Chronic Hard Abdominal Swelling: 8 Differential Diagnoses & Workup

Chronic hard abdominal distension requires systematic evaluation—causes range from benign to malignant.

Differential Diagnosis

1. Ascites: Fluid in peritoneal cavity; shifting dullness, fluid wave. Causes: cirrhosis (portal HTN), heart failure, nephrotic syndrome, peritoneal carcinomatosis
2. Abdominal masses: Hepatomegaly, splenomegaly, ovarian tumor, uterine fibroids, aortic aneurysm, fecal impaction
3. Inflammatory bowel disease: Crohn's (transmural → strictures, masses), UC (toxic megacolon — acute)
4. Chronic infections: TB (peritonitis, adhesions), parasitic (hydatid cyst), actinomycosis
5. Splenomegaly: Portal HTN, hematologic malignancies, infiltrative diseases → LUQ mass
6. Adhesions: Post-surgical bands → obstruction, fixed distension
7. Hernias: Ventral, incisional, umbilical, Spigelian — reducible vs. incarcerated
8. Obesity: Central adiposity (soft, not hard); but can coexist
9. Pseudomyxoma peritonei: Mucinous implants (appendiceal/ovarian origin)
10. Meigs syndrome: Ovarian fibroma + ascites + pleural effusion

Diagnostic Approach

• History: Onset, progression, pain, weight loss, bowel habits, surgery
• Exam: Percussion (shifting dullness), palpation (mass, organomegaly), hernia sites
• Labs: CBC, LFTs, albumin, CA-125, CEA, AFP, inflammatory markers
• Imaging: US (first-line), CT abdomen/pelvis (gold standard), MRI if needed
• Paracentesis: If ascites (SAAG, cell count, culture, cytology)

Red Flags

• Weight loss, anorexia, early satiety
• New onset >50 years
• Family history GI/ovarian cancer
• Ascites + nodular liver

Hard, chronic distension warrants thorough workup—malignancy must be excluded.