נפיחות בטנית וגזים

Abdominal distension may be generalised, or may be localised to a discrete mass or enlargement of an organ. The main causes of generalised abdominal distension are easily remembered by the five Fs:

• Fat (obesity).

• Faeces (constipation).

• Fetus (pregnancy).

• Flatus (gastrointestinal).

• Fluid (ascites).

The most common causes are:

• השמנת יתר.

• הריון.

• תסמונת המעי הרגיז.

• עצירות.

• שרירנים.

• Enlarged bladder.

Causes of generalised abdominal distension

Non-obstructive causes

• השמנת יתר.

• הריון.

• Gas - eg, תסמונת המעי הרגיז and other functional gut conditions.

• Ascites - eg, אי ספיקת לב גודשית, שחמת, תסמונת נפרוטית, peritoneal carcinomatosis, peritoneal tuberculosis.

• Lymphadenopathy.

• Intra-abdominal bleeding - eg, ruptured aortic aneurysm.

Mechanical bowel obstruction

• Neoplasms: intraluminal, extraluminal.

• זיהומים: מחלת סעיפים, intra-abdominal abscess, parasitic infections.

• Foreign bodies: bezoar, ingested foreign body.

• Miscellaneous: adhesions, אנדומטריוזיס, pregnancy, strangulated hernia, volvulus, intussusception, אבני מרה, faecalith/meconium ileus, haematoma, pneumatosis intestinalis (pneumatosis coli), superior mesenteric artery syndrome, annular pancreas, מחלת הירשפרונג, stenosis (radiation, surgical anastomosis site, מחלת קרוהן, tuberculous).

Non-mechanical bowel obstruction

• Vascular insufficiency: thrombosis, embolism.

• Retroperitoneal irritation: renal colic, neoplasm, infection.

• Extra-abdominal infection: sepsis, דלקת ריאות, empyema, spinal אוסטאומיאליטיס.

• Metabolic/toxic: hypokalaemia, uraemia, lead poisoning.

• Chemical irritation: perforated peptic ulcer, דלקת לבלב, biliary peritonitis.

• Miscellaneous: excessive intraluminal gas, intra-abdominal infection, trauma, mechanical ventilation, other causes of peritoneal inflammation, severe pain and non-steroidal anti-inflammatory drugs (NSAIDs).

Localised causes of abdominal distension

רביע עליון ימני

• Hepatomegaly, hepatoma, סרטן הכבד.

• Gallbladder - eg, mucocele, empyema, secondary to carcinoma of pancreas.

• Right colon - eg, colonic carcinoma, faeces, caecal volvulus, intussusception.

• Right kidney - eg, polycystic kidney, hydronephrosis, cyst, renal tumour, שחפת.

רביע עליון שמאלי

• הגדלת טחול.

• Stomach: סרטן הקיבה, gastric distension (eg, היצרות פילורית).

• Pancreas - eg, pseudocyst, carcinoma.

• Left kidney - eg, polycystic kidney, hydronephrosis, cyst, tumour, שחפת.

• Colon - eg, carcinoma, faeces, diverticular mass.

ראה את הנפרד כאב ברביע העליון השמאלי article for further detail.

אזור הבטן העליונה

• Abdominal wall - eg, lipoma, מתרחש.

• Stomach - eg, carcinoma, distension due to pyloric stenosis.

• Pancreas - eg, pseudocyst, carcinoma.

• Transverse colon - eg, carcinoma, faeces, diverticular mass.

• הגדלת כבד.

• Retroperitoneum - eg, מפרצת אבי העורקים, lymphadenopathy.

• Omentum - eg, secondaries from בטן או ovary.

Umbilical

• בקע, paraumbilical or umbilical.

• Stomach - eg, carcinoma.

• Transverse colon - eg, carcinoma, faeces, diverticular mass.

• Small bowel - eg, מחלת קרוהן.

• Omentum - eg, secondaries from stomach or ovary.

• Retroperitoneum - eg, מפרצת אבי העורקים, lymphadenopathy.

Right and left lower quadrants

• Abdominal wall - eg, lipoma, hernia.

• Colon - eg, carcinoma, faeces, volvulus, intussusception (right lower quadrant), appendix mass (right lower quadrant).

• Small bowel - eg, מחלת קרוהן, לימפומה.

• Gynaecological - eg, ציסטה שחלתית, קרצינומה של השחלה, הריון חוץ רחמי, fibroid.

• Kidney - eg, polycystic kidney, hydronephrosis, cyst, בשלפוחית השתן, tuberculosis.

על-חיקי

• Enlarged bladder - eg, acute or chronic retention, סרטן שלפוחית השתן.

• Uterus - eg, pregnancy, מיומות, cancer of uterus.

• Bowel - eg, מחלת קרוהן, colorectal carcinoma.

Abdominal distension symptoms (presentation)

• Careful history taking and abdominal examination are essential. Clinical assessment will usually indicate the nature of abdominal distension (ie whether ascites, gastrointestinal gas, pregnancy, etc) but further investigations are often required to determine the precise aetiology.

• Resonance on percussion may be misleading because there may be bowel overlying a solid tumour or enlarged organ.

• Weight loss associated with abdominal distension suggests malignancy.

• Constipation needs to be fully evaluated to establish any underlying cause.

• Obesity may make examination very difficult to provide a clear assessment and an ultrasound scan or cross-sectional imaging may then be required, irrespective of the likely cause of distension.

חקירות

These should be directed by history and examination and tailored to each patient. Possible investigations include:

• FBC: raised white cell count in infection or malignancy, anaemia with abnormal vaginal bleeding associated with fibroids, or as a consequence of malignancy.

• U&Es: renal dysfunction; hypokalaemia or uraemia may cause non-mechanical bowel obstruction.

• LFTs: liver failure, cholestatic hyperbilirubinaemia with carcinoma of pancreas, hypoalbuminaemia associated with ascites.

• Coeliac serology.

• CA 125: in women, particularly postmenopausal women, to look for evidence of סרטן השחלות. (Note though that CA 125 is nonspecific - it is physiologically elevated during menstruation, the first trimester of pregnancy, and postpartum, and can also increase due to endometriosis, uterine fibroids, and non-malignant ascites, amongst other things.)

• C-reactive protein, if inflammation/infection is suspected.

• Faecal calprotectin.

• Urinalysis: may show haematuria in patients with tumours of kidney or bladder.

• Pregnancy test.

• Quantitative faecal immunochemical (qFIT) testing: colorectal cancer.

• Abdominal X-ray, barium enema: constipation, large bowel pathology, bowel obstruction.

• Abdominal ultrasound.

• Transvaginal ultrasound.

• Oesophagogastroduodenoscopy (OGD).

• Sigmoidoscopy, colonoscopy.

• Further investigations might include CT scans and paracentesis.

הפניה

• Referral decisions depend upon the underlying cause; many causes can be managed, at least initially, in primary care (such as IBS).

• In general, referral is recommended if there is abdominal distension without any clear diagnosis.

נפיחות

Bloating is a very common and subjective ailment which can affect patients of all ages. It can be associated with any of the causes of abdominal distension but it is most commonly associated with irritable bowel syndrome. Bloating can have a major impact both socially and psychologically. It is incompletely understood and often inadequately treated.

Interventions include:¹

• Keeping a food and symptom diary to identify and avoid triggers.

• Avoiding artificial sweeteners containing poorly-absorbed sugar alcohols (eg, sorbitol, mannitol and xylitol).

• Following a low FODMAP diet.

• Probiotics (although evidence is limited).

• Antispasmodics, such as mebeverine, peppermint oil, and hyoscine butylbromide.

• Secretagogues, such as linaclotide.

• Neuromodulatory drugs, such as amitriptyline and some SSRIs.

• Biofeedback therapy.

• Gut-directed hypnotherapy.

For further information see the related separate תסמונת המעי הרגיז מאמר.

• Sigmoidoscopy, colonoscopy.