ABDOMINAL MASS

Prof. Dr. Turgut IPEK

A Palpable abdominal mass must be presumed to be due to serious abdominaldisease unless the doctor is certain that themass is a normal abdominal viscus.

PALPABLE ABDOMINAL MASS

Normal

In abdominal wall

At umbilicus

Intra-abdominal

Normal

BladderRight (left) kidneyAortaIntestine with gas and liquidFaecesPregnant uterusNeonatal liver

Normal abdominal masses

The normal bladder becomes palpable in everyone if it is sufficiently distended byretained urine. The lower pole of the rightkidney is sometimes, of the left kidney rarely, palpable. In a thin person with left kidney rarely, palpable. In a thin person with ill-developedmusculature, the abdominal aorta is palpable in the epigastrium.

Status of the liver

Every abdominal surgeon knows from theexperience of laparotomy that, in the patientlying supine, the liver projects well below thecostal margin in the vast majority of patients, sothat this projection in itself is unlikely to be thecause of the palpability of the normal liver.

Site

Most palpable abdominal swellings can be classified according to their site into one of the following categories:hernial orifices including the umbilicus, rightupper quadrant, left upper quadrant, mid-lineepigastric, right lower puadrant, left lowerquadrant and suprapubic.

Abdominal wall or intra-abdominal?

When the patient contracts his abdominalmuscles, an intra-abdominal swelling becomesless prominent or disappears while a mass in the abdominal wall becomes firmer and moreobvious.

Movement with respiratory excursions

The part of the organ connecting the mass withthe under-surface of the diaphragm must be rigid enough to transmit the thrust, and that themass will move with ventilation if it is in indirectcontact with the diaphragm via anotherinterposed organ which is rigid enough totransmit the thrust.

PALPABLE ABDOMINAL MASS

Normal

In abdominal wall

At umbilicus

Intra-abdominal

In abdominal wall (more prominent on tensingabdominal wall muscles)

At hernial orificeCough impulse present Hernia:inguinal

femoralmid-lineincisionalSpigelianlumbar(umbilical)

No cough impulse.Lump tense and tender Strangulated hernia

Not at hernial orifice Various skin andsubcutaneous lesions

Lumps of the anterior abdominal wall

Lumps superficial to the muscles, i.e.in the skin and subcutaneous tissues, may be of the samenature as lesions occurring in the skin andsubcutaneous tissues elsewhere, i.e. lipoma, fibroma, etc.

Hernias

These occur when the scar of an abdominal incision is weak (incisional hernia), or at specific hernial orifices-thatis,places where the musculature of the abdominal wall is normally defective and the gap is closed only by fibroustissue.The lateral border of the rectus musucle is also a point of potential weakness, especially in the lowver third of theabdomen where it has no posterior sheath, and a herniacoming through between the rectus and the lateralabdominal muscles is called a Spigelian hernia, a rareentity.

The umbilicus is an obvious site of weakness, and twodifferent kinds of hernia occur. One is a persistence of the fetal prolongation of the peritoneum through theumbilical scar. This true umbilical hernia is common in infants and requires no treatment except reassurance of the mother, because it is a selflimiting condition thatalways undergoes spontaneous cure, usually by the ageof 2 years and certainly by 5.There is a much more severe form of this defect, exomphalos, in which the neonate’s whole abdominalcontents may lie outside the umbilicus.The second form of hernia at the umbilicus protrudesthrough a defect in the linea alba very close to, but not actually through, the umbilical scar. This is theparaumbilical hernia, common in the elderly obesesubject, and it requires formal operation for its cure.

PALPABLE ABDOMINAL MASS

Normal

In abdominal wall

At umbilicus

Intra-abdominal

At umbilicus

(NB hernias)

GranulomaForeign bodyTumours, primary or secondary

Umbilical nodules

Apart from hernias, umbilical nodulesinclude a granuloma in the neonateresulting from low–grade infection of thestump of the umbilical cord, a primarytumour, or secondary deposit from an intra-abdominal neoplasm.

Intra-abdominal masses

Right upper quadrant

Left upper quadrant

Mid-line epigastric

Right and left lower quadrants

Suprapubic

Right upper quadrantMoves with ventilation Liver (inferior edge)

Kidney (inferiorrounded surface,palpable via lion)Gall bladder(inferior roundedsurface, notpalpable via lion)

Does not move with ventilationColon, duodenum, head ofpancreas, small intestineand mesentary, lympnodes,

Rihgt upper quadrant

If the mass moves with ventilation, the likelypossibilities are liver, kidney, and gall bladder.A mass in the region of the pylorus or the portahepatis- for example, a carcinoma of the antrum or a mass of secondary carcinoma in the lymph nodes of the free edge of the lesser omentum – may also be sufficiently mobile and sufficiently in contact with theunder – surface of the liver to move.

Masses in the right upper quadrant that do not move with respiration may arise in thehepatic flexure and neighbouring segmentsof the large bowel, the duodenum or head of pancreas, the small bowel and itsmesentery, or in structures such as lymphnodes on the posterior abdominal wall.

Liver

A palpable solitary mass in the liver is eitherbasically inflammatory, the inflammatory typeof lesion includes pyogenic abscess andamoebic abscess, while the well patientgroup includes primary neoplasm(hepatoma), secondary neoplasm, a congenital cyst or a hydatid cyst.

Gall bladder

If the patient is not jaundiced, the cystic ductis obstructed by a stone and cholecystectomyis indicated.If the patient shows the features of obstructivejaundice, the likely cause of the obstruction is a carcinoma at the lower end of the bile duct, arising from the ampulla of Vater or the headof the pancreas.

Kidney

Bilateral abnormalities suggest congenitalanomalies such as polycystic kidneys orhorseshoe kidney, or else obstruction of thelower urinary tract (bladder and below) wherea single locus of obstruction produces back-pressure in both upper renal tracts. If theabnormality is confined to one side, anyobstructive lesion must be in the upper tract on that side and neoplasia becomes a possibility.

Intra-abdominal masses

Right upper quadrant

Left upper quadrant

Mid-line epigastric

Right and left lower quadrants

Suprapubic

Left upper quadrantMoves with ventilation Liver (inferior edge)

Kidney (inferior roundedsurface)Spleen (notch)

Does not move with ventilationColon, small intestine andmesentery, tail of pancreas, lymphnodes

Left upper quadrant

In this quadrant a mass that moves withrespiration arises from liver, kidney or spleen, while one that does not probably arises fromcolon, small bowel, mesentery, or lymphnodes, etc., of the posterior abdominal wall.

Intra-abdominal masses

Right upper quadrant

Left upper quadrant

Mid-line epigastric

Right and left lower quadrants

Suprapubic

Mid-line epigastric SpleenLiverStomach(pulsatile) aneurysm

Mid-line epigastric

Masses in the mid-line of the epigastrium that move withrespiration are either spleen, liver or, occasionally, a mass in the pyloric region of the stomach, and all thesehave received consideration.The dividing line between a normally palpable aorta andan aneurysm is usually set at a width of 5 cm, but theclinical decision can be difficult.

Intra-abdominal masses

Right upper quadrant

Left upper quadrant

Mid-line epigastric

Right and left lower quadrants

Suprapubic

Right lower quadrant AppendixCarcinoma of caecumİleocaecal tuberculosisCrohn’s disease

Left lower quadrant Carcinoma of colonDiverticula

Appendix mass is by far the bestcontraindication to appendectomy; a masspalpable in the right lower quadrant of theabdomen. The conclusion that the mass is a zone of omentum and coils of smallintestine wrapped around an inflamedappendix isnatural, and probably correct, but occasionally the diagnosis turns out tobe some quite different condition such as carcinoma of the caecum or ileocaecaltuberculosis.

Intra-abdominal masses

Right upper quadrant

Left upper quadrant

Mid-line epigastric

Right and left lower quadrants

Suprapubic

Suprapubic patient empties bladder

Arising from pelvis Dull, domed, pressureproduces desire to urinate

BladderMoves with uterus=uterinefibroid(or neoplasm of uterusMoves separately fromuterus=origin from ovaries ortubesRarely, prostate or other

Not arising from pelvis

Suprapubic

One situation relatively easy to assess is that themass arises from the pubic bone. If the lump is not attached to bone, the nextquestion to ask is, can one get below the swelling ordoes it arise from the pelvis? Masses emergingfrom the pelvis are likely to be the urinary bladder, an ovarian cyst, a uterine fibroid or, much lesscommonly, an enlargement of other pelvicstructures such as the prostate or rectum.

An ovarian cyst may grow to such a largesize, and be so soft in consistency, that itsphysical signs can be confused with the fluidthrill and shifting dullness of ascites. Ultrasound is also valuable here.

The difficult case

Essentially this section comprises masses in the upper ormid-abdomen that do not move on respiration, and massesin the suprapubic region that do not arise from the pelvis.First, if the mass is mobile it is likely to arise from structureswhich normally possess a mesentery; i.e. thegastrointestinal tract, excluding the duodenum, theascending and descending colon, and the hepatic andsplenic flexures of the colon. If the mass is fixed, thepossibilities are that it was originally mobile but has become secondarily attached by inflammation or tumourgrowth, or that it arises in retroperitoneal parts of thegastrointestinal tract, including the pancreas, or otherstructures fixed to the posterior abdominal wall such as lymph nodes.

Secondly, ultrasonography is the investigationstatistically most likely to give diagnostic information ifthe nature of the swelling cannot be deduced fromphysical examination. Thirdly, it is difficult to get a view of the whole of bothkidneys during the laparotomy, and therefore an exploratory laparotomy should always be preceded byan ultrasound examination and if necessary an intravenous pyelogram to exonerate the kidneys.Fourthly, ultrasonography and CT-scanning of suchorgans as the pancreas are very helpful, but angiograms of the major abdominal visceral arteriessuch as the hepatic, coeliac, and superior and inferiormesenteric may yield valuable clues in expert hands.

Finally, preliminary investigations should not be prolonged indefinitely; an undiagnosedintraabdominal swelling must be subjected todiagnostic laparotomy at some time, andpreferably while it is still amenable to treatment!