TABLE 99 Protuberant Abdomens

Tympany

Dullness

Tympany

Dullness

Fat is the most common cause of a protuberant abdomen and is associated with generalized obesity. The abdominal wall is thick. Fat in the mesentery and omentum also contributes to abdominal size. The umbilicus may appear sunken. The percussion note is normal. A pannus, or apron of fĂ tty tissue, may extend below the inguinal ligaments. Lift it to look for inflammation in the skin fold or even for a hidden hernia.

Gaseous distention may be localized or generalized. It causes a tympanitic percussion note. Increased intestinal gas production due to certain foods may cause mild distention. More serious are intestinal obstruction and adynamic (paralytic) ileus. Note the location of the distention. Distention becomes more marked in colonic than in small bowel obstruction.

Tumor

A large, solid tumor, usually rising out of the pelvis, is dull to percussion. Air-filled bowel is displaced to the periphery. Causes include ovarian tumors and uterine myomata. Occasionally, a markedly distended bladder may be mistaken for such a tumor.

Tympany

Dullness

Tympany

Dullness

Pregnancy

Pregnancy is a common cause of a pelvic "mass.'' Listen for the fetal heart (see pp. 421-422).

Tympany

Bulging flank

Tympany

Bulging flank

Dullness

Umbilicus may be protuberant

Dullness

Umbilicus may be protuberant

- Tympany

Dullness cx> o

Ascitic Fluid

Ascitic fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness). (See pp. 345-347 for the assessment of ascites.)

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