What is the management of abdominal distension?

Management of Abdominal Distension

The management of abdominal distension depends critically on distinguishing acute life-threatening causes requiring immediate intervention from chronic functional disorders that respond to conservative measures. 1

Immediate Assessment and Red Flag Identification

Obtain a focused history targeting specific red flags: acute onset with severe pain, constipation, vomiting, fever, tachycardia, weight loss, and hemodynamic instability—these indicate mechanical obstruction, bowel ischemia, or perforation requiring emergency intervention. 1, 2

Physical examination findings guide urgency:

• Complete absence of bowel sounds = paralytic ileus 1
• Diminished bowel sounds with distension = mechanical obstruction (sigmoid volvulus) 1
• Peritoneal signs (rigidity, rebound tenderness) = perforation or ischemia 2
• Asymmetric gaseous distention with left iliac fossa emptiness = sigmoid volvulus 1

Diagnostic Algorithm

Order plain abdominal radiographs immediately in all acute presentations to identify "coffee bean sign" (sigmoid volvulus) or free air (perforation). 1

Obtain CT scan with IV contrast urgently when:

• Plain films are non-diagnostic 1
• Bowel ischemia or perforation is suspected 1, 2
• Patient has peritoneal signs or elevated lactate 1

Essential laboratory testing includes:

• Complete blood count, lactate, electrolytes, renal function, CRP, liver function tests 1, 2
• Stool testing for C. difficile toxin to exclude infectious causes 1
• Serial lactate monitoring in suspected ischemia 1

Management Based on Etiology

Acute Life-Threatening Causes (Immediate Action Required)

For sigmoid volvulus, bowel ischemia, or perforation with peritoneal signs:

• NPO status immediately 1
• IV fluid resuscitation 1
• Nasogastric tube for decompression 1
• Broad-spectrum antibiotics (piperacillin/tazobactam 4 g/0.5 g q6h or meropenem 1 g q6h by extended infusion if septic shock) 2
• Emergency surgical consultation 1
• Serial lactate monitoring 1

Critical pitfall: Never assume absence of peritoneal signs means absence of ischemia—lactate levels and serial examinations are essential. 1

Paralytic Ileus (Conservative Management)

For complete absence of bowel sounds without peritoneal signs:

• NGT decompression 1
• Correct electrolyte abnormalities 1
• Minimize or discontinue opioids 1
• Consider prokinetic agents 1
• Peripheral mu-opioid antagonists (methylnaltrexone for opioid-induced cases) 2

Chronic Functional Abdominal Distension

When Rome IV criteria are met and organic disease is excluded, proceed with stepwise management: 2

First-line dietary interventions:

• Trial dietary restriction for 2 weeks to diagnose food intolerances (lactose, fructose, sucrose) 2
• Low FODMAP diet under gastroenterology dietitian supervision 2
• Avoid in malnourished patients 2

If dietary measures fail, consider hydrogen breath testing for carbohydrate malabsorption or small intestinal bacterial overgrowth (SIBO) in refractory cases. 2

For confirmed or suspected SIBO:

• Rifaximin is the most studied antibiotic option (though expensive and off-label) 2
• Alternative antibiotics include amoxicillin, fluoroquinolones, or metronidazole 2
• Careful patient selection required as none are FDA-approved for SIBO 2

If constipation is present:

• Rule out pelvic floor dyssynergia with anorectal manometry 2
• Use medications for constipation (osmotic laxatives, secretagogues like linaclotide) 2
• Biofeedback therapy if pelvic floor disorder identified 2

For visceral hypersensitivity and abdominophrenic dyssynergia:

• Central neuromodulators (tricyclic antidepressants, SNRIs) to reduce visceral hypersensitivity 2
• Diaphragmatic breathing exercises 2
• Brain-gut behavioral therapies (cognitive behavioral therapy, hypnotherapy) 2
• Antispasmodics (dicycloverine, hyoscine butylbromide) 2

Avoid probiotics—they should not be used to treat abdominal bloating and distention. 2

Special Considerations

For inflammatory bowel disease presenting with distension:

• Endoscopy with biopsy for diagnosis 1
• Treatment with aminosalicylates, corticosteroids, immunomodulators, or biologics based on severity 1

In chronic severe dysmotility:

• Avoid high-dose opioids and cyclizine due to risk of narcotic bowel syndrome and psychological dependence 1, 2
• Consider venting gastrostomy (>20 French gauge) if nasogastric drainage provides symptom relief 2

Critical pitfall: Do not attribute chronic symptoms solely to functional disorders without excluding channelopathies, especially with family history of sudden cardiac death. 1