular mass.

• Epatomegalia.

• Retroperitoneum - eg, aneurisma aortico, lymphadenopathy.

• Omentum - eg, secondaries from stomaco o ovary.

Umbilical

• Hernia, paraumbilical or umbilical.

• Stomach - eg, carcinoma.

• Transverse colon - eg, carcinoma, faeces, diverticular mass.

• Small bowel - eg, morbo di Crohn.

• Omentum - eg, secondaries from stomach or ovary.

• Retroperitoneum - eg, aneurisma aortico, lymphadenopathy.

Right and left lower quadrants

• Abdominal wall - eg, lipoma, hernia.

• Colon - eg, carcinoma, faeces, volvulus, intussusception (right lower quadrant), appendix mass (right lower quadrant).

• Small bowel - eg, morbo di Crohn, lymphoma.

• Gynaecological - eg, cisti ovarica, ovarian carcinoma, gravidanza ectopica, fibroid.

• Kidney - eg, polycystic kidney, hydronephrosis, cyst, tumore, tuberculosis.

Suprapubic

• Enlarged bladder - eg, acute or chronic retention, cancro alla vescica.

• Uterus - eg, pregnancy, fibromi, cancer of uterus.

• Bowel - eg, morbo di Crohn, colorectal carcinoma.

• Careful history taking and abdominal examination are essential. Clinical assessment will usually indicate the nature of abdominal distension (ie whether ascites, gastrointestinal gas, pregnancy, etc) but further investigations are often required to determine the precise aetiology.

• Resonance on percussion may be misleading because there may be bowel overlying a solid tumour or enlarged organ.

• Weight loss associated with abdominal distension suggests malignancy.

• Constipation needs to be fully evaluated to establish any underlying cause.

• Obesity may make examination very difficult to provide a clear assessment and an ultrasound scan or cross-sectional imaging may then be required, irrespective of the likely cause of distension.

These should be directed by history and examination and tailored to each patient. Possible investigations include:

• FBC: raised white cell count in infection or malignancy, anaemia with abnormal vaginal bleeding associated with fibroids, or as a consequence of malignancy.

• U&Es: renal dysfunction; hypokalaemia or uraemia may cause non-mechanical bowel obstruction.

• LFTs: liver failure, cholestatic hyperbilirubinaemia with carcinoma of pancreas, hypoalbuminaemia associated with ascites.

• Coeliac serology.

• CA 125: in women, particularly postmenopausal women, to look for evidence of il cancro ovarico. (Note though that CA 125 is nonspecific - it is physiologically elevated during menstruation, the first trimester of pregnancy, and postpartum, and can also increase due to endometriosis, uterine fibroids, and non-malignant ascites, amongst other things.)

• C-reactive protein, if inflammation/infection is suspected.

• Faecal calprotectin.

• Urinalysis: may show haematuria in patients with tumours of kidney or bladder.

• Pregnancy test.

• Quantitative faecal immunochemical (qFIT) testing: colorectal cancer.

• Abdominal X-ray, barium enema: constipation, large bowel pathology, bowel obstruction.

• Abdominal ultrasound.

• Transvaginal ultrasound.

• Oesophagogastroduodenoscopy (OGD).

• Sigmoidoscopy, colonoscopy.

• Further investigations might include CT scans and paracentesis.

• Referral decisions depend upon the underlying cause; many causes can be managed, at least initially, in primary care (such as IBS).

• In general, referral is recommended if there is abdominal distension without any clear diagnosis.

Bloating is a very common and subjective ailment which can affect patients of all ages. It can be associated with any of the causes of abdominal distension but it is most commonly associated with irritable bowel syndrome. Bloating can have a major impact both socially and psychologically. It is incompletely understood and often inadequately treated.

Gli interventi includono:¹

• Keeping a food and symptom diary to identify and avoid triggers.

• Avoiding artificial sweeteners containing poorly-absorbed sugar alcohols (eg, sorbitol, mannitol and xylitol).

• Following a low FODMAP diet.

• Probiotics (although evidence is limited).

• Antispasmodics, such as mebeverine, peppermint oil, and hyoscine butylbromide.

• Secretagogues, such as linaclotide.

• Neuromodulatory drugs, such as amitriptyline and some SSRIs.

• Biofeedback therapy.

• Gut-directed hypnotherapy.

For further information see the related separate Irritable Bowel Syndrome articolo.

• Sigmoidoscopy, colonoscopy.