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Abdominal distension- Practice pearls from case studies: Dr. YK Amdekar

M3 India Newsdesk Jun 29, 2020

Abdominal distension is a worrisome presentation in both the clinic and emergency room setting, therefore physicians always need to be vigilant in their approach to the patient. Here, Dr. Amdekar discusses 8 case studies explaining how abdominal distension can be present in children.


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Abdominal distension- Clinical application of basic concepts

Abdominal distension may be generalised due to accumulation of gas, collection of fluid, or chronic constipation with accumulation of faeces. Distension caused by flatus or faeces wax and wane while there is no variation in other conditions.

  1. Typically, an enlarged liver presents as upper abdominal distension that displaces umbilicus downwards from its usual mid-position.
  2. An enlarged spleen or any other mass in the abdomen presents as a lump in a specific quadrant of the abdomen.
  3. Surgical conditions leading to abdominal distension are usually acute while medical conditions are often chronic. Of course there are exceptions on both side such as- congenital megacolon a chronic surgical problem and paralyitic ileus following diarrhea is an acute medical problem.
  4. Hypotonia of abdominal muscles and excess of abdominal fat may also lead to abdominal distension though it is not a primary presentation.

Case based discussions

Case 1

An 8-year-old child presented with periumbilical pain and generalised abdominal distension for 2 days. It was accompanied with mild fever, occasional vomiting, and loose stools. Vomitus contained food particles and was not bile stained.

Sudden onset of abdominal pain and abdominal distension suggest acute inflammatory pathology and occasional vomit and loose stools rule out primary intestinal disease, but are related to structures near to intestine. If it was intestinal, loose stools and/or vomit would have been prominent symptoms. Mild fever rules out primary infection; fever would have been prominent symptom and so this must be non-infective inflammation.

Physical examination on D2 showed a sick-looking child and generalised abdominal distension, tenderness all over and guarding. It denotes oncoming acute inflammatory condition. The next day, the pain shifted to the right iliac fossa and became severe. Diagnosis of appendicitis was considered and proved on USG. Visceral abdominal pain is diffuse, not severe, and is often accompanied by vomiting or loose stools, while parietal pain is severe and localised.

This is why pain in appendicitis starts near umbilicus (appendix originates from midgut and hence initial location of pain) and then when the peritoneum is involved, pain shifts to right iliac fossa and becomes severe. It is classical of appendicitis.

Parents refused surgery and next day, the pain disappeared. On physical examination, child looked much more sick, HR 140, BP 0/50 mmHg, CRT >4 seconds, and the child was in shock This suggests appendix has developed gangrene and so while the pain disappeared, the child went into shock, endangering life.

This case illustrates a fact that symptom relief may not be all well and we should go by the overall condition.


Case 2

A 1-year-old infant presented with gradually progressive abdominal distension. He was breastfed for the first 7 months and then was also on semisolid food. On direct questioning, he was constipated from the first month, had not gained weight over the last few months. His development was normal.

A breastfed infant is never constipated unless there is something abnormal. Progressive abdominal distension and failure to gain weight are both a result of worsening constipation. This is likely to be chronic progressive lower intestinal obstruction, mostly congenital megacolon.

Physical examination showed weight 7.2 kg, length 70 cm, moderate pallor, abdomen loaded with faeces, per rectal examination revealed empty rectum and ribbon like stool coming out, suggesting colonic obstruction proximal to rectum. Diagnosis was conformed as congenital megacolon by barium enema and rectal biopsy showing absent ganglion cells. He was surgically treated.


Case 3

A 1-year-old infant presented with loose stools and abdominal distension for 2 days. Loose stools stopped suddenly but abdominal distension worsened. There was no vomiting or any other symptom. When any symptom suddenly and unexpectedly gets better, it is often indicative of a complication.

In this child, loose stools suddenly stopped, it may suggest either intussusception or paralytic ileus. Intussusception presents as abdominal pain and vomiting and so not likely in this child. Paralytic ileus may be a manifestation of sepsis or hypokalemia. As this child has had no fever, sepsis is not likely and so it may be hypokalemia.

Potassium is excreted by the kidneys only if it is in excess, but it is also secreted by tubules in the kidneys that continues irrespective of potassium pool in the body. That is why the person may feel tired even after a short duration of illness such as viral fever or diarrhoea. However, it settles down by itself in the next 2 to 3 days.

Physical examination on D3 showed HR 120/min, RR 25/min, generalised abdominal distension, poor peristalsis, muscle hypotonia, and deep tendon reflexes sluggish. Disproportionate tachycardia, muscle hypotonia and sluggish DTR suggest hypokalemia. Potassium is an intracellular ion and so its deficiency affects skeletal and heart muscles besides intestinal muscle. That explains tachycardia and sluggish DTR. Serum potassium was low and diagnosis of hypokalemia was confirmed.

If the child had been healthy prior to this illness, hypokalemia would settle down by itself but if this child was malnourished and so already low in potassium, hypokalemia after diarrhoea may be life threatening due to cardiac rhythm dysfunction or severe muscle paralysis affecting respiratory muscles. Such a complication may need potassium supplements urgently. Thus, potassium-containing liquids such as coconut water or ORS should be given to a child with diarrhoea to prevent such a complication.


Case 4

A 2-year-old child presented with fever and skin rash for 2 days. Fever abated but the child developed abdominal distension and became more sick. Fever and skin rash suggests viral infection that seemed to settle by itself as expected. Whenever new symptoms appear unexpectedly while original symptoms get better, this is likely to be either metabolic or immune-mediated complication.

As this child also got sicker, it is likely to be immune reaction to viral infection. Sudden development of abdominal distension denotes fluid collection – ascites due to capillary leak. Sickness in such a case is due to the child being in shock.

Physical examination showed signs of shock, mild oedema of feet, and ascites. It suggests diagnosis of capillary leak syndrome following dengue viral infection that can be confirmed with NS1 antigen and IgM antibodies. Such a complication must be diagnosed in its early stage of compensation as denoted by poor urine output and change in behavior of the child in spite of fever abating. At this stage, there are no obvious signs of shock and the child can be salvaged by IV fluids maintaining intravascular volume in spite of capillary leak. However, once uncompensated shock develops with low blood pressure besides CRT >3 seconds and cold clammy skin with poor peripheral pulsations, it may be irreversible.


Case 5

An 8-year-old child presented with abdominal distension for a week. There were no other symptoms. Acute onset of abdominal distension would have other symptoms such as vomiting/constipation in case of intestinal obstruction or fever, skin rash in case of capillary leak syndrome or diarrhoea preceding abdominal distension. As this child did not report any such symptoms, on direct questioning, it was revealed that he was not well for the last 5 months with loss of appetite and weight as well as mild abdominal distension.

So, it is clear now that this child has chronic disease that seems have developed much more abdominal distension. It suggests ascites in a child with chronic liver disease.

Physical examination showed weight 23 kg, height 120 cm, mild pallor, oedema of the feet, no jaundice, liver 4F+, firm, not tender, span 9 cm, spleen 2F+, and ascites+. These findings are in favour of chronic liver disease – cirrhosis with ascites. Cause may be either exposure to poisons such as alcohol or previous infections such as HBV or HCV.

Laboratory investigations showed serum bilirubin 1.2 mg, D 0.6 mg, ALT 230, AST 10, Alk phos- normal, serum proteins 5.3 Gm%, and albumen 2.1 Gm%. Diagnosis of cirrhosis is made that can be proved by liver biopsy and further tests to assess probable cause. Treatment is merely symptomatic.


Case 6

A 10-year-old child presented with gradually increasing generalised abdominal distension over the last 6 months. There were no other symptoms. He remained healthy during this time. This child seems to have a slowly progressive space occupying lesion in the abdomen that has not caused any organ dysfunction. So it must be a benign condition.

As abdominal distension was generalised, it may be either ascites or very large mass. Ascites would have presented with other symptoms as generalised oedema in nephrotic syndrome or other symptoms as in chronic liver disease. Both are unlikely in this child. A very large benign mass is possible though it could have produced pressure on some organs with some symptoms. So at this stage, history fails to find out most probable diagnosis.

Physical examination showed healthy normal child with generalised abdominal distension with dullness all over suggestive of ascites. However, typical ascites presents with shifting dullness that this child did not show. So this child has a fluid filled mass – a cyst. USG confirmed it to be mesenteric cyst. It was removed surgically.


Case 7

An 8-year-old child presented with gradually progressive abdominal distension over last one year, loss of appetite and weight over the last 6 months and feeling tired over the last 3 months. This is a slowly progressive disease with probable hepatosplenomegaly and lately has developed severe anaemia as suggested by a feeling of tiredness. So, the disease must have started in the liver and/or spleen and now spread to the bone marrow. Such a disease is likely to be due to storage of abnormal metabolites – metabolic disorder.

Physical examination showed wasted and stunted child with severe pallor, liver 3F+, firm, span 10 cm, spleen 5F+, no ascites, or jaundice. Such a massive enlargement of liver and spleen without any liver dysfunction is typical of storage disorder that has spread to the bone marrow and hence, severe anaemia.

Laboratory tests showed Hb 5 Gm%, WBC 2300, Pl 0.4 lakhs, and LFT normal. USG showed large liver and spleen and no evidence of portal hypertension. Further specific enzyme studies confirmed diagnosis of Gaucher disease. If diagnosed early before significant damage, enzyme replacement is possible though such a therapy is very costly. Once disease spreads to the brain, there would be no use of enzyme replacement therapy.


Case 8

An 8-year-old child presented with abdominal distension off and on for the last 6 months. Abdominal distension would be waxing and waning and he also had occasional loose stools. He had not lost weight or appetite. Waxing and waning abdominal distension is either due to flatus or constipation. As this child is not constipated, it must be flatus.

We need to find out cause of flatus. As he has remained healthy, it is unlikely to be any significant pathology. It could be due to irregular food habits, lifestyle, or due to stress or anxiety – functional disorder. Physical examination did not reveal any abnormality except moderate abdominal distension with tympanic note on percussion, suggestive of gas. This child does not need any tests but need lots of counseling.

 

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.

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