Approach to the Problem
An increase in the girth of a child’s abdomen, abdominal distension, may be physiologic (e.g., swallowed air, lumbar lordosis in toddlers) or pathologic (e.g., intestinal obstruction, functional or mechanical). It occurs at all ages and in healthy, acutely ill, and chronically ill children. Abdominal distension can be the result of accidental and nonaccidental trauma. For example, a pneumomediastinum may occur in a child on a ventilator, or a pneumoperitoneum may be the result of blunt trauma. The mechanisms that result in abdominal distension are intraluminal or extraluminal accumulation of air or fluid, intra-abdominal mass, organomegaly, ascites, and abdominal wall hypotonia. Rapid recognition of pathologic abdominal distension is essential to reducing morbidity and mortality. Imaging studies and laboratory tests often have a role in determining the etiology of a child’s enlarged abdomen.
Key Points in the History
• A child typically complains of minimal pain with an ileus, but significant pain with an intestinal obstruction.
• Assume bilious vomiting is secondary to intestinal obstruction until proven otherwise.
• Delayed passage of meconium (after 48 hours of life) in the newborn period is highly concerning for Hirschsprung disease, gastrointestinal structural abnormality, cystic fibrosis, and hypothyroidism.
• Hematemesis, melena, and jaundice are clinical features of portal hypertension.
• Failure to thrive, rapid weight loss or gain, fever, fatigue, irritability, and bone pain suggests malignancy.
• Absence of historical details in an ill child with abdominal distension is a red flag for nonaccidental trauma.
• Gastrointestinal infections, pneumonia, and peritonitis with recent history of surgery may be associated with paralytic ileus.
• Ovulation may precede onset of menses, and therefore pregnancy should be considered in all pubertal females with lower abdominal distension. Cyclical distension, with or without abdominal pain, may represent hemato(metro)colpos.
• Pica-induced bezoars should be considered in neurologically or psychologically impaired children.
• Children with hemolytic disease are at risk for distension from splenomegaly.
• A prenatal history of oligohydramnios may result in distal urinary obstruction in the newborn, whereas polyhydramnios is associated with upper intestinal obstruction.
• History of abdominal surgery puts a child at risk for adhesions and small-bowel obstruction.
• Family history should include asking about metabolic diseases, early infant death among relatives, polycystic kidney disease, and cystic fibrosis.
• Constipation and ileus can be caused by misuse of medications (e.g., tricyclic antidepressants, antihistamines, antidiarrheal agents), ingestion of herbal products contaminated with belladonna alkaloids (e.g., teas, meat seasonings, stews), and exposure to anticholinergic substances through recreational drug use (e.g., smoking jimsonweed, use of jimsonweed-laced heroin).
• A history of greasy, foul-smelling stools in the setting of abdominal distension suggests malabsorption.
Key Points in the Physical Examination
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