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Abdominal mass

Palpable abdominal mass is serious, unless it is a;


Normal distended bladder
Lower pole of right kidney
Abdominal aorta
Liver (in infants: firm for a few weeks)
Liver (in adults: just below costal margin)
Intestinal loops ? (Palpable colon and cecum: spongy sensation and squelching noise on
pressure)
Fecal mass
Pregnancy

Signs
a. Abdominal wall Vs. intra abdominal
o When contracting the abdominal muscles;
Lumps superficial to the abdominal wall muscles --> becomes more
obvious
Lumps attached to the deep fascia --> becomes less mobile
Lumps arising within the muscle layer --> becomes fixed and less obvious
Lumps arising deep to the abdominal wall --> becomes impalpable
b. Movement with respiration
o If intra peritoneal and in contact with the diaphragm
c. Percussion note
o Resonance --> intra luminal or extra luminal gas
o Pelvis mass --> dull
o Posterior abdominal wall mass --> resonance is retained


GALL BLADDER

Causes of GB enlargement;
o Obstruction of the cystic duct:
By a gallstone or intrinsic/extrinsic ca
Not jaundiced
GB contains bile; mucus(mucocoele) non-tender; pus(pyocoele/empyema)
tender
o Obstruction of the CBD:
By a stone or ca of the head of the pancreas
Jaundice
+


Physical features of an enlarged GB;
o Beneath the tip of the R/ 9
th
costal cartilage (if tender
+
Murphys sign)
o Smooth and hemi-ovoid
o Moves with respiration
o No space b/w the lump and the edge of the liver
o Dull to percussion

In an acutely inflamed GB (surrounded by adherent omentum and bowel);
o Diffuse and tender
o Lies in the RHC
o Does not move much with respiration

Courvoisiers Law interpretation:
In the presence of a non-tender palpable GB, painless jaundice is unlikely to be
caused by gallstones.

GB pain/biliary colic
o Not a true colic does not remit b/w exacerbations
o Felt in RHC and radiates to the back, close to the tip of the scapula
o Exacerbated by moving/breathing

Similar physical signs with;
o Other masses in the region attached to liver (antrum, pylorus, porta hepatis)
o Lower pole of kidney

GB Lower pole of palpable Kidney
Smooth, hemispherical; with no edge
Not palpable in the loin Always present in the loin
Not ballotable Ballotable
Dull to percussion Band of resonance

Investigations:
o USS Abd: detects stones better
o CT Abd: defines lesions better
o Superseded by MRCP

LIVER

Causes of Hepatomegaly
o Smooth, generalized enlargement, without jaundice:
CCF (raised JVP, oedema)
Cirrhosis
Lymphoma
Hepatic vein thrombosis (Budd-Chiari syndrome)
Amyloid disease
Kalae-azar, Gauchers disease
o Smooth, generalized enlargement, with jaundice:
Infective hepatitis
Biliary tract obstruction (intra/extra hepatic)
Cholangitis
Haemochromatosis
Portal pyemia
o Knobby generalized enlargement, without jaundice:
Metastatic deposits
Alcoholic cirrhosis (stigmata of liver failure, coarsely nodular liver)
Polycystic disease
I
ry
liver ca (hepatocellular and cholangiocarcinoma)
o Knobby generalized enlargement, with jaundice:
Metastatic deposits (I
ry
in breast, broncus, oesophagus, stomach, rectum,
melanoma)
I
ry
biliary cirrhosis ( scratch marks, polished nails, finely nodular liver)
o Localized swelling
Riedels lobe
I
ry
or II
ry
liver carcinoma
Hydatid cyst
Liver abscess ( tender, sepsis
+
)
- Pyogenic (biliary sepsis, portal pyemia II
ry
to appendicitis/divertivulitis
- Amoebic (endemic area, toddy intake)
Benign liver adenoma
Physical signs of an enlarged liver
o Descends below the R/costal margin
o Cannot feel its upper limit
o Moves with respiration
o Dull to percussion upto 8
th
rib in mid axillary line
o Sharp/rounded edge with a smooth or irregular surface

Investigations:
o USS: cystic? Solid?
o CT: nature, extent, relation to adjacent structures
o Imaging guided biopsy/drainage

RETROPERITONEAL MASS

Causes of a retroperitoneal mass;
Teratoma, Neuroblastoma, Lymphoma, LN masses, renal tumours, liposarcoma

Physical signs:
o Abdominal distension
o Fixed to post. Abd wall (due to anatomical site + inflammatory adhesion/infiltrations to
adjacent viscera or otherwise mobile viscus)
o Resonant on percussion
o Limited movement with respiration
o May transmit aortic pulsations

KIDNEYS

Causes of enlargement of the kidney (Congenital, Obstructive or Neoplastic);
o Hydronephrosis
o Pyonephrosis
o Malignancy: ca of the kidney and nephroblastoma
o Solitary cyst
o Polycystic disease
o hypertrophy

Physical signs:
o Can be reduced into the loin
o Lower pole- smooth and hemi ovoid
o Moves with respiration
o Not dull to percussion has a band of resonance
o Can palpate bimanually
o Ballotable

Investigations:
o USS: size, shape, dilatation, calculi, cysts
o CT: to distinguish b/w ca and other pathology
o IVU in ureteric colic

LEFT UPPER QUADRANT (LUQ)

Moves with respiration liver, kidney or spleen
Does not move with respiration colon, small intestines, mesentry or LNs

Physical signs of an enlarged spleen:
o Appears from below the tip of the L/ 10
th
rib
o Firm, smooth
o Notch on upper edge
o Cannot get above it
o Moves with respiration down and right (along the line of the rib, toward umbilicus)
o Dull to percussion
o Cannot be felt bimanually or balloted.

Palpable liver and spleen:
o Portal hypertension
o Reticuloses ?

EPIGASTRIC MASSES

Causes of an epigastric mass:
o Enlarged liver or spleen ( around midline, moves with respiration)
o Ca in the distal stomach/transverse colon (do USS before endoscopy)
o Ca in the body of the pancreas/pancreatic cyst ( does not move with respiration)
o AAA ( expansile pulsatility
+
)

GASTRO-INTESTINAL STROMAL TUMOUR
Tumours of connective tissues ( sarcomas)
Eg: stomach 70%; SI 20%; oesophagus <10%
Small tumours generally benign
Large tumours disseminate to liver, omentum and peritoneal cavity
Thought to arise from intestinal cells of Cajal
Most due to a mutation in a gene called c-kit
Tumour tends to grow out intestinal obstruction is rare

AORTIC ANEURYSM
Physical signs:
o Expansile pulsation
o Firm and smooth
o +/- tenderness (if present, signifies inflammatory changes or the wall of aneurysm is
stretching)
Investigations:
o X-ray abd lateral: calcific shadow of the anterior and posterior walls
o USS and CT: reliable, for diagnosis and size (>2.5cm)
CT more precise, to show relationship to renal arteries
o Aortography: misleading due to thrombus, useful if there is LL ischaemia
Size:
o Upto 2.5cm normal
o 2.5 to 5.5 cm small AAA; elective Sx to prevent rupture
o >5.5cm needs urgent Sx management

SUPRA PUBIC MASS

Causes of a supra pubic mass:
o From pubic bone:
Hard, fixed
Likely to be neoplastic/osteitis pubis
o From pelvic viscera:
Lies against pubic crest (cannot feel lower edge)
Usually dull to percussion
Bimanual palpation to discriminate uterine from adnexal lesions
Bladder Dome shaped
Desire to micturate on pressure
Cannot move side to side when abd muscles are contracted
Diverticulum of bladder remains or becomes more palpable when abd muscles
are contracted
Ovarian cyst lie centrally
Soft
Fill the abd (may be confused with ascites)
Other (differentiate using DRE or PV examination): ca rectum, ca sigmoid, uterine
fibroid, ovarian cyst, tubo ovarian mass, invading prostatic ca

Investigations:
o Xray and USS of pelvis
o Endo vaginal USS
o CT/MRI: for clear demarcation, in assessing respectability

RIF

Causes of RIF masses:
o Appendicular mass (smooth, firm, tender, not mobile, well-localised)
o Crohns ileitis
o Ca caecum (nodular, hard, initially mobile, impaired resonance, later intestinal
obstruction)
o Ileocaecal TB (Hx of PTB not helpful; smooth, hard. Resonant, non tender, restricted
mobility, caecum pulled up)
o Ca ovary/salphingo oophorits ( abd examination and bi manual palpation with DRE and
PV)
o Amoeboma (Hx of dysentery, pain in RIF , smooth, hard, well defined mass +/-
tenderness)
o Psoas abscess (localised, smooth, non mobile, psoas spasm, spine gibbus, paraspinal
spasm, tenderness, restricted spinal movements)
o LN mass (mesenteric/ext.iliac)
o Other: bony mass, ectopic kidney, UDT, actinomycosis, iliac artery aneurysm, ovarian
mass/cyst, tubo ovarian mass, uterine pedunculate fibroid

Investigations:
o USS: abdomen, pelvis or endo vaginal USS
o CT



LIF

Causes of a LIF mass:
o Ca sigmoid/descending colon
o Sigmoid diverticulitis, para aortic abscess
o Bony mass
o Ovarian/uterine
o Other: Psoas abscess, ectopic kidney, UDT, LN masses

Investigations:
o DRE
o CT abd

ANTRIOR ABDOMINAL WALL

Causes of lumps in the anterior abd wall:
o Umbilicus umbilical/paraumbilical hernia
Exomphalos
Umbilical fistulae
Umbilical granuloma
o Cellulitis
o Trauma (rupture of rectus abdominis heamatoma)
o Herniae umbilical/para umbilical
Divarication of recti/spigelian hernia
Epigastric hernia
o Benign tumours SC lipoma/Dercums disease
Campbell de morgan spots
o Desmoids tumour/malignant fibro sarcoma/malignant melanoma

Physical signs:
o Sister Mary Josephs nodule
o Skin discolouration
o Cullens sign - superficial edema and bruising in the subcutaneous fatty tissue around the
umbilicus
o Flank bruising
o Abdominal striae striae gravidarum
Purple striae of Cushings
o Distended abd veins caput medusa
Veins due to IVC obstruction

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