Abdominal guarding

Abdominal guarding

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Key words and synonyms: rebound, rigidity, rigid abdomen.

Overview

Abdominal guarding: Tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdomen wall is pressed.

Guarding is a characteristic finding in the physical examination for an abruptly painful abdomen (an acute abdomen) with inflammation of the inner abdominal (peritoneal) surface due, for example, to appendicitis or diverticulitis. The tensed muscles of the abdominal wall automatically go into spasm to keep the tender underlying tissues from being touched.

Medical Emergencies Associated with Abdominal Guarding

• Abdominal aortic aneurysm
• Appendicitis
• Bowel obstruction
• Hepatic or splenic contusion/laceration
• Ileus
• Incarcerated hernia
• Mesenteric ischemia
• Peritonitis
• Pyelonephritis
• Volvulus

Complete Differential Diagnosis of Causes of Abdominal guarding (alphabetical):

• Abdominal aortic aneurysm
• Abdominal migraine
• Abdominal wall strain/injury
• Abscess (e.g. iliopsoas)
• Aneurysm
• Anxiety
• Appendicitis
• Bowel obstruction
• Diverticulitis
• Ectopic pregnancy
• Fluid/blood secondary to trauma
• Hepatic or splenic contusion/laceration
• Ileus
• Incarcerated hernia
• Insect toxins (e.g. black widow spider)
• Intussusception
• Malingering
• Mesenteric ischemia
• Nephrolithiasis
• Organ contusion
• Organ laceration
• Ovarian cyst
• Pancreatitis
• Pelvic inflammatory disease
• Peptic ulcer disease
• Peritonitis
• Pneumoperitoneum secondary to trauma
• Pyelonephritis
• Spontaneous bacterial peritonitis (SBP)
• Urinary tract infection
• Volvulus

Complete Differential Diagnosis of the Causes of Abdominal guarding (by organ system)

Cardiovascular	• Abdominal aortic aneurysm • Aneurysm • Mesenteric ischemia
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	• Abscess (e.g. iliopsoas) • Appendicitis • Bowel obstruction • Diverticulitis • Hepatic or splenic contusion/laceration • Ileus • Intussusception • Incarcerated hernia • Mesenteric ischemia• Pancreatitis • Peptic ulcer disease • Peritonitis • Pneumoperitoneumsecondary to trauma • Spontaneous bacterial peritonitis (SBP) • Volvulus
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	No underlying causes
Musculoskeletal / Ortho	• Abdominal wall strain/injury• Organ contusion
Neurologic	• Abdominal migraine
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	• Ectopic pregnancy • Ovarian cyst • Pelvic inflammatory disease
Oncologic	• Ovarian cyst
Opthalmologic	No underlying causes
Overdose / Toxicity	• Insect toxins (e.g. black widow spider)
Psychiatric	• Anxiety • Malingering
Pulmonary	No underlying causes
Renal / Electrolyte	• Nephrolithiasis • Pyelonephritis • Urinary tract infection
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	• Fluid/blood secondary to trauma • Hepatic or splenic contusion/laceration • Organ contusion• Organ laceration • Pneumoperitoneumsecondary to trauma
Urologic	• Nephrolithiasis • Pyelonephritis • Urinary tract infection
Miscellaneous	No underlying causes

Laboratory Findings

• Complete blood count (CBC)
• Blood urea nitrogen (BUN)/creatinine
• Liver function tests (LFTs)
• Glucose
• Amylase/lipase
• Urine culture
• Urinalysis
• Beta-human chorionic gonadotropin (beta-hCG)
• Cervical cultures are recommended to diagnose pelvic inflammatory disease

Electrolyte and Biomarker Studies

• Electrolytes

MRI and CT

• CT diagnoses:

  • Organ contusion
  • Organ laceration
  • Aneurysm
  • Diverticulitis
  • Appendicitis

Echocardiography or Ultrasound

• Pelvic, abdominal and/or transvaginal ultrasound diagnoses:

  • Peritonitis
  • Ectopic pregnancy
  • Ovarian cysts
  • Fluid/blood secondary to trauma
  • Appendicitis
  • Aneurysm

Other Imaging Findings

• KUB x-rays (kidney, ureter, bladder) could reveal nephrolithiasis and bowel gas pattern

Other Diagnostic Studies

• Symptomatic relief may be provided by paracentesis, which may also diagnose spontaneous bacterial peritonitis (SBP)
• Gastrointestinal endoscopy may be used or patients with suspected peptic ulcer disease

  • Helicobacter pylori" testing may also be used

• Trial medications may be beneficial for the diagnosis and treatment of:

  • GERD / dyspepsia: Proton pump inhibitors or H2 blockers
  • Abdominal wall strain: Nonsteriodal anti-inflammatory drugs (NSAIDs)
  • Anxiety: Lorazepam
  • Zoster: Acyclovir

Treatment

• Specific conditions need direct treatment
• Hemodynamic status and life-theratening disease require immediate attention

  • Volume replacement with a possible blood transfusion, and with normal saline

• For obstruction and persistent vomiting, place nasogastric (NG) tube

Pharmacotherapy

Acute Pharmacotherapies

• If perforated viscus or intra-abdominal infection suspected, administer broad-spectrum empiric antibiotics

Surgery and Device Based Therapy

• Early sepsis, or evidence of hemorrhage may require surgery (likely to be life-threatening emergency)