Lump abdomen

approach to a patient presenting with lump abdomen. a guide for medical students.

1. Approach to a patient with lump in abdomen Dr.Ankita Singh Department Of Surgical Disciplines AIIMS Delhi

2. Objectives Adopt sequential approach to a patient complaining about abdominal lump by Extracting relevant history Thorough clinical examination Clue to right diagnosis by conducting investigations guided by above history & examination Offering adequate treatment

3. history Demography: age gender occupation address socio economic status

4. History… Presenting complaints: abdominal lump: appearance, duration, site, approx size, progression/regression, any association with meals/posture/straining/trauma/*pain, disappears spontaneously pain: site, onset, duration, character, radiation/migration/ reffered , any relieving / aggrevating factors

5. History … other associated complaints- nausea/vomiting: character, amount, frequency, content ( hemetemesis ), relieving/ aggrevating factors, altered bowel habit: diarrhea, constipation, obstipation, flatulent dyspepsia etc melaena / hematochezia jaundice: onset, duration,progression etc.

6. History… associated fever episodes appetite weight loss any other relevant history

7. History… Past & personal history: comorbidity/ treatments- medical or surgical Sleep-wake cycle/ eating habits/ appetite/ bladder & bowel habits/ substance abuse Family/ menstrual & obstetric history: some diseases run in family (peptic ulcers/ crohn’s /ulcerative colitis/diverticulitis/ some CA

8. Physical examination Prerequisites: Consent,environment,chaperon General survey: built, nutrition, mentation vitals signs-pallor, icterus, cyanosis, pedal edema, lymphadenopathy, clubbing. Systemic examination: CNS/Respiratory/Cardiovascular examination

9. Physical examination Abdominal examination: Inspection: C ontour (normal/scaphoid/obese/distension), symmetric/asymmetric Skin- scars, pigmentation, signs of inflammation, wounds/ulcer, engorged veins etc Umbilicus- position Visible abnormal protuberance/lump Movement-with respiration/peristalsis/pulsations Hernial orifices

10. Right hypochondrium Epigastrium Left hypochondrium Right lumbar Left lumbar umbilical Right iliac fossa left iliac fossa Hypogastrium Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant

11. Physical examination Palpation: Soft/tense/distention Temperature tenderness Palpable organomegaly & its description Palpable lump : site, tenderness, size, surface, shape, consistency, margins, movement(respiration/all directions/ ballotable ), pulsatile(transmitted/ expansile ), * intraperitonial vs parietal wall vs retroperitonial . Hernial sites

12. Physical Examination… * The abdominal muscles made taut by asking patient ( i) to raise his shoulders from the bed with the arms folded over the chest — the 'rising-test' or ( ii) to raise both the extended legs from the bed — the 'leg lifting test’( Carnett's test) or ( iii) to try to blow out with his nose and mouth shut.

13. Physical examination If the swelling is parietal the swelling will be more prominent when the abdominal muscles are made taut and will be freely movable over the taut muscle. If the swelling is parietal but fixed to the abdominal muscle the swelling will not be movable when the muscles are made taut Another differentiating point is that if the swelling moves vertically with respiration it is obviously an intra-abdominal swelling.

14. Physical examination Percussion: Technique for lump Technique for evaluation of ascites Span of organomegaly *solid lump-dull(superficial),resonant(coils of bowel overlying) # Band of colonic resonance ~ Hydatid thrill

15. Auscultation: 1.Bowel sounds 2.Abnormal sounds (bruit, hums)

16. Physical examination… Scrotal examination Left supraclavicular lymph nodes examination Rectal & vaginal examination

17. I nvestigations To confirm diagnosis, based on site: USG abdomen- origin of lump, nature, invovement of adjacent structures, other findings Organ specific: Stomach, duodenum, Hepatobiliary , spleen, pancreas, small bowel vs large bowel, urinary organs, adenexa etc. Supporting blood investigations and imaging

18. Differential diagnosis of abdominal lumps

19. Right hypochondrium

20. Lump in Right hypochondrium PARIETAL SWELLINGS: skin & subcutaneous tissue-sebaceous cyst, lipoma , fibroma, neurofibroma , angioma , etc . cold abscess INTRA ABDOMINAL: 1. liver- hepatomegaly(fatty liver, infections, malignancy), isolated palpable liver lesion( hydatid )

21. Lump in Right hypochondrium (a) congenital riedel’s lobe (b) amoebic hepatitis & abscess (c) suppurative pylephlebitis (d) suppurative cholangitis (e) gumma of liver (f) hydatid cyst (g) liver carcinoma- primary vs secondary (h) cirrhosis

22. Lump in Right hypochondrium 2. Gall bladder: benign- smooth globular lump, upper margin not defined, movement with respiration +. Mucocele Empyema with stone impaction neck Porceliene gall bladder Carcinoma gall bladder

23. Lump in Right hypochondrium 3. Subdiaphragmatic abscess 4. Pylorus stomach & duodenum: Carcinoma Subacute perforation of peptic ulcer 5. Hepatic flexure of colon: Intussusseption Hypertrophic tuberculosis- ileo-caecal Colonic ca

24. Lump in Right hypochondrium 6. kidney: bean shaped firm lump, slight movement with respiration, ballotable , bimanual palpable Hydropehrosis / pyonephrosis Renal cell carcinoma Lymphoma 7. suprarenal/ adrenal: (a) adrenal hyperplasia

25. Lump in Right hypochondrium (b) Pheochromocytoma (c) Benign ganglioneuroma (d) Malignant neuroblastoma

26. Epigastrium Right upper quadrant Left upper quadrant

27. Lump in epigastrium PARIETAL LUMP: Skin & subcutaneous tissue lumps Cold/liver/ subphrenic / perigastric abscess Epigastric hernia b. INTRA ABDOMINAL LUMP: 1.Liver & subphrenic space: discussed previously 2.Stomach & duodenum: (a) Congenital pyloric stenosis

28. Lump in epigastrium (b) Subacute perforation of peptic ulcer (c) Carcinoma stomach 3. Transverse colon: Intussusception Diverticulitis Hyperplastic TB Neoplasm

29. Lump in epigastrium 4. omentum : tuberculosis, pancreatitis 5. pancreas: pseudocyst , tumour 6. Abdominal aorta: aneurysm 7. Lymph nodes: tabes mesentrica , lymphosarcoma , secondary 8. Retroperitonium : sarcoma, teratoma

30. Left hypochondrium Left upper quadrant

31. Lump in left hypochondrium PARIETAL LUMPS:as discussed previously INTRA ABDOMINAL LUMPS: spleen: palpation and characteristics infections- malaria, kala azar , schistosomiasis et Hemolytic anemias - congenital & acquired ITP Porphyria Felty’s syndrome Leukemia Tumours & cysts

32. Right lumbar Left lumbar Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant

33. Lump in left & right lumbar region PARIETAL SWELLINGS: as previously discussed Lumbar cold abscess ( pott’s disease) Lumbar hernia INTRA ABDOMINAL LUMP: Ascending & descending colon b/l kidney & adrenals Extension of swellings of liver, GB, spleen

34. umbilical Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant

35. Lump in umbilical region PARIETAL LUMP: previously discussed umbilicus: hernia (congenital, aquired , incisional), caput medusae , sister joseph mary nodule Rectus sheath: hematoma, abscess, desmoid tumour INTRA ABDOMINAL LUMP: 1.stomach & duodenum 2.transverse colon 3. omentum : as discused

36. Lump in umbilical region 4. small bowel & mesentry : TB, tumour -adenoma, submucous lipoma , leiomyoma, sarcoma, mesentric cyst 5. Retroperitonial tissue: cyst, lymphoma, sarcoma 6. LN , pancreas, aorta: as disscused

37. Right iliac fossa Right lower quadrant

38. Lump in Right iliac fossa PARIETAL LUMP: Appendicular abscess may rupture into parietal INTRA ABDOMINAL: appendix: abscess, appendicular mass Ileo caecal region- hyperplastic TB, amoebic typhilitis , crohn’s (inflammatory stage), caecal cancer, actinomycosis caecum, round worm inpaction .

39. Lump in Right iliac fossa 3, lymph nodes, retroperitonium : as discussed 4. Iliopsoas sheath: abscess (TB & pyogenic) 5.Iliac hematoma/abscess 6. Iliac bone swelling 7. Unascended kidney/ dropped or moveable kidney 8. Gall bladder: hydrops wit hepatomegaly 9. Uterus & its appendages: tubo ovarian mass, pyosalpinx , cyst, abscess of broad ligament, fibroid, ovarian cyst

40. Lump in Right iliac fossa 10. Urinary bladder: diverticulum 11. retained/ undescended testis 12. Inguinal: hernia, lymph node, abscess 13. Pelvic abscess

41. Hypogastrium Right lower quadrant Left lower quadrant

42. Lump in hypogastrium *Urinary bladder must be emptied prior PARIETAL LUMP: urachal cyst, rectal hematoma /abscess INTRA ABDOMINAL LUMP: Urinary bladder: urinary retension , bladder mass Uterus & adenexa : gravid, large fibroid, tubo ovarian mass, ruptured tubal ectopic, cysts, tumours

43. left iliac fossa Left lower quadrant

44. Lump in left iliac fossa PARIETAL LUMP: iliac abscess(pyogenic/ TB) INTRA ABDOMINAL LUMP: same as RIF except ileo caecal , appendix. 1. Sigmoid & descending colon: diverticulitis, carcinoma.