Abdominal DistensionAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

580 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx91

Symptom overview

›Distension timeline and trajectory

›Sudden onset

›Gradual onset

›Progressive over days to weeks

›Intermittent or fluctuating

›Baseline abdominal size and change from baseline

›Functional impact

›Oral intake intolerance

›Early satiety

›Reduced mobility due to discomfort

›Sleep disruption

›Prior episodes and prior diagnoses

›Similar prior episodes

›Prior bowel obstruction or ileus

›Prior ascites

›Prior constipation pattern

OPQRST Onset

›Onset features

›Time of first noticed distension

›Triggering event

›Recent illness or hospitalization

›Postoperative timing

OPQRST Provocation and palliation

›Modifiers

›Worse with meals

›Worse through the day

›Worse supine

›Worse with movement

›Relief with flatus

›Relief with bowel movement

›Relief with vomiting

›Relief with diuretics

›Relief after paracentesis history

OPQRST Quality

›Associated sensation

›Pressure

›Tightness

›Bloating

›Cramping pain

›Constant pain

OPQRST Region and radiation

›Location pattern

›Generalized

›Upper abdomen predominant

›Lower abdomen predominant

›Right upper quadrant predominant

›Left lower quadrant predominant

›Radiation pattern

›To back

›To shoulder

OPQRST Severity

›Severity anchors

›Degree of visible distension

›Clothing fit change

›Pain severity scale if present

›Respiratory compromise sensation

OPQRST Timing

›Timing features

›Continuous

›Episodic

›Postprandial timing

›Nocturnal symptoms

Associated symptoms

›Gastrointestinal symptoms

›Nausea

›Vomiting

›Bilious vomiting

›Feculent vomiting

›Obstipation

›Decreased flatus

›Diarrhea

›Hematochezia

›Melena

›Abdominal pain pattern

›Systemic symptoms

›Fever

›Chills

›Weight loss

›Night sweats

›Fatigue

›Hepatobiliary symptoms

›Jaundice

›Pruritus

›Dark urine

›Pale stools

›Hematemesis

›Cardiopulmonary symptoms

›Dyspnea

›Orthopnea

›Leg swelling

›Chest pain

›Genitourinary and gynecologic symptoms

›Dysuria

›Urinary retention symptoms

›Vaginal bleeding

›Pelvic pain

›Missed period

›Pregnancy possibility

02Alarm Features/alarm33

Immediate escalation triggers

›High risk physiology

›Systolic blood pressure less than 90 mmHg

›Heart rate greater than 120 per minute

›Respiratory rate greater than 30 per minute

›Oxygen saturation less than 92 percent on room air

›Temperature 38.5 C or higher

›Altered mental status

›High risk abdominal findings

›Peritoneal signs

›Rigid abdomen

›Severe focal tenderness

›Rebound tenderness

›Involuntary guarding

›Hernia with severe pain

›Skin changes over hernia

›High risk symptom patterns

›Persistent vomiting with inability to tolerate fluids

›Obstipation with worsening pain

›Hematemesis

›Melena with hemodynamic symptoms

›Rapidly increasing abdominal girth over hours

›Time critical actions

›If shock or peritonitis then resuscitation bay and immediate surgical consult

›If suspected bowel ischemia then lactate and urgent CT angiography if stable

›If suspected ruptured abdominal aortic aneurysm then immediate vascular activation and permissive hypotension local protocol dependent

High risk populations

›High risk patient factors

›Pregnancy

›Immunocompromised state

›Older adult

›Anticoagulated

›Known cirrhosis

›Known abdominal malignancy

›Recent abdominal surgery

03Medications/meds24

Medication exposures linked to distension

›Motility slowing agents

›Opioids

›Anticholinergics

›Tricyclic antidepressants

›Calcium channel blockers

›Antipsychotics

›Constipating supplements

›Iron

›Calcium supplements

›Bleeding risk agents

›Anticoagulants

›Antiplatelet agents

›Liver and fluid balance agents

›Diuretics

›Recent diuretic dose change

›Nonsteroidal anti-inflammatory drugs

›Endocrine and metabolic agents

›Glucagon like peptide 1 receptor agonists

›Metformin gastrointestinal intolerance

Recent medication changes and adherence

›Pattern of use

›New medication within last 2 weeks

›Missed doses of diuretics or laxatives

›Recent antibiotic exposure

›Recent chemotherapy or immunotherapy

04Diet/diet16

Recent intake and triggers

›Intake pattern

›Reduced oral intake

›High volume intake

›High fiber change

›Very low fiber pattern

›Fluid and salt pattern

›High sodium intake pattern

›Low sodium restriction adherence

›Poor hydration

›Gas producing triggers

›High fermentable carbohydrate pattern

›Carbonated beverages

›Sugar alcohols

›Alcohol exposure

›Recent binge

›Chronic heavy use pattern

05Review of Systems/ros34

Gastrointestinal

›Gastrointestinal review

›Vomiting

›Bilious vomiting

›Hematemesis

›Diarrhea

›Constipation

›Obstipation

›Flatus pattern change

›Gastroesophageal reflux symptoms

›Dysphagia

›GI bleeding symptoms

Constitutional and infectious

›Constitutional review

›Fever

›Chills

›Unintentional weight loss

›Night sweats

›Recent sick contacts

›Recent travel

›Recent antibiotics

Cardiopulmonary and edema

›Cardiopulmonary review

›Dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Chest pain

›Palpitations

›Peripheral edema

Genitourinary and gynecologic

›Genitourinary and gynecologic review

›Dysuria

›Hematuria

›Urinary retention symptoms

›Vaginal bleeding

›Pelvic pain

›Pregnancy possibility

›Last menstrual period timing

06Collateral History and Family History/chafh11

Collateral sources and reliability

›Collateral information

›Family report reliability

›Caregiver report reliability

›Medication list confirmation source

›Baseline cognitive status confirmation

Family history relevant to abdominal distension

›Heritable and familial conditions

›Colorectal cancer family history

›Ovarian cancer family history

›Inflammatory bowel disease family history

›Liver disease family history

›Thrombotic disorder family history

07Risk Factors/rf24

Surgical and mechanical risks

›Obstruction risk factors

›Prior abdominal surgery

›Known hernia

›History of bowel obstruction

›Abdominal or pelvic malignancy

›Pelvic radiation history

Ascites and fluid accumulation risks

›Ascites risk factors

›Cirrhosis

›Heart failure

›Nephrotic syndrome

›Malignancy

›Peritoneal dialysis

Constipation and ileus risks

›Motility risks

›Opioid exposure

›Anticholinergic exposure

›Electrolyte disturbance history

›Hypothyroidism

›Neurologic disease affecting motility

›Recent immobilization

Infection and inflammation risks

›Infection and inflammatory risks

›Inflammatory bowel disease

›Recent gastrointestinal infection

›Immunosuppression

›Recent intraabdominal procedure

08Differential Diagnosis/ddx70

Life threatening

›Cannot miss diagnoses

›Mechanical bowel obstruction with strangulation

›Severe pain out of proportion

›Persistent tachycardia

›Fever

›Leukocytosis

›Elevated lactate

›Peritoneal signs

›Perforated viscus

›Sudden severe pain

›Rigid abdomen

›Free air on imaging

›Toxic megacolon

›Systemic toxicity

›Severe colitis symptoms

›Marked colonic dilation on imaging

›Mesenteric ischemia

›Pain out of proportion

›Metabolic acidosis

›Elevated lactate

›Atrial fibrillation history

›Spontaneous bacterial peritonitis in cirrhosis (K65.2)

›Fever

›Encephalopathy

›Abdominal tenderness

›Ascites

›Ruptured abdominal aortic aneurysm (I71.3)

›Hypotension

›Back pain

›Syncope

Common

›Frequent etiologies

›Constipation (K59.00)

›Reduced stool frequency

›Hard stools

›Straining

›Functional bloating and irritable bowel syndrome (K58.9)

›Symptom fluctuation

›Relation to meals

›Improvement after bowel movement

›Ascites due to portal hypertension (R18.8)

›Progressive girth

›Peripheral edema

›Stigmata of chronic liver disease

›Gastroenteritis

›Diarrhea

›Sick contacts

›Pregnancy related uterine enlargement (Z32.01)

›Missed period

›Positive pregnancy test

Less common

›Less frequent etiologies

›Acute colonic pseudo obstruction (Ogilvie syndrome) (K59.81)

›Recent hospitalization

›Electrolyte abnormalities

›Marked colonic dilation without mechanical transition point

›Gastroparesis (K31.84)

›Early satiety

›Postprandial nausea

›Pancreatic malignancy (C25.9)

›Weight loss

›Painless jaundice

›Ovarian mass or ovarian cancer (C56.9)

›Early satiety

›Pelvic fullness

›Ascites

›Celiac disease (K90.0)

›Chronic diarrhea

›Weight loss

›Small intestinal bacterial overgrowth

›Bloating after meals

›Risk after bowel surgery

09Past Medical History/pmh14

Relevant chronic disease

›Chronic conditions

›Cirrhosis and portal hypertension

›Heart failure

›Chronic kidney disease

›Diabetes mellitus

›Hypothyroidism

›Inflammatory bowel disease

Prior abdominal history

›Prior events and procedures

›Prior bowel obstruction episodes

›Prior abdominal or pelvic surgeries

›Prior hernia repairs

›Prior endoscopy findings

›Prior paracentesis and results

›Prior cancer diagnoses and treatments

10Physical Exam/exam45

Initial impression and vitals interpretation

›General assessment

›Ill appearance

›Diaphoresis

›Dehydration signs

›Respiratory distress

›Hemodynamic pattern

›Shock index elevated

›Orthostatic changes

›Fever pattern

Abdominal exam

›Abdominal inspection and palpation

›Degree of distension

›Surgical scars

›Visible peristalsis

›Tenderness location

›Rebound tenderness

›Guarding

›Abdominal percussion and auscultation

›Tympany predominant

›Dullness predominant

›Bowel sounds high pitched

›Bowel sounds absent

›Ascites maneuvers

›Shifting dullness

›Fluid wave

Hernia and rectal

›Mechanical obstruction screen

›Inguinal hernia

›Femoral hernia

›Umbilical hernia

›Incisional hernia

›Rectal exam decision points

›Rectal vault stool burden

›Gross blood

Extraabdominal clues

›Liver disease and portal hypertension clues

›Jaundice

›Spider angiomas

›Palmar erythema

›Caput medusae

›Asterixis

›Heart failure clues

›Elevated jugular venous pressure

›Crackles

›Peripheral edema

›Pelvic and pregnancy clues

›Pelvic tenderness

›Adnexal mass suspicion

11Lab Studies/labs24

Core laboratory evaluation

›Baseline labs by syndrome

›Complete blood count

›Electrolytes and renal function

›Liver enzymes

›Bilirubin

›International normalized ratio

›Lipase

›Venous blood gas if toxic appearance

›Lactate if ischemia or sepsis concern

Targeted labs

›Etiology directed tests

›Pregnancy test for patients with pregnancy potential

›Urinalysis for urinary infection or retention mimics

›C reactive protein if inflammatory bowel disease flare consideration

›Thyroid stimulating hormone if chronic constipation and hypothyroid concern

›Blood cultures if sepsis concern

Ascites fluid studies when present

›Diagnostic paracentesis panels

›Cell count with differential

›Albumin

›Total protein

›Gram stain

›Culture inoculated at bedside

›Interpretation pearls

›Neutrophils 250 per microliter or higher supports spontaneous bacterial peritonitis

›Serum ascites albumin gradient pattern for portal hypertension classification

12Imaging/img46

Scoring Systems

›Severity and risk scores that guide imaging and disposition

›MELD Na score for cirrhosis severity

›Higher score supports higher risk of complications

›Use for prognosis and disposition planning

›Child Pugh class for chronic liver disease

›Class B to C associated with higher infection and bleeding risk

›Use for procedural risk framing

›Colonic dilation risk thresholds in pseudo obstruction

›Cecal diameter 12 cm or higher higher perforation risk

›Persistent dilation over 6 days higher perforation risk

MRI

›MRI indications

›MRCP for suspected biliary obstruction when ultrasound equivocal

›Pelvic MRI for adnexal mass characterization when ultrasound indeterminate

›MRI constraints and contraindications

›Non MRI compatible implanted devices

›Unstable patient physiology limiting scan tolerance

›Interpretation pearls

›MRCP best for ductal obstruction and stones beyond ultrasound window

›Pelvic MRI improves soft tissue characterization for complex masses

›CT abdomen pelvis role

›Suspected mechanical bowel obstruction

›Suspected perforation

›Suspected intraabdominal abscess

›Suspected malignancy complication

›CT angiography role

›Suspected mesenteric ischemia

›Suspected acute vascular catastrophe

›Contrast and radiation cautions

›Chronic kidney disease risk stratification and hydration plan local protocol dependent

›Pregnancy risk benefit discussion

›Key interpretation targets

›Transition point and level of obstruction

›Closed loop obstruction features

›Pneumatosis intestinalis

›Portal venous gas

›Free air

Ultrasound

›Point of care ultrasound applications

›Ascites detection and procedural guidance

›Gallbladder evaluation in right upper quadrant pain

›Bladder volume for urinary retention mimic

›Ultrasound pitfalls

›Bowel gas limiting visualization

›Obesity limiting image quality

›Interpretation pearls

›Ascites pocket selection for safer paracentesis

›Gallbladder wall thickening is nonspecific without supportive findings

13Special Tests/spec11

Bedside procedures and diagnostics

›Diagnostic paracentesis when ascites present

›Indicated with new onset ascites

›Indicated with cirrhosis and any clinical deterioration

›Avoid if abdominal wall cellulitis at puncture site

›Nasogastric tube decompression when severe vomiting and suspected obstruction

›Symptom relief and aspiration risk reduction

›Output character supports proximal obstruction vs distal patterns

Specialty and outpatient tests

›Additional diagnostics by course

›Colonoscopy for suspected malignancy or inflammatory bowel disease as outpatient when stable

›Hydrogen breath testing for small intestinal bacterial overgrowth outpatient setting

›Gastric emptying study for gastroparesis outpatient setting

14ECG/ecg10

Indications in abdominal distension presentations

›ECG utility

›Electrolyte disturbance concern

›Sepsis physiology

›Ischemic symptoms

›Tachyarrhythmia contributing to mesenteric ischemia risk

High risk patterns

›ECG red flags

›Hyperkalemia features

›New atrial fibrillation

›Ischemic ST segment changes

›Conduction block with hemodynamic compromise

15Assessment/ax20

Problem representation and leading diagnosis

›Syndrome classification

›Distension with vomiting and obstipation consistent with bowel obstruction pattern

›Distension with peripheral edema and chronic liver disease signs consistent with ascites pattern

›Distension with diarrhea and systemic toxicity consistent with severe colitis pattern

›Working diagnoses with coding when applicable

›Ascites (R18.8)

›Constipation (K59.00)

›Intestinal obstruction unspecified (K56.60)

›Spontaneous bacterial peritonitis (K65.2)

Severity and risk stratification

›High risk features present

›Peritoneal signs

›Persistent tachycardia

›Elevated lactate

›Acute kidney injury

›Fever with ascites

›Complications to rule out

›Bowel ischemia

›Perforation

›Sepsis

›Variceal bleeding in liver disease context

16Plan/plan42

First 5 minutes

›Immediate stabilization pathway

›Cardiac monitor if unstable or high risk physiology

›Pulse oximetry continuous if respiratory symptoms or abnormal saturation

›Two large bore IVs if shock or suspected surgical abdomen

›Oxygen if saturation less than 92 percent

›Initial fluid resuscitation if hypotension

›Early analgesia and antiemetic with reassessment for masking peritoneal signs not supported

Diagnostic sequencing

›Time critical diagnostics

›Pregnancy test early when pregnancy potential

›Lactate early when ischemia or sepsis concern

›CT abdomen pelvis when obstruction or perforation concern and patient stable

›Ultrasound for ascites confirmation and guidance when ascites suspected

›Decision linked testing

›If ascites with fever or encephalopathy then paracentesis before antibiotics when feasible without delaying antibiotics

›If suspected mesenteric ischemia then CT angiography if stable

Therapeutics

›Symptom control and bowel rest

›Nothing by mouth for suspected obstruction or peritonitis

›Intravenous crystalloid for dehydration

›Antiemetic example ondansetron 4 mg IV

›Analgesia example fentanyl 25 to 50 mcg IV titrated

›Obstruction management

›Nasogastric decompression if ongoing vomiting or significant distension

›Early surgical consult for suspected mechanical obstruction

›Ascites management

›Large volume paracentesis for tense ascites with respiratory compromise

›Albumin replacement after large volume paracentesis local protocol dependent

›Diuretics initiation or adjustment in stable patients with known ascites local protocol dependent

›Infection management

›If spontaneous bacterial peritonitis suspected then ceftriaxone 2 g IV daily

›If perforation or intraabdominal sepsis suspected then broad spectrum antibiotics local protocol dependent

›If severe colitis with toxic megacolon concern then early gastroenterology and surgery coordination

Reassessment loop

›Iterative reassessment targets

›Vital signs every 15 to 30 minutes if unstable

›Pain trajectory after analgesia titration

›Abdominal exam trend for evolving peritonitis

›Urine output trend when resuscitating

›Response to decompression and antiemetic therapy

›Escalation triggers

›Rising lactate

›New peritoneal signs

›Worsening tachycardia or hypotension

›Increasing oxygen requirement

17Disposition/dispo28

Level of care criteria

›Intensive care unit indications

›Vasopressor requirement

›Persistent hypotension despite fluids

›Respiratory failure or impending failure

›Severe metabolic acidosis

›Toxic megacolon with systemic toxicity

›Inpatient admission indications

›Confirmed bowel obstruction

›Suspected bowel ischemia

›Spontaneous bacterial peritonitis

›New ascites requiring diagnostic evaluation

›Acute kidney injury in cirrhosis

›Observation pathway considerations

›Partial obstruction with symptom improvement and reliable follow up

›Constipation requiring short interval reassessment

›Discharge criteria

›No alarm features

›Tolerating oral intake

›Pain controlled with oral regimen

›Clear outpatient plan and reliable return precautions

›No concerning findings on indicated imaging and labs

Consultation and follow up timing

›Consultation triggers

›Surgery for suspected mechanical obstruction or peritonitis

›Gastroenterology for new ascites or decompensated cirrhosis

›Obstetrics gynecology for suspected ectopic pregnancy or adnexal mass with instability

›Follow up timing targets

›Primary care within 48 to 72 hours for constipation or functional bloating

›Specialty follow up within 1 to 2 weeks for suspected chronic ascites etiology workup

18Discharge Instructions/di22

Copy discharge instructions

›Summary

›You were seen for abdominal bloating and distension

›Your tests today did not show an emergency cause that requires admission

›Medications

›Take prescribed anti nausea medication as directed if provided

›Avoid opioid pain medicines unless specifically prescribed

›If constipation plan provided then follow the dosing schedule exactly

›Diet and activity

›Small frequent meals if nausea

›Increase fluids unless you were told to restrict fluids

›Avoid alcohol until symptoms resolved

›Follow up

›See your clinician within the recommended timeframe

›If you have known liver disease then follow up with your liver specialist

›Return to emergency care immediately for

›Severe or worsening abdominal pain

›Persistent vomiting or inability to keep fluids down

›Fever

›Black stools or vomiting blood

›Fainting or severe weakness

›New confusion

›Shortness of breath

19References/r15

Guidelines and decision resources

›American Association for the Study of Liver Diseases practice guidance on ascites and spontaneous bacterial peritonitis 2021

›Diagnostic paracentesis recommended for new ascites and hospitalized cirrhosis with clinical change

›Antibiotic therapy selection and albumin considerations local protocol dependent

›European Association for the Study of the Liver clinical practice guidelines on ascites spontaneous bacterial peritonitis and hepatorenal syndrome 2018

›Ascites evaluation framework and complication prevention

›Spontaneous bacterial peritonitis diagnostic thresholds

›World Society of Emergency Surgery guidelines for small bowel obstruction 2017

›CT based evaluation for obstruction and ischemia concern

›Early operative management criteria and nonoperative pathway considerations

›American College of Gastroenterology clinical guideline for management of constipation 2021

›Stepwise laxative therapy framework for functional constipation

›Alarm features prompting further evaluation

›American College of Radiology appropriateness criteria for suspected small bowel obstruction updated periodically local protocol dependent

›Imaging modality selection based on stability and suspected complication

›Contrast considerations and radiation risk framing

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Abdominal DistensionAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

580 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx91

Symptom overview

›Distension timeline and trajectory

›Sudden onset

›Gradual onset

›Progressive over days to weeks

›Intermittent or fluctuating

›Baseline abdominal size and change from baseline

›Functional impact

›Oral intake intolerance

›Early satiety

›Reduced mobility due to discomfort

›Sleep disruption

›Prior episodes and prior diagnoses

›Similar prior episodes

›Prior bowel obstruction or ileus

›Prior ascites

›Prior constipation pattern

OPQRST Onset

›Onset features

›Time of first noticed distension

›Triggering event

›Recent illness or hospitalization

›Postoperative timing

OPQRST Provocation and palliation

›Modifiers

›Worse with meals

›Worse through the day

›Worse supine

›Worse with movement

›Relief with flatus

›Relief with bowel movement

›Relief with vomiting

›Relief with diuretics

›Relief after paracentesis history

OPQRST Quality

›Associated sensation

›Pressure

›Tightness

›Bloating

›Cramping pain

›Constant pain

OPQRST Region and radiation

›Location pattern

›Generalized

›Upper abdomen predominant

›Lower abdomen predominant

›Right upper quadrant predominant

›Left lower quadrant predominant

›Radiation pattern

›To back

›To shoulder

OPQRST Severity

›Severity anchors

›Degree of visible distension

›Clothing fit change

›Pain severity scale if present

›Respiratory compromise sensation

OPQRST Timing

›Timing features

›Continuous

›Episodic

›Postprandial timing

›Nocturnal symptoms

Associated symptoms

›Gastrointestinal symptoms

›Nausea

›Vomiting

›Bilious vomiting

›Feculent vomiting

›Obstipation

›Decreased flatus

›Diarrhea

›Hematochezia

›Melena

›Abdominal pain pattern

›Systemic symptoms

›Fever

›Chills

›Weight loss

›Night sweats

›Fatigue

›Hepatobiliary symptoms

›Jaundice

›Pruritus

›Dark urine

›Pale stools

›Hematemesis

›Cardiopulmonary symptoms

›Dyspnea

›Orthopnea

›Leg swelling

›Chest pain

›Genitourinary and gynecologic symptoms

›Dysuria

›Urinary retention symptoms

›Vaginal bleeding

›Pelvic pain

›Missed period

›Pregnancy possibility

02Alarm Features/alarm33

Immediate escalation triggers

›High risk physiology

›Systolic blood pressure less than 90 mmHg

›Heart rate greater than 120 per minute

›Respiratory rate greater than 30 per minute

›Oxygen saturation less than 92 percent on room air

›Temperature 38.5 C or higher

›Altered mental status

›High risk abdominal findings

›Peritoneal signs

›Rigid abdomen

›Severe focal tenderness

›Rebound tenderness

›Involuntary guarding

›Hernia with severe pain

›Skin changes over hernia

›High risk symptom patterns

›Persistent vomiting with inability to tolerate fluids

›Obstipation with worsening pain

›Hematemesis

›Melena with hemodynamic symptoms

›Rapidly increasing abdominal girth over hours

›Time critical actions

›If shock or peritonitis then resuscitation bay and immediate surgical consult

›If suspected bowel ischemia then lactate and urgent CT angiography if stable

›If suspected ruptured abdominal aortic aneurysm then immediate vascular activation and permissive hypotension local protocol dependent

High risk populations

›High risk patient factors

›Pregnancy

›Immunocompromised state

›Older adult

›Anticoagulated

›Known cirrhosis

›Known abdominal malignancy

›Recent abdominal surgery

03Medications/meds24

Medication exposures linked to distension

›Motility slowing agents

›Opioids

›Anticholinergics

›Tricyclic antidepressants

›Calcium channel blockers

›Antipsychotics

›Constipating supplements

›Iron

›Calcium supplements

›Bleeding risk agents

›Anticoagulants

›Antiplatelet agents

›Liver and fluid balance agents

›Diuretics

›Recent diuretic dose change

›Nonsteroidal anti-inflammatory drugs

›Endocrine and metabolic agents

›Glucagon like peptide 1 receptor agonists

›Metformin gastrointestinal intolerance

Recent medication changes and adherence

›Pattern of use

›New medication within last 2 weeks

›Missed doses of diuretics or laxatives

›Recent antibiotic exposure

›Recent chemotherapy or immunotherapy

04Diet/diet16

Recent intake and triggers

›Intake pattern

›Reduced oral intake

›High volume intake

›High fiber change

›Very low fiber pattern

›Fluid and salt pattern

›High sodium intake pattern

›Low sodium restriction adherence

›Poor hydration

›Gas producing triggers

›High fermentable carbohydrate pattern

›Carbonated beverages

›Sugar alcohols

›Alcohol exposure

›Recent binge

›Chronic heavy use pattern

05Review of Systems/ros34

Gastrointestinal

›Gastrointestinal review

›Vomiting

›Bilious vomiting

›Hematemesis

›Diarrhea

›Constipation

›Obstipation

›Flatus pattern change

›Gastroesophageal reflux symptoms

›Dysphagia

›GI bleeding symptoms

Constitutional and infectious

›Constitutional review

›Fever

›Chills

›Unintentional weight loss

›Night sweats

›Recent sick contacts

›Recent travel

›Recent antibiotics

Cardiopulmonary and edema

›Cardiopulmonary review

›Dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Chest pain

›Palpitations

›Peripheral edema

Genitourinary and gynecologic

›Genitourinary and gynecologic review

›Dysuria

›Hematuria

›Urinary retention symptoms

›Vaginal bleeding

›Pelvic pain

›Pregnancy possibility

›Last menstrual period timing

06Collateral History and Family History/chafh11

Collateral sources and reliability

›Collateral information

›Family report reliability

›Caregiver report reliability

›Medication list confirmation source

›Baseline cognitive status confirmation

Family history relevant to abdominal distension

›Heritable and familial conditions

›Colorectal cancer family history

›Ovarian cancer family history

›Inflammatory bowel disease family history

›Liver disease family history

›Thrombotic disorder family history

07Risk Factors/rf24

Surgical and mechanical risks

›Obstruction risk factors

›Prior abdominal surgery

›Known hernia

›History of bowel obstruction

›Abdominal or pelvic malignancy

›Pelvic radiation history

Ascites and fluid accumulation risks

›Ascites risk factors

›Cirrhosis

›Heart failure

›Nephrotic syndrome

›Malignancy

›Peritoneal dialysis

Constipation and ileus risks

›Motility risks

›Opioid exposure

›Anticholinergic exposure

›Electrolyte disturbance history

›Hypothyroidism

›Neurologic disease affecting motility

›Recent immobilization

Infection and inflammation risks

›Infection and inflammatory risks

›Inflammatory bowel disease

›Recent gastrointestinal infection

›Immunosuppression

›Recent intraabdominal procedure

08Differential Diagnosis/ddx70

Life threatening

›Cannot miss diagnoses

›Mechanical bowel obstruction with strangulation

›Severe pain out of proportion

›Persistent tachycardia

›Fever

›Leukocytosis

›Elevated lactate

›Peritoneal signs

›Perforated viscus

›Sudden severe pain

›Rigid abdomen

›Free air on imaging

›Toxic megacolon

›Systemic toxicity

›Severe colitis symptoms

›Marked colonic dilation on imaging

›Mesenteric ischemia

›Pain out of proportion

›Metabolic acidosis

›Elevated lactate

›Atrial fibrillation history

›Spontaneous bacterial peritonitis in cirrhosis (K65.2)

›Fever

›Encephalopathy

›Abdominal tenderness

›Ascites

›Ruptured abdominal aortic aneurysm (I71.3)

›Hypotension

›Back pain

›Syncope

Common

›Frequent etiologies

›Constipation (K59.00)

›Reduced stool frequency

›Hard stools

›Straining

›Functional bloating and irritable bowel syndrome (K58.9)

›Symptom fluctuation

›Relation to meals

›Improvement after bowel movement

›Ascites due to portal hypertension (R18.8)

›Progressive girth

›Peripheral edema

›Stigmata of chronic liver disease

›Gastroenteritis

›Diarrhea

›Sick contacts

›Pregnancy related uterine enlargement (Z32.01)

›Missed period

›Positive pregnancy test

Less common

›Less frequent etiologies

›Acute colonic pseudo obstruction (Ogilvie syndrome) (K59.81)

›Recent hospitalization

›Electrolyte abnormalities

›Marked colonic dilation without mechanical transition point

›Gastroparesis (K31.84)

›Early satiety

›Postprandial nausea

›Pancreatic malignancy (C25.9)

›Weight loss

›Painless jaundice

›Ovarian mass or ovarian cancer (C56.9)

›Early satiety

›Pelvic fullness

›Ascites

›Celiac disease (K90.0)

›Chronic diarrhea

›Weight loss

›Small intestinal bacterial overgrowth

›Bloating after meals

›Risk after bowel surgery

09Past Medical History/pmh14

Relevant chronic disease

›Chronic conditions

›Cirrhosis and portal hypertension

›Heart failure

›Chronic kidney disease

›Diabetes mellitus

›Hypothyroidism

›Inflammatory bowel disease

Prior abdominal history

›Prior events and procedures

›Prior bowel obstruction episodes

›Prior abdominal or pelvic surgeries

›Prior hernia repairs

›Prior endoscopy findings

›Prior paracentesis and results

›Prior cancer diagnoses and treatments

10Physical Exam/exam45

Initial impression and vitals interpretation

›General assessment

›Ill appearance

›Diaphoresis

›Dehydration signs

›Respiratory distress

›Hemodynamic pattern

›Shock index elevated

›Orthostatic changes

›Fever pattern

Abdominal exam

›Abdominal inspection and palpation

›Degree of distension

›Surgical scars

›Visible peristalsis

›Tenderness location

›Rebound tenderness

›Guarding

›Abdominal percussion and auscultation

›Tympany predominant

›Dullness predominant

›Bowel sounds high pitched

›Bowel sounds absent

›Ascites maneuvers

›Shifting dullness

›Fluid wave

Hernia and rectal

›Mechanical obstruction screen

›Inguinal hernia

›Femoral hernia

›Umbilical hernia

›Incisional hernia

›Rectal exam decision points

›Rectal vault stool burden

›Gross blood

Extraabdominal clues

›Liver disease and portal hypertension clues

›Jaundice

›Spider angiomas

›Palmar erythema

›Caput medusae

›Asterixis

›Heart failure clues

›Elevated jugular venous pressure

›Crackles

›Peripheral edema

›Pelvic and pregnancy clues

›Pelvic tenderness

›Adnexal mass suspicion

11Lab Studies/labs24

Core laboratory evaluation

›Baseline labs by syndrome

›Complete blood count

›Electrolytes and renal function

›Liver enzymes

›Bilirubin

›International normalized ratio

›Lipase

›Venous blood gas if toxic appearance

›Lactate if ischemia or sepsis concern

Targeted labs

›Etiology directed tests

›Pregnancy test for patients with pregnancy potential

›Urinalysis for urinary infection or retention mimics

›C reactive protein if inflammatory bowel disease flare consideration

›Thyroid stimulating hormone if chronic constipation and hypothyroid concern

›Blood cultures if sepsis concern

Ascites fluid studies when present

›Diagnostic paracentesis panels

›Cell count with differential

›Albumin

›Total protein

›Gram stain

›Culture inoculated at bedside

›Interpretation pearls

›Neutrophils 250 per microliter or higher supports spontaneous bacterial peritonitis

›Serum ascites albumin gradient pattern for portal hypertension classification

12Imaging/img46

Scoring Systems

›Severity and risk scores that guide imaging and disposition

›MELD Na score for cirrhosis severity

›Higher score supports higher risk of complications

›Use for prognosis and disposition planning

›Child Pugh class for chronic liver disease

›Class B to C associated with higher infection and bleeding risk

›Use for procedural risk framing

›Colonic dilation risk thresholds in pseudo obstruction

›Cecal diameter 12 cm or higher higher perforation risk

›Persistent dilation over 6 days higher perforation risk

MRI

›MRI indications

›MRCP for suspected biliary obstruction when ultrasound equivocal

›Pelvic MRI for adnexal mass characterization when ultrasound indeterminate

›MRI constraints and contraindications

›Non MRI compatible implanted devices

›Unstable patient physiology limiting scan tolerance

›Interpretation pearls

›MRCP best for ductal obstruction and stones beyond ultrasound window

›Pelvic MRI improves soft tissue characterization for complex masses

›CT abdomen pelvis role

›Suspected mechanical bowel obstruction

›Suspected perforation

›Suspected intraabdominal abscess

›Suspected malignancy complication

›CT angiography role

›Suspected mesenteric ischemia

›Suspected acute vascular catastrophe

›Contrast and radiation cautions

›Chronic kidney disease risk stratification and hydration plan local protocol dependent

›Pregnancy risk benefit discussion

›Key interpretation targets

›Transition point and level of obstruction

›Closed loop obstruction features

›Pneumatosis intestinalis

›Portal venous gas

›Free air

Ultrasound

›Point of care ultrasound applications

›Ascites detection and procedural guidance

›Gallbladder evaluation in right upper quadrant pain

›Bladder volume for urinary retention mimic

›Ultrasound pitfalls

›Bowel gas limiting visualization

›Obesity limiting image quality

›Interpretation pearls

›Ascites pocket selection for safer paracentesis

›Gallbladder wall thickening is nonspecific without supportive findings

13Special Tests/spec11

Bedside procedures and diagnostics

›Diagnostic paracentesis when ascites present

›Indicated with new onset ascites

›Indicated with cirrhosis and any clinical deterioration

›Avoid if abdominal wall cellulitis at puncture site

›Nasogastric tube decompression when severe vomiting and suspected obstruction

›Symptom relief and aspiration risk reduction

›Output character supports proximal obstruction vs distal patterns

Specialty and outpatient tests

›Additional diagnostics by course

›Colonoscopy for suspected malignancy or inflammatory bowel disease as outpatient when stable

›Hydrogen breath testing for small intestinal bacterial overgrowth outpatient setting

›Gastric emptying study for gastroparesis outpatient setting

14ECG/ecg10

Indications in abdominal distension presentations

›ECG utility

›Electrolyte disturbance concern

›Sepsis physiology

›Ischemic symptoms

›Tachyarrhythmia contributing to mesenteric ischemia risk

High risk patterns

›ECG red flags

›Hyperkalemia features

›New atrial fibrillation

›Ischemic ST segment changes

›Conduction block with hemodynamic compromise

15Assessment/ax20

Problem representation and leading diagnosis

›Syndrome classification

›Distension with vomiting and obstipation consistent with bowel obstruction pattern

›Distension with peripheral edema and chronic liver disease signs consistent with ascites pattern

›Distension with diarrhea and systemic toxicity consistent with severe colitis pattern

›Working diagnoses with coding when applicable

›Ascites (R18.8)

›Constipation (K59.00)

›Intestinal obstruction unspecified (K56.60)

›Spontaneous bacterial peritonitis (K65.2)

Severity and risk stratification

›High risk features present

›Peritoneal signs

›Persistent tachycardia

›Elevated lactate

›Acute kidney injury

›Fever with ascites

›Complications to rule out

›Bowel ischemia

›Perforation

›Sepsis

›Variceal bleeding in liver disease context

16Plan/plan42

First 5 minutes

›Immediate stabilization pathway

›Cardiac monitor if unstable or high risk physiology

›Pulse oximetry continuous if respiratory symptoms or abnormal saturation

›Two large bore IVs if shock or suspected surgical abdomen

›Oxygen if saturation less than 92 percent

›Initial fluid resuscitation if hypotension

›Early analgesia and antiemetic with reassessment for masking peritoneal signs not supported

Diagnostic sequencing

›Time critical diagnostics

›Pregnancy test early when pregnancy potential

›Lactate early when ischemia or sepsis concern

›CT abdomen pelvis when obstruction or perforation concern and patient stable

›Ultrasound for ascites confirmation and guidance when ascites suspected

›Decision linked testing

›If ascites with fever or encephalopathy then paracentesis before antibiotics when feasible without delaying antibiotics

›If suspected mesenteric ischemia then CT angiography if stable

Therapeutics

›Symptom control and bowel rest

›Nothing by mouth for suspected obstruction or peritonitis

›Intravenous crystalloid for dehydration

›Antiemetic example ondansetron 4 mg IV

›Analgesia example fentanyl 25 to 50 mcg IV titrated

›Obstruction management

›Nasogastric decompression if ongoing vomiting or significant distension

›Early surgical consult for suspected mechanical obstruction

›Ascites management

›Large volume paracentesis for tense ascites with respiratory compromise

›Albumin replacement after large volume paracentesis local protocol dependent

›Diuretics initiation or adjustment in stable patients with known ascites local protocol dependent

›Infection management

›If spontaneous bacterial peritonitis suspected then ceftriaxone 2 g IV daily

›If perforation or intraabdominal sepsis suspected then broad spectrum antibiotics local protocol dependent

›If severe colitis with toxic megacolon concern then early gastroenterology and surgery coordination

Reassessment loop

›Iterative reassessment targets

›Vital signs every 15 to 30 minutes if unstable

›Pain trajectory after analgesia titration

›Abdominal exam trend for evolving peritonitis

›Urine output trend when resuscitating

›Response to decompression and antiemetic therapy

›Escalation triggers

›Rising lactate

›New peritoneal signs

›Worsening tachycardia or hypotension

›Increasing oxygen requirement

17Disposition/dispo28

Level of care criteria

›Intensive care unit indications

›Vasopressor requirement

›Persistent hypotension despite fluids

›Respiratory failure or impending failure

›Severe metabolic acidosis

›Toxic megacolon with systemic toxicity

›Inpatient admission indications

›Confirmed bowel obstruction

›Suspected bowel ischemia

›Spontaneous bacterial peritonitis

›New ascites requiring diagnostic evaluation

›Acute kidney injury in cirrhosis

›Observation pathway considerations

›Partial obstruction with symptom improvement and reliable follow up

›Constipation requiring short interval reassessment

›Discharge criteria

›No alarm features

›Tolerating oral intake

›Pain controlled with oral regimen

›Clear outpatient plan and reliable return precautions

›No concerning findings on indicated imaging and labs

Consultation and follow up timing

›Consultation triggers

›Surgery for suspected mechanical obstruction or peritonitis

›Gastroenterology for new ascites or decompensated cirrhosis

›Obstetrics gynecology for suspected ectopic pregnancy or adnexal mass with instability

›Follow up timing targets

›Primary care within 48 to 72 hours for constipation or functional bloating

›Specialty follow up within 1 to 2 weeks for suspected chronic ascites etiology workup

18Discharge Instructions/di22

Copy discharge instructions

›Summary

›You were seen for abdominal bloating and distension

›Your tests today did not show an emergency cause that requires admission

›Medications

›Take prescribed anti nausea medication as directed if provided

›Avoid opioid pain medicines unless specifically prescribed

›If constipation plan provided then follow the dosing schedule exactly

›Diet and activity

›Small frequent meals if nausea

›Increase fluids unless you were told to restrict fluids

›Avoid alcohol until symptoms resolved

›Follow up

›See your clinician within the recommended timeframe

›If you have known liver disease then follow up with your liver specialist

›Return to emergency care immediately for

›Severe or worsening abdominal pain

›Persistent vomiting or inability to keep fluids down

›Fever

›Black stools or vomiting blood

›Fainting or severe weakness

›New confusion

›Shortness of breath

19References/r15

Guidelines and decision resources

›American Association for the Study of Liver Diseases practice guidance on ascites and spontaneous bacterial peritonitis 2021

›Diagnostic paracentesis recommended for new ascites and hospitalized cirrhosis with clinical change

›Antibiotic therapy selection and albumin considerations local protocol dependent

›European Association for the Study of the Liver clinical practice guidelines on ascites spontaneous bacterial peritonitis and hepatorenal syndrome 2018

›Ascites evaluation framework and complication prevention

›Spontaneous bacterial peritonitis diagnostic thresholds

›World Society of Emergency Surgery guidelines for small bowel obstruction 2017

›CT based evaluation for obstruction and ischemia concern

›Early operative management criteria and nonoperative pathway considerations

›American College of Gastroenterology clinical guideline for management of constipation 2021

›Stepwise laxative therapy framework for functional constipation

›Alarm features prompting further evaluation

›American College of Radiology appropriateness criteria for suspected small bowel obstruction updated periodically local protocol dependent

›Imaging modality selection based on stability and suspected complication

›Contrast considerations and radiation risk framing

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.