ABDOMINAL MASS.pptx

General surgery

1. ABDOMINAL MASS BY Dr. G . Sireesha DIPLOMA FAMILY MEDICINE

2. INTRODUCTION DEFINATION: An abdominal mass is any localised enlargement or swelling or abnormal growth in the abdomen. Depending on its location, abdominal mass may be caused by an 1.enlarged liver ( hepatomegaly ) 2.spleen ( spleenomegaly ), 3. protruding kidney , 4. a pancreatic mass, 5.retroperitoeal mass ( a mass in the posterior of the peritoneum).

3. 6.Various tumours such as those caused by abdominal carcinomatosis and omental metastasis. The treatments depend on the cause , and may range from watchful waiting to radical surgery .

4. ANATOMY OF ABDOMINAL WALL

5. Anatomy of abdomen There are nine layers to the abdominal wall 1.skin 2.subcutaneous tissue 3.superficial fascia 4.external oblique muscle 5. internal oblique muscle 6.transverse abdominal muscle 7.transversalis fascia 8.preperitonial adipose and areolar tissue 9.peritoneum

6. Continued…. The skin is the most superficial layer of the anterior abdominal wall The superficial fascia is located just below the skin and consists of connective tissue.The AAW ,superior to the umbilicus it is similar and continuous to the superficial fascia of the body and is made up mostly one layer . Inferior to the umbilicus it is divided in to two layers 1, superficial campers fascia which is thicker fatty layer that can have a variable degree of thickness.

7. Deep scarpa’s fascia, which is a thinner and denser membranous layer overlying the muscle layer of the abdominal wall. It is firmly attached to linea alba and pubic symphysis and fuses with the fascia lata (deep fascia of the thigh ) right below the inguinal ligament.

8. Divisions of the abdomen 9 REGIONS AND 4 QUANDRANTS

9. DIVISION S OF THE ABDOMEN Abdomen is divided in to nine regions by two horizontal lines and two vertical lines Upper horizontal line or transpyloric line is midway between the xiphisternum and umbilicus. Lower horizontal line is transtubercular line at the level of the two tubercles on the iliac crest 5 cm s behind the anterior superior iliac spine

10. The two vertical lines are drawn on either side through midpoint between anterior superior iliac spine and symphysis pubis . 1.right hypochondrium 6.left lumbar region 2.epigastrium 7.right iliac fossa 3.left hypochondrium 8.hypogastrium 4.right lumbar region 9.left iliac fossa. 5.umbilical region

11. Abdominal regions – with specific organs

12. Cont..

13. Symptoms of the abdominal mass Many abdominal symptoms are discovered incidentally during routine physical examination . An abdominal mass may accompany other symptoms , which will vary depending on the underlying disease. 1. abdominal pain a .dull aching pain b. colicky pain c. referred pain 2.sensation of fullness/early satiety. Eg . ca.stomach , pyloric obstruction. 3.vomitings.eg bilious vomiting in intestinal obstruction ileocaecal tb ,strictures

14. Cont …. Non bilious vomiting in pyloric stenosis 4.haematemesis eg ca stomach ,portal hypertension . 5.bleeding per rectum eg fresh blood in ca rectum , malaena seen in ca stomach and portal hypertension . 6.Loss of weight and loss of appetite eg ca stomach-early feature is loss of appetite, ca body of pancreas-weight loss is early feature. Significant weight loss means loss of 10 kgs and more in last 6 months.

15. Cont.. 7.Altered bowel habits eg blood and mucus , fresh blood seen in ca rectum , altered constipation and diarrohea – ca colon 8.Jaundice- Eg.progressive J.- ca head of pancreas, mild recurrent .J- in haemolytic anaemia,intermittent jaundice seen in common bile duct obstruction. 9.Haematuria-RCC 10.Fever eg high grade – with chills and rigors in common bile duct stones,low grade in hepatoma ,RCC, lymphoma .

16. E xamination to abdominal mass Contents Inspection Palpation Percussion A uscultation

17. INSPECTION 1.POSITION Position should be described according to the nine anatomical regions of the abdomen . 2.SKIN OVERLYING THE SWELLING Tense , red, shiny pigmented and engorged veins. 3.MOVEMENTS WITH THE RESPIRATION Swelling originating from liver, gallbladder,spleen and stomach move freely with respiration. Swelling arising from kidneys and suprarenal gland move very little with respiration

18. cont VISIBLE PERESTALSIS Conditions giving rise to visible perestalsis are intestinal obstruction and carcinoma of pylorus of stomach and transverse colon . Incase of obstruction In pyloric end of stomach : from left to right In small intestine: ladder pattern peristalsis IN large intestine: from right to left in form of inverted u. In case of carcinoma : ca stomach left to right , in ca transverse colon – from right to left.

19. Cont.. 4.SWELLING IN HERNIAL SITES If the swelling is situated over one of the hernial sites,the patient asked to cough, if cough impuse is present it is a case of hernia .lump on hernial site is not always a hernia 5.THE SCROTUM In case of abdominal lump, the scrotum is always examined . In case of malignancy of testes, the pre and paraaortic lymph nodes are involved and metastasized.

20. Cont.. LEFT SUPRACLAVICULAR REGION Left supraclavicular lymph node s are often secondarily involved and enlarged in case of malignancy of breast, stomach , colon , pancreas and testes. This os known as TROISIERS sign

21. Palpation LOCAL TEMPERATURE Local rise of temperature indicates inflammatomy swelling TENDERNESS Pain on pressure indicates inflammatory swelling . POSITION Position indicates the origin of the swelling SIZE,SHAPE ,SURFACE it indicates the underlying pathology

22. cont MARGINS Margins defined by getting all round the swelling Well defined margin indicates neoplasm Ill defined margin indicates inflammatory of traumatic swelling Defining the margins may be difficult if the swelling is present under coastal margins or pelvis.

23. Cont .. CONSISTENCY Define consistency like soft, cystic, firm, hard and stony hard . Same consistency through out the swelling or different consistencies at different parts of the swelling Cystic selling will show positive fluctuation and fluid thrill. If cystic swelling becomes tense then it may be difficult to elicit the fluid thrill . Pitting on pressure can see in parietal abcess and colon loaded with faecus .

24. MOVEMENT MOVEMENT WITH RESPIRATION Swelling associated with the liver, gallbladder,stomach and spleen move freely with respiration.this movement is up and down . one hand is placed on the lower border of the swelling and patient is asked to take deep breath, hand will move downwards with downward displacement of the swelling during inspiration .

25. Is the swelling movable in all directions? the swelling is held and tried to move in vertical and horizontal direction a mesenteric cyst moves only at right angle to the line of attachment of cyst . Is swelling ballotable ? one hand behind the loin and other hand infront of abdomen and swelling is tried to move between two hands example renal swelling .

26. IS SWELLING PARIETAL OR INTRAABDOMINAL? for differentiating this following methods should be applied a. Leg raising test ( carnett ‘s test ) b. Shoulder raising test c. Blow out air with mouth and nose shut . in all the tests , abdominal muscles are taut and if the swelling is parietal , it will become prominent , while it will disappear if it is an intra abdominal swelling .

27. Is the swelling pulsatile If it is pulsatile then differentiate between expansile pulsation and transmitted pulsation METHOD 1 index finger of each hand is put on the swelling . Two fingers will get diverted in case of expansile pulsation whereas fingers will not be diverted in transmitted pulsation . Method 2 the patient is placed in knee elbow position . Swelling infront of abdominal aorta will get seperated from the aorta and will become non pulsatile whereas aortic aneurysm will continue to pulsate.

28. Percussion Swelling arising from the solid organ will be dull on percussion if coils of intestine overlie the swelling then percussion note will be resonant . that is why swelling arising from the liver and spleen are dull whereas renal swelling are resonant . shifting dullness and fluid thrill should be looked for in case of fluid is suspected in peritoneal cavity the dullness of ascitis shifts with the change in position of the patient whereas the dullness of ovarian cyst does not shift with change in position .

29. Auscultation Peristaltic movement will be heard in hernia containing coils of intestine aortic pulsation can be heard in aortic aneurysm .

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