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Why is this woman's abdomen swollen?

This usually slim woman had come to see Dr Mike Wyndham, worried about her swollen stomach – but what was causing it?


The patient

This 58-year-old woman had always been pleased with her weight and shape. But in recent weeks she had noticed her abdomen changing shape and becoming much more distended. She had some mild pain, particularly on her left side. Although her bowels had slowed up, she couldn't believe that this was the cause of her problem. Apart from a large lipoma being removed from her abdominal skin,

she had been fit and healthy. She had reached the menopause seven years previously. Her last smear was two years ago and was entirely normal. She hardly ever drank alcohol.

First instinct

A complaint of a distended abdomen is not an uncommon symptom and usually, I find, is a subjective feeling that the patient has, and not really backed up by physical signs. Sometimes it results from lax abdominal wall muscles or it may be a symptom of premenstrual fluid retention. It's useful to inquire whether the symptom is present the whole time or comes and goes.

But once this woman undressed, there was obviously a very real problem – a pathologically swollen abdomen that felt very firm.

Differential diagnosis

• Benign ovarian cyst

• Fibroids

• Ascites

• Ovarian cancer

An ovarian cyst was a definite possibility, although only a small percentage of cases occur in the postmenopausal woman – about 6%. The discomfort and swelling being unilateral would also fit with this diagnosis.

Fibroids were a bit of long shot as they tend to shrink after the menopause and the swelling is really too large. The largest fibroid uterus I've ever encountered in a postmenopausal woman reached her umbilicus.

Ascites was a definite possibility with such a distended abdomen. Liver disease may be the underlying cause for ascites but with no stigmata visible on clinical examination and little alcohol consumption, this seemed an unlikely reason. But malignancy could be a cause for fluid in the peritoneal cavity.

Finally, a large hard mass of unilateral origin could certainly be an ovarian cancer.

Getting on the right track

With the firm, distorted swelling present, it was most likely to be a solid tumour. An ultrasound was going to give us a good indication of the problem. But there was one more fact to be identified. Was there a family history of a similar problem? Yes, her mother had suffered from ovarian cancer. There is a 4-5% risk of developing ovarian cancer if there has been a first-degree family member who has suffered the condition. Ultrasound confirmed the presence of a large ovarian tumour that was confirmed as cancer at surgery.

Dr Mike Wyndham is a GP in Edgware, north London

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Why is this woman's abdomen swollen? Why is this woman's abdomen swollen?

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