Right Hypochondrial Mass.BS Surgery.pptx

Surgery

1. Right Hypochondrial Mass

2. PARIETAL SWELLINGS: Skin and s/c tissue : sebaceous cyst, lipoma, fibroma, neurofibroma( pain +pigmentation), angioma etc - secondary deposits: malignant melanoma, bronchogenic carcinoma,hepatoma Cold abscess (caries of rib or spine) Soft,cystic and fluctuating swelling No signs of inflammation Irregularity in the affected rib or spine xray Non Hodgkins lymphoma- T cell type

3. I NTRA ABDOMINAL SWELLINGS Liver, GB, subphrenic space, pylorus and duodenum, hepatic flexure of colon, rt kidney, rt suprarenal gland LIVER It usually moves with respiration. Upper border is not felt. It is dull on percussion (This dullness continues over liver dullness above). Fingers can not be insinuated under right costal margin Liver swelling- Edge:Sharp /round Surface:Smooth /Irregular

4. 1: Soft, smooth, nontender liver: Hydrohepatosis .: obstruction of CBD - dilatation of intrahepatic biliary radicles. CCF Hydatid cyst of the liver: Here mass is well-localised , typical hydatid thrill. # Three finger test : Three fingers are placed over the mass widely. When central finger is tapped fluid movement is elicited in lateral two fingers. 2. Soft, smooth, tender liver: Amoebic liver abscess: liver often gets adherent to the anterior abdominal wall and will not move with respiration. - Intercostal tenderness, right-sided pleural effusion are common. 3 . Hard, multinodular liver: Multiple secondaries in liver: umbilication - central necrosis. Macronodular cirrhotic liver.

5. 4. Hard, smooth liver: Hepatoma (HCC): large, single, hard nodule is palpable in the liver. - there can be multiple nodules when it is multicentric. - Rapidly growing tumour can be soft also. - tender due to tumour necrosis or stretching of the liver capsule. - Vascular bruit may be heard over the liver during auscultation. - It mimics amoebic liver abscess in every respect. Solitary secondary in liver. 5. Lymphoma - Liver is palpable, one or two finger-breadths, firm or hard, smooth or irregular, nontender. - Splenomegaly and lymphadenopathy will help in the diagnosis. 6. Congenital Riedel's lobe: - It is a tongue-shaped projection from the inferior border of liver along ant.axillary line. It is on the right side, can be mistaken for gall- bladder.

6. GALL BLADDER It is smooth and soft (except in carcinoma gallbladder). It is mobile horizontally (side-to-side). It moves with respiration. It is dull on percussion Soft, nontender gallbladder. Mucocele of the gallbladder. Enlarged gallbladder in obstructive jaundice due to carcinoma head of the pancreas or periampullary carcinoma or growth in the CBD .2. Hard gallbladder: Carcinoma gallbladder. 3. Tender gallbladder-empyema GB

7. SUBPHRENIC ABSCESS. - Accumulation of pus under the diaphragm. - Majority follow intraperitoneal conditions e.g. perforated peptic ulcer (commonest), following abdominal trauma, following operations on biliary tract, following operation on the stomach or colon and acute appendicitis. - complain of anorexia and nausea. - A rise of temperature = high rise of temperature with rigor, sweating and rapid pulse, or there may be slight rise of temperature but the patient always looks abnormally ill. - Rigor - concomitant pylephlebitis or a liver abscess. - *pulse rate which always becomes abnormally fast irrespective of the temperature. Tachypnoea is also often present. - X-ray screening will show sluggish movement of the diaphragm. The diaphragm becomes raised and gas may be found beneath

8. PYLORUS OF THE STOMACH AND DUODENUM .- Carcinoma - to obstructive symptoms. - . Barium meal X-ray will show 'filling-defect' which is very diagnostic. b) Subacute perforation of peptic ulcer- rare - localized tender mass . - The patient gives history suggestive of peptic ulcer and sudden excruciating pain before formation of the mass. - It may lead to a subphrenic abscess. HEPATIC FLEXURE OF THE COLON: Intussusception Hypertrophic tuberculosis- usually starts in the ileo- caecal region. Carcinoma of this part of the colon - a lump only or with anaemia,anorexia and occult blood in the stool. - The lump is irregular and hard with slight or no movement. Barium enema - constant filling defect

9. KIDNEY. It is a reniform swelling; moves very slightly with respiration as it comes down a little at the height of inspiration; It is ballottable A sickening sensation is often felt during manipulation A hand can be easily insinuated between the upper pole of swelling and the costal margin Percussion will reveal resonant note in front of a kidney swelling as coils of intestine and colon will always be in front of the kidney Eg : carcinoma kidney, hydronephrotic kidney

10. SUPRARENAL TUMOURS. - cortex - may be bilateral hyperplasia, a benign adenoma or a malignant carcinoma. - medulla - phaeochromocytoma, a benign ganglioneuroma , malignant neuroblastoma may appear. Hyperplasia (rare) In the lesions of the cortex, 1-excess of aldosterone causes aldosteronism, 2- excess cortisol causes Cushing's syndrome, 3- excess of androgen causes andrenogenital syndrome 4- excess of oestrogen causes feminisation in the male. In medullary tumours - depend on the relative amounts of adrenaline and noradrenaline which are produced .

11. D/d of Lump in Right Hypochondriun

12. E XAMINATION OF RIGHT HYPOCHONDRIAL MASS INSPECTION Condition of the skin over the swelling : Tense/Red/Shining /Pigmented Position ,Size and Shape Movement with respiration : Liver,GB,stomach,spleen Kidney,Suprarenal moves very little with respiration Visible peristalsis : Carcinoma at pylorus-Lt to Rt The hernial sites : Impulse on coughing

13. Local rise of temparature : Inflammatory swelling Tenderness: Pain on pressure Position ,Size,Shape ,Surface Margin: Well defined:-Neoplasm Ill-defined:-Inflammatory /traumatic swelling Consistency : Fluctuation,fluid thrill Pitting of skin- parietal abscess PALPATION

14. 6.Movement Does the swelling move with respiration or not? Place the hand over the lower border of the swelling ,patient asked to take deep breath in & out. During inspiration ,swelling moves downward During expiration ,goes back to normal position Is the swelling movable in all directions? Is the swelling ballotable

15. 7.Parietal or Intra abdominal Abdominal muscles made taut by asking patient to:- Raise both shoulders com bed with arms folded over chest RISING TEST Raise both extended legs from bed LEG LIFTING TEST/CARNETT’S TEST Try to blow out with mouth and nose shut Parietal swelling : More prominent , freely movable over taut muscle Intra abdominal : Disappears/becomes smaller, moves vertically with respiration

16. 8 .Palpation of Intra abdominal organs: STOMACH : h/s/o pyloric stenosis – Visible peristalsis , Succussion splash LIVER : RIF –fingers pointing towards axilla Palpable liver l/f :- i) Extent of enlargement below costal margin ii)Character of edge –Sharp or Rounded iii)Surface- Smooth,Irregular or nodular with/ cout umbilication in the nodules. iv)Consistency- soft,firm or stony hard v) Prescence / absence of tenderness . Stony hard,irregular liver-s/o metastatic carcinomatous deposits in the liver .Irregular firm liver with small nodules- Liver cirrhosis . Soft,very tender liver-Amoebic hepatitis

17. GALL BLADDER: Distended-Tense globular swelling projecting downward & forwards below the liver Gall bladder becomes palpable:- a) Mucocele & Empyema b)Enlarged GB in a jaundiced pt is mainly d/t Ca HOP or Ca CBD KIDNEY: Bimanual palpation Charecteristics of a kidney swelling:- a)Lies in the loin or can be moved into the loin b) Reniform shape c)It’s a ballots me swelling d)Moves only slightly with respiration e)It’s dull posteriorly f)There’s always a band of colonic resonance anteriorly g)Fingers can be insinuated b/w the costal margin & swelling

18. PERCUSSION Swelling arising from liver,spleen -Dull on percussion Renal swelling- Resonant Upper limit of liver dullness raised in:Subphrenic abscess,Liver abscess,Hydatid cyst occuring at the superior aspect of liver Percuss loin just outside erector spinae : Renal swelling becomes dull ,Splenic swelling –resonance preserved Hydatid thrill : Placing 3 fingers over the swelling & percussing over middle finger & after thrill felt by other 2 fingers

19. MANAGEMENT Management includes investigations and treatment. The investigations may be classified as: Investigations for diagnosis. Investigations for staging. Investigations for surgical treatment. The most important investigations is imaging.

20. Investigations for diagnosis Ultrasound for imaging liver -It is a screening test -Can identify mass lesions -Can identify bile duct dilatation - Useful for guiding biopsy. - Used for evaluation of portal vein Triple phase, multislice spiral CT is the investigation of choice for liver mass .A mass lesion up to 1 cm size can be identified

21. Lipiodol-enhanced CT scan is the gold standard investigation for diagnosis of HCC MRI is useful for patients with iodine sensitivity, who cannot undergo a lipiodol enhanced CT. Imaging of the biliary tract (MRCP) possible. Indication for a needlebiopsy - Unresectable tumors -Diagnostic dilernma .

22. Investigations for staging CT abdomen with oral and IV contrast CT chest to rule out metastases to lung Bone scan to rule out metastases Laparoscopy. Investigations required for surgery Liver function test Viral markers.(INR)(PG) Tumor markers-AFP, CEA, CA19-9 PIVKA II (protein induced by vitamin K abnormality by antagonism)-it is positive in 80% HCC Lens culinaris agglutinin reactive AFP (isoform of alpha fetoprotein) Assessment of cardiac status Pulmonary status Renal status.

23. Surgical options available in HCC: Resection. Liver transplantation.