13 Abdominal swellings (localized): upper abdominal/1

 

 

 KEY POINTS
• Hepatic mass: moves with respiration, dull to percussion, cannot ‘get
above’ it, enlarges/descends towards RIF.
• Splenic mass: moves with respiration, dull to percussion, cannot ‘get
above’ it, enlarges/descends towards RIF, may have a notched border.
• Renal mass: moves somewhat with respiration, usually resonant due
to overlying bowel gas, bimanually palpable (ballotable).
• Retroperitoneal mass: no movement with respiration, difficult to
delineate, resonant to percussion.
• Bowel masses: often mobile, may be well defined.
Liver
• Riedel’s lobe: smooth, non-tender, lateral/right lobe:, ‘tonguelike’,
men < women.
• Infective hepatitis: smooth, tender, global enlargement.
• Liver abscess: usually one large abscess, ?amoebic, very tender,
systemically unwell.
• Hydatid cyst: smooth, may be loculated, ?history of tropical
travel.
• Venous congestion: smooth, tender, pulsatile (slightly irregular
(cirrhotic) if chronic).
• Cirrhosis: irregular, firm, ‘knobbly’.
• Tumours:
primary: solitary, large, non-tender, ?lobulated
secondary: often multiple, irregular, rock hard, centrally
umbilicated.
Gallbladder
• Generally: oval, smooth, projects towards RIF, beneath the tip
of the ninth rib, moves with respiration.
• Mucocele: large gallbladder, moderately tender, smooth
walled.
• Empyema: acutely tender, difficult to palpate clearly because
of pain.
• Carcinoma of gallbladder: nodular, hard, irregular.
Renal masses
• Perinephric abscess/pyonephrosis: acutely tender, systemic
signs, rarely large.
• Hydronephrosis: large, smooth, tense kidney. May be massive.
• Solitary cyst: smooth, non-tender, may be massive.
• Polycystic disease: frequently very large, lobulated, smooth.
• Renal carcinoma: irregular, nodular, often hard, ?fixed.
• Nephroblastoma: large mass in children.
Suprarenal gland
• Generally: only palpable when large, moves with respiration,
difficult to define borders.
• Adenomas: usually cystic if palpable.
• Infections: ?chronic fungal infections, may be tender, systemic
features.
• Congenital hyperplasia: young children, endocrine disorders
associated, smooth, non-tender.
Colon
• Faeces: soft, putty-like mass, mobile, non-tender, can be
indented.
• Carcinoma: firm–hard, irregular, non-tender, may be mobile
(fixity strongly suggests carcinoma).
• Intussusception: mobile, smooth, sausage-shaped mass.
Stomach
• Gastric distension: soft, fluctuant, succussion splash present.
• Neoplasm: irregular, hard, craggy, immobile, does not
descend on inspiration.
Pancreas
• Generally: does not move with respiration, fixed to retroperitoneum,
poorly defined.
• Pseudocyst/cyst: mildly tender (worse if infected), symptoms
of gastric obstruction.
• Carcinoma: hard, irregular, non-tender, fixed.
Retroperitoneum
• Lymphadenopathy: solid, immobile, irregular, ‘rubbery’, may
be massive, particularly if lymphomatous.
• Dermoid cysts (rare): deep seated, smooth, recurrent after
surgery.
• Aortic aneurysm: smooth, fusiform, pulsatile, expansile, may
be tender.
Omentum
Secondary carcinoma: hard, irregular, mobile, ‘pancake like’,
often ovarian carcinoma.
KEY INVESTIGATIONS
• FBC: anaemiabtumours.
• WCC: lymphomas, Crohn’s disease, appendicitis/diverticulitis.
• LFTs: liver lesions.
• Ultrasound: pancreatic (pseudo)cysts, aortic aneurysm.
• CT scan: pancreatic tumours, lymphadenopathy,
retroperitoneal/mesenteric cysts, aortic aneurysm, omental deposits.
• Gastroscopy: stomach tumours.
• Colonoscopy: colonic tumours.
• Small bowel enema: small intestinal tumours.
• Barium enema: colonic tumours.