Right Hypochondrial Masses.pptx

right hypochondriac mass

1. Right Hypochondrial Masses Presenter: Dr. Mohammad Masoom Parwez Moderator: Dr. M P Singh

2. Regions of Abdomen

3. Depending on origin Parietal Intra-Abdominal Retroperitoneal

4. Parietal swellings Arising from the skin and subcutaneous tissues Sebaceous cyst Lipoma Fibroma Neurofibroma Angioma Cold abscess-- caries rib >> caries spine, soft, cystic & fluctuant swelling, no signs of inflammation. Irregularity of rib/deformity of spine ++ Parietal abscess (hepatic/subphrenic/ perigastric )

5. Intra abdominal swellings Liver (1) Reidels lobe – tongue shaped projection from lower border of right lobe. Can be mistaken for an enlarged gallbladder but it is more wide and flat and lacks the spherical outline Incidence: 3.3-31%, more frequently in women (1:3)

6. Intra abdominal swellings (2)Amoebic hepatitis/abscess – pain in RHC referred to right shoulder with fever , past h/o amoebic dysentery Swelling indicates formation of an abscess Patient pale and icteric. Liver is palpable and very tender Intercostal tenderness + , upper limit of liver dullness is raised Subcutaneous edema which pits on pressure Xray – diaphragm is abnormally raised and immobile Entamoeba in stool– diagnostic Aspiration of anchovy sauce pus is confirmatory

7. Intra abdominal swellings Hydatid cyst – When it occurs near the lower margin of the liver it gives rise to a palpable spherical and smooth swelling, with hydatid thrill and fluctuations. Diagnosis is made by the history of a ttack of urticaria, eosinophilia, complement fixation test and Casoni’s intradermal reaction. X-ray and ultrasound are helpful when the cyst occurs at the upper surface of the liver. If suppuration takes place the signs and symptoms of infection may dominate

8. Intra abdominal swellings Suppurative pylephlebitis – Infective thrombosis of portal vein usually a complication of intra abdominal sepsis like: diverticulitis, perforated appendicitis or peritonitis presents with fever, rigor + Liver palpable and tender t/t: long course broad spectrum antibiotics + anticoagulants Can cause bowel ischaemia --- bowel infarction

9. Intra abdominal swellings Hepatic Carcinoma – Primary carcinoma is rare( hepatoma or cholangioma ) Secondary carcinoma – more common. results from metastasis from carcinoma of the gastrointestinal tract via portal vein or from organs like breast through lymphatics Liver is enlarged, irregular with nodules of varying size and shape and becomes hard The nodules may show softening in the centre and may become umbilicated The patient may be jaundiced sooner or later and ascites may be associated with Primary focus should be searched

10. Hepatic carcinoma in 52yr old man with cirrhosis Late arterial phase- enhancing nodule Portal venous phase: washout appearance with capsule

11. Intra abdominal swellings Cirrhosis of the liver : I n this condition the liver is not always enlarged; on the contrary it may be shrunk In pre-cirrhotic stage the liver may be firm, irregular with small nodules which are never umbilicated (cf. carcinoma) Portal hypertension will be present with enlargement of the spleen Ascites may be associated with but jaundice is never present These cases often come to the surgical clinic with haematemesis from rupture of oesophageal varices

12. Intra abdominal swellings Melanotic CA of liver : secondary to similar growth on the palm, foot or eye. An enlarged liver with malignant melanoma anywhere in the body should clinch the diagnosis

13. Intra abdominal swellings Suppurative cholangitis – h/o cholelithiasis, stone impacted in the CBD. High rise of temperature with tender liver. Jaundice + Gumma of liver – very rare, resembles carcinoma, late presentation. Manifestation of 3 rd stage of syphilis. Presence of other syphilitic signs are confirmatory

14. Intra abdominal swellings Conditions where liver gets enlarged: 1. Soft, smooth, nontender liver: • Hydrohepatosis —It is due to obstruction of CBD causing dilatation of intrahepatic biliary radicles. • Congestive cardiac failure. • Hydatid cyst of the liver—Here mass is well localised in the liver with 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.

15. Intra abdominal swellings 2 . Soft, smooth, tender liver: • Amoebic liver abscess: Here liver often gets adherent to the anterior abdominal wall and will not move with respiration. Intercostal tenderness, right sided pleural effusion are common

16. Intra abdominal swellings Gallbladder — oval smooth swelling which is tense and cystic lower border of the liver and moves freely up and down with respiration along with liver The swelling may be tender depending on the amount of inflammation present It can be moved sideways a little It is not ballottable as a kidney swelling

17. Intra abdominal swellings Conditions where gallbladder is palpable: 1. 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

18. Subphrenic abscess causes of accumulation of pus under the diaphragm: perforated peptic ulcer (commonest), following abdominal trauma, following operations on biliary tract, following operation on the stomach or colon and acute appendicitis The patient looks very much anxious. They may complain of anorexia and nausea, associated with rise of temperature Rigor only occurs when there is concomitant pylephlebitis or a liver abscess Tachycardia, tachypnoea are present

19. Subphrenic abscess Pain usually becomes localised to the site of lesion. Right hypochondrium or epigastrium is the usual site of pain. Very occasionally it may be complained of in the lower part of thorax, right lumbar region or even referred to the right shoulder. Jaundice is not a sign of this condition but if present indicates obstruction of the common bile duct with a stone or suppurative pylephlebitis Tenderness just below the costal margin or xiphoid process or more precisely tenderness over the 11th intercostal space X-ray screening will show sluggish movement of the diaphragm. The diaphragm becomes raised and gas may be found beneath it. Aspiration of pus from the subdiaphragmatic space leaves no doubt about the diagnosis

20. Ca pylorus of stomach Carcinoma of this region usually gives rise to obstructive symptoms Barium meal X-ray will show 'filling-defect' which is very diagnostic

21. Subacute perforation of peptic ulcer forms a localized tender mass which is a rare condition The patient gives history suggestive of peptic ulcer and sudden excruciating pain before formation of the mass It may lead to a subphrenic abscess

22. Intraabdominal swelling Hepatic flexure of colon: Intussusception : abdominal distension, pain, passage of red currant jelly stools Hypertrophic TB : starts in the ileo- cecal junction and may move upto this region CA hepatic flexure : may present with a lump only or with anaemia , anorexia and occult blood in the stool. lump is irregular and hard with slight or no movement. Barium enema X-ray reveals constant filling defect which is very diagnostic

23. Colo-colic intussusception at hepatic flexure

24. Carcinoma hepatic flexure of colon

25. Intraabdominal swelling Kidney : features of a kidney swelling are: ( i ) It is a reniform swelling; (ii) It moves very slightly with respiration as it comes down a little at the height of inspiration; (iii) It is ballottable ; (iv) A sickening sensation is often felt during manipulation; (v) A hand can be easily insinuated between the upper pole of swelling and the costal margin; (vi) 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

26. Intraabdominal swelling Kidney: Wilms tumor Renal cell cancer Hydronephrosis Pyonephrosis Polycystic kidney Adrenal mass: B/L Hyperplasia Adenoma/carcinoma Medulla: phaeochromocytoma , ganglioneuroma, neuroblastoma

27. Retroperitoneal swellings Cyst : A cyst developing in the retroperitoneal tissue may attain very large dimensions. Pyelography may be required to differentiate cyst from a hydronephrosis. These cysts may be derived from remnants of the Wolfian ducts when the containing fluid will be clear or the cyst may be a teratoma when it is filled with sebaceous material

28. Retroperitoneal cyst

29. Lymphoma : mainly affects women and will also require pyelography for differential diagnosis Sarcoma : An indefinite abdominal pain or subacute intestinal obstruction from pressure on the colon may be the presenting symptom. On examination, a fixed smooth swelling may be discovered which will require pyelography to rule out the possibility of a renal swelling

30. 81yr old Asian male with abdominal pain Imaging demonstrated a large left retroperitoneal soft tissue mass

31. Thank you