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Probability diagnosis



Constipation, esp. chronic

Irritable bowel syndrome

Enlarged bladder

Fibroid uterus/ovarian tumour/cyst

Serious disorders not to be missed


  • CCF (ascites)

  • aortic aneurysm


  • intrabdominal abscess

  • peritoneal tuberculosis

  • hydatid cyst

  • clostridial intra-abdominal infection


  • ovary, stomach, colon, other

  • carcinomatosis peritonei


  • ascites (several causes)

  • intestinal obstruction (large bowel)

  • acute gastric dilatation

Pitfalls (often missed)

Hepatomegaly, splenomegaly


Massive lymphadenopathy/lymphosarcoma


  • chronic idiopathic pseudo-obstruction

Is the patient trying to tell me something?

Consider pseudocyesis.

Consider the classic five:

  • fat

  • flatus

  • fluid

  • faeces

  • fetus

Key history

  • Is the swelling intermittent, variable or progressive (the most serious)?

  • Associated symptoms, especially gastrointestinal, menstrual (?pregnancy)

  • Red flags, especially weight loss, fever, pain, lymph nodes

  • History of alcoholism, hepatitis, kidney disease, heart disorder

  • Past history of abdominal surgery, cancer

Key examination

  • General appearance

  • Vital signs

  • Abdomen (inspection, palpation, auscultation, percussion)

  • Rectal and vaginal examination

  • Tests for ascites (if present)

  • Dipstick of urine

Key investigations

  • FBE and ESR/CRP

  • Urinalysis

  • U&E and LFTs

  • Plain abdominal X-ray, ultrasound (best)

  • Pregnancy test in females with amenorrhoea

  • Specialised imaging according to findings, e.g. CT scan

Diagnostic tips

  • Be alert for pregnancy in women of childbearing age, especially teenagers and perimenopausal women.

  • Be alert for constipation, especially in the elderly.

  • Weight loss with abdominal swelling suggests malignancy.

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