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If i have observed abdominal distension in a
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In a patient what d/ds shiuld i think of
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Here is a thorough, textbook-based breakdown of the differential diagnoses for abdominal distension:
Differential Diagnosis of Abdominal Distension
The classic mnemonic is the "6 F's" - each representing a broad category of causes:
1. Fat (Obesity)
- Generalized obesity
- Intra-abdominal lipomatosis
- Retroperitoneal fat deposition
2. Fluid (Ascites)
This is one of the most important categories. Causes of ascites include:
| Category | Examples |
|---|---|
| Portal hypertension | Cirrhosis (most common), hepatic vein thrombosis (Budd-Chiari), cardiac cirrhosis |
| Hypoalbuminemia | Nephrotic syndrome, protein-losing enteropathy, malnutrition |
| Malignancy | Ovarian cancer, peritoneal metastases, hepatocellular carcinoma |
| Infectious | Tuberculous peritonitis, bacterial peritonitis |
| Inflammatory | Pancreatitis (pancreatic ascites) |
| Cardiac | Right heart failure, constrictive pericarditis |
- Grainger & Allison's Diagnostic Radiology; Bailey and Love's Surgery 28th Ed.
3. Flatus / Gas (Gaseous Distension)
- Bowel obstruction - small bowel or large bowel
- Mechanical: adhesions, hernia, tumor, volvulus (cecal or sigmoid - "bent inner tube" sign on X-ray)
- Functional: paralytic ileus, pseudo-obstruction (Ogilvie syndrome)
- Aerophagia (swallowed air)
- Megacolon - Hirschsprung disease, toxic megacolon
- Lactase deficiency / malabsorption - gas due to fermentation
- Goldman-Cecil Medicine; Yamada's Textbook of Gastroenterology
4. Feces (Constipation / Obstruction)
- Severe constipation / fecal impaction
- Colorectal carcinoma causing obstruction
- Hirschsprung disease (in neonates/children - constipation + distension)
- Strictures (Crohn's disease, radiation)
5. Fetus
- Pregnancy (always rule out in women of reproductive age)
6. Fatal Mass / Tumor / Organomegaly
- Organomegaly: hepatomegaly, splenomegaly
- Tumors: colorectal, gastric, ovarian, uterine, bladder
- Cysts: ovarian cyst, mesenteric cyst, enteric duplication cyst, pancreatic pseudocyst, polycystic kidneys
- Retroperitoneal tumors: sarcoma, lymphoma with bulky nodes
- Bailey and Love's Surgery; Fischer's Mastery of Surgery
Other Important Causes Not in the Mnemonic
| Condition | Key Features |
|---|---|
| Abdominal compartment syndrome | Tense distension + hemodynamic instability, post-trauma/surgery |
| Mesenteric ischemia / ischemic bowel | Pain out of proportion, post-op or AF patient |
| Neutropenic enterocolitis (Typhlitis) | Fever + distension in immunocompromised patients |
| Necrotizing enterocolitis (NEC) | Neonates - distension + bilious vomiting + pneumatosis on X-ray |
| Pancreatitis | Ileus + distension + epigastric pain radiating to back |
| Post-operative ileus | Common after abdominal surgery |
| Hollow viscus perforation | Peritonitis + distension + free gas under diaphragm |
Clinical Approach at the Bedside
To narrow the differential, ask:
- Is it gas? - Tympanic on percussion, bowel sounds (obstructed = high-pitched; ileus = absent)
- Is it fluid (ascites)? - Shifting dullness, fluid thrill
- Is it a mass? - Palpable organomegaly or tumor
- Is it fat? - Generalized; no shifting dullness or resonance pattern change
Key investigations: AXR (bowel pattern, free gas), USS abdomen (ascites, masses), CT abdomen, serum albumin, LFTs, CA-125.
Bottom line: Always think of the 6 F's, but remember serious surgical emergencies (obstruction, perforation, ischemia, compartment syndrome) must be ruled out first. In a neonate, think bowel obstruction, NEC, meconium ileus, and duplication cysts specifically. - Grainger & Allison's Diagnostic Radiology; Bailey and Love's; Yamada's Gastroenterology
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