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Investigations: o USS Abd: detects stones better o CT Abd: defines lesions better o Superseded by MRCP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