Pediatric emergency medicine trisk 0352 0352
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CHAPTER 12 ■ ABDOMINAL DISTENSION
JEFFREY R. AVNER
INTRODUCTION
Distension may occur in any structure that has an encircling and restricting wall.
Abdominal distension is generally defined as an increase in the breadth of the
abdominal cavity. Bloating is the feeling of increased abdominal pressure that
may or may not be accompanied by distension. On presentation, the distension is
often large and thus easily noticeable to the child or parent. However, subtle
increases in abdominal girth may be first appreciated by the child’s sensation of
abdominal pressure, fullness, or bloating. In general, abdominal distension is
often due to an increase in intra-abdominal volume by air, fluid, stool, mass, or
organomegaly. Nevertheless, care should be taken not to confuse true abdominal
distension with certain conditions that cause an apparent increase in abdominal
girth such as poor posture, the natural exaggerated lordosis of childhood,
abdominal wall weakness, obesity, and pulmonary hyperinflation. Examination of
the patient in both the supine and upright positions assists the clinician in
recognizing these factors before considering diagnoses that truly increase the
volume of the abdominal cavity.
Abdominal distension is usually a nonspecific symptom of an underlying
disease process. The causes of abdominal distension are numerous ( Table 12.1 ).
Even when the discussion is limited to the more common causes ( Table 12.2 ) or
emergent and urgent causes of abdominal distension ( Table 12.3 ), the list is
long. When confronted with a patient with abdominal distension, one approach is
to divide the causes into the following generic categories: distended bowel,
extraluminal gas (e.g., free air), extraluminal fluid, extreme hepatomegaly,
extreme splenomegaly, and other causes (e.g., mass, cyst, pregnancy). This
categorization is more easily described on paper than discerned at the bedside. A
large cystic mass can be easily mistaken for ascitic fluid. A Wilms tumor may
feel much like splenomegaly. Another difficulty in the clinical application of this
categorization is that many pathologic processes that lead to abdominal distension
do so through several of the previously mentioned categories. For example,
kwashiorkor causes abdominal distension secondary to hepatosplenomegaly and
ascites. For these reasons, the reader is urged to regard this initial categorization,
when used at the bedside, as tentative, pending confirmation from plain
radiograph, ultrasound, computed tomography (CT), or other imaging studies.
