Abdominal Masses

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Abdominal masses are usually detected on physical examination rather than presented by the patient. Any patient with an unexplained abdominal mass should be referred for urgent specialist assessment.[1]

  • Examine supraclavicular and inguinal nodes.
  • Inspection - scars (especially around the umbilicus for laparoscopy scars), distension, prominent veins, local swelling, pulsation, visible peristalsis, skin lesions, asymmetrical movement at eye level. Exclude lesions of the abdominal wall: the patient raises their head (no good for the lateral abdomen); the patient does straight leg-raising (Carnett's method), 'blowing test' (Valsalva's test); the patient strains as if toileting (Kamath's test).[3]
  • Palpation - use warm hands, and examine the tender areas last. Light palpation, then deep. Check for guarding, rigidity and rebound tenderness. Determine for any mass: site, tenderness, size and shape, surface (irregular or smooth), edge (regular or irregular), consistency (soft or hard), mobility, whether pulsatile or ballotable.

Causes of Abdominal Mass by Location

Right upper quadrant
  • Cholecystitis - very tender mass
  • Cholangiocarcinoma - moderately tender, irregularly shaped mass
  • Hepatomegaly
  • Liver cancer - firm, lumpy mass
Epigastric
  • Hepatomegaly - firm, irregular mass (also in right costal margin)
  • Pancreatic abscess or pseudocyst
  • Gastric carcinoma
Left upper quadrant
  • Splenomegaly
  • Gastric carcinoma
  • Pancreatic abscess or pseudocyst
  • Disorders of kidney and colon
  • Neurofibroma (rare)
Right flank
  • Hydronephrosis - smooth spongy mass
  • Renal cell carcinoma (smooth, firm, non-tender mass)
Periumbilical
  • Abdominal aortic aneurysm (pulsating mass)
  • Tumour somewhere in the gastrointestinal tract
Left flank
  • Hydronephrosis (smooth spongy mass)
  • Renal cell carcinoma (smooth, firm, non-tender mass)
Right iliac fossa
  • Actinomycosis
  • Amoebic abscess
  • Appendix mass or abscess
  • Caecal/colon cancer or distension
  • Crohn's disease (multiple tender, sausage-shaped masses)
  • Hernia
  • Ileocaecal mass caused by tuberculosis
  • Intussusception
  • Kidney abnormality
  • Ovarian tumour
  • Tumour in intra-abdominal testicle
Suprapubic
  • Distended bladder (firm mass can extend up to the umbilicus in extreme cases)
  • Neuroblastoma (in children and infants)
  • Uteropelvic junction obstruction
Left iliac fossa
  • Diverticulitis (abscess)
  • Hernia
  • Kidney abnormality
  • Ovarian tumour
  • Colorectal cancer
  • Tumour in intra-abdominal testicle
 Pelvis
(should not be able to palpate below mass)
  • Ovarian cyst - smooth, round, rubbery mass
  • Ovarian tumour
  • Pregnancy
  • Uterine fibroids (round, lumpy mass) or malignancy
 

Investigations will depend on the site and likely clinical diagnosis The following may be helpful:

  • Early ultrasound or CT scan.
  • Hollow organs may require the use of a contrast medium (eg, barium enema, gastrointestinal series, intravenous pyelogram).
  • FBC with film, ESR, U&Es.
  • LFTs.
  • CXR and abdominal X-ray.
  • Ultrasound or CT-guided fine-needle biopsy.
  • Mantoux test.
  • Paracentesis with fluid examination if ascites is present.
  • Laparoscopy or laparotomy may ultimately be necessary to achieve a diagnosis.

Further reading and references

  1. ; NICE Clinical Guideline (2005)

  2. ; whonamedit.com

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