31 Abdominal distension

Checklist P MP F

Checklist P MP F Associated symptoms:

• Gastrointestinal/colorectal symptoms:
Appropriate introduction
• Abdominal pain
Confirms patient’s name and age • Flatulence
Explain reason for consultation • Nausea/vomiting
Obtains consent • Bowel habit/diarrhoea/constipation: any
correlation of distension with opening
Open question to elicit presenting complaint
bowels?
Allows patient to open up, listens carefully, • Dysphagia/dyspepsia
remains silent and does not interrupt the patient Ascites:
Signposts: e.g. ‘Mr Gregory, thank you for telling • Facial swelling
me about this problem. I would like to ask a few • Ankle swelling
more detailed questions. Is that all right?’ • Shortness of breath/orthopnoea
Liver/hepatobiliary symptoms: right upper
History of presenting complaint:
quadrant pain, jaundice, dark stools, pale
• Site: urine
• Generalised Renal symptoms: urinary symptoms, frothy
• Localised urine (nephrotic syndrome), lethargy, pruritus
• Onset (how it started): Heart failure symptoms: chest pain
• How did the patient first notice it? Hypothyroidism
• Sudden Females: gynaecological symptoms:
• Gradual • Correlation with menstrual periods
• Character: • Irregular/painful periods
• Soft fluctuant/fluid swelling • Intermenstrual/postcoital bleeding
• Hard, mass-like swelling • Pelvic pain
• Radiation: Females: obstetric symptoms:
• To testicles/groin (hernia) • Possibility of patient being pregnant
• Time: • Last menstrual period
• Duration • Unprotected sexual intercourse: must
• Intermittent/continuous/progressive signpost before taking sexual history
• Correlation with menstrual periods • Contraception
• Alleviating factors:
‘Red flags’:
• Dietary factors
• Bleeding (rectal, melaena, vaginal)
• Opening bowels
• Weight loss, loss of appetite, night sweats
• Exacerbating factors:
(malignancy)
• Dietary factors/meals
Review of systems
• Position (e.g. worse on lying down/standing
– hernia), coughing (hernia) Past medical history:
• Worse at the end of the day (oedema) • Constipation
• Pain/tenderness • Abdominal surgery –especially laparoscopic
• Bloating/discomfort surgery
• Local compression-related symptoms (e.g. urge • Gynaecological history: fibroids, ovarian cysts
incontinence) • Heart failure
• Asks if patient is suffering from any other Family history:
symptoms • Colorectal cancer
• Asks about any recent illnesses • Ovarian cancer
• Previous episodes of abdominal distension • Polycystic kidney disease
• Family members/contacts with similar • Hernia
symptoms • Fibroids

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144 Histories: 31 Abdominal distension

Checklist P MP F Checklist P MP F
Drug history: Systematic approach
• Laxative history: any recent changes, stopped Explores and responds to ICE:
taking • Ideas
• Oral contraceptive pill (OCP, if patient female) • Concerns
• Over-the-counter medication • Expectations
Allergies Shows empathy
Social history: Non-verbal skills
• Alcohol (peptic ulcer disease, gastritis)
Avoids technical jargon
• Smoking
• Illicit drug use (especially intravenous drug Devises holistic management plan and addresses
abuse for hepatitis B/C) psychosocial issues as well as medical problems
• Diet: Summarises
• Intake of fibre
Offers to answer any questions
• Recent change in diet
• Occupation Thanks patient
• Activities of daily living
Use of non-verbal cues, e.g. good eye contact,
nodding head and good body posture

Summary of common conditions seen in OSCEs

Condition Key points ‘Red flags’ Management

Small bowel obstruction Adhesions (70%) Vomiting (early) Investigations: full blood count, Us + Es,
Acute hernia (20%) Colicky abdominal pain amylase, abdominal X-ray, erect chest X-ray,
Malignancy (high in abdomen) Gastrograffin follow-through, CT
Stricture Constipation Strangulation
Foreign body – gallstone (blood supply compromised) – surgery
Intussusception Nil by mouth
Volvulus Nasogastric tube insertion and intravenous
fluids – drip and suck
Analgesia
Monitor fluid status
Large bowel Malignancy (60%) Vomiting (late) Call surgeon
obstruction Stricture – diverticular, Constant abdominal pain Surgery
Crohn’s disease (20%) Constipation
Volvulus – sigmoid, caecal
Impacted faeces
Hernia See Chapter 12 on hernia
examination
Malignancy Abdominal distension may Generalised symptoms Bloods: full blood count, Us + Es, liver
be due to cancer mass, Smoker function tests, carcinoembryonic antigen,
bowel obstruction, Older patient faecal occult blood
ascites or organomegaly Family history Imaging: sigmoidoscopy, colonoscopy, CT/MRI,
liver ultrasound scan
Special test: genetic testing (hereditary
non-polyposis rectal cancer)
Management: surgery (some scope for
radiotherapy and chemotherapy)
 Histories: 31 Abdominal distension 145

Condition Key points ‘Red flags’ Management

Irritable bowel Abdominal pain Alternating diarrhoea and Reassurance: in 50%, symptoms improve by 1
syndrome Mucous per rectum constipation year
Related to mood/stress Explore food allergies
May be postinfectious Constipation: ispaghula, methylcellulose
Chronic course Diarrhoea: fibre, loperamide
Check the ROME III criteria Bloating: mebeverine
Proton pump inhibitor
Amytriptyline
Pregnancy Missed period(s) Folic acid
History of unprotected intercourse Follow-up in antenatal clinic
Poor compliance with OCP
Drug interaction with OCP (e.g. antibiotics and OCP)
Splenomegaly See Chapter 3 on
abdominal examination
Hepatomegaly See Chapter 3 on
abdominal examination
Ascites See Chapter 3 on
abdominal examination
Abdominal aortic Abdominal/back pain Trauma See Chapter 14 on arterial examination
aneurysm Pulsatile Peripheral vascular disease
Expansile Risk factors for atheroma
Pelvic mass Fibroids Cannot get below it on Pelvic ultrasound
Bladder palpation Refer to gynaecologist
Fetus
Ovarian cyst/malignancy
Renal cell carcinoma Haematuria Generalised symptoms Bloods: full blood count, Us + Es, alkaline
Flank pain Left varicocele phosphatase, erythrocyte sedimentation rate
Abdominal mass Urine microscopy and cytology
Imaging: renal ultrasound, CT/MRI, chest
X-ray, IVU
Surgery
Robson Staging

Hints and tips for the exam

Remember the ‘5 Fs and 1 T’ of abdominal
distension (Figure 31.1)
• Fat (hypothyroidism, Cushing’s disease)
• Fluid (is this ascites?)
• Faeces (constipation, obstruction – is it complete?)
• Flatus (complete obstruction, food intolerance, irri-
table bowel syndrome)
• Fetus (pregnancy test)
• Tumour

Women’s health
The sex of the patient will help rule out a number of
pathologies that only affect women. If your patient is Figure 31.1 Abdominal distension