ABDOMINAL MASS

Prof. Dr. Turgut IPEK

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

PALPABLE ABDOMINAL MASS Normal In abdominal wall At umbilicus Intra-abdominal

Normal Bladder Right (left) kidney Aorta Intestine with gas and liquid Faeces Pregnant uterus Neonatal liver

Normal abdominal masses The normal bladder becomes palpable in everyone if it is sufficiently distended by retained urine. The lower pole of the right kidney is sometimes, of the left kidney rarely, palpable. In a thin person with left kidney rarely, palpable. In a thin person with ill-developed musculature, the abdominal aorta is palpable in the epigastrium.

Status of the liver Every abdominal surgeon knows from the experience of laparotomy that, in the patient lying supine, the liver projects well below the costal margin in the vast majority of patients, so that this projection in itself is unlikely to be the cause 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, right upper quadrant, left upper quadrant, mid-line epigastric, right lower puadrant, left lower quadrant and suprapubic.

Abdominal wall or intra-abdominal? When the patient contracts his abdominal muscles, an intra-abdominal swelling becomes less prominent or disappears while a mass in the abdominal wall becomes firmer and more obvious.

Movement with respiratory excursions The part of the organ connecting the mass with the under-surface of the diaphragm must be rigid enough to transmit the thrust, and that the mass will move with ventilation if it is in indirect contact with the diaphragm via another interposed organ which is rigid enough to transmit the thrust.

PALPABLE ABDOMINAL MASS Normal In abdominal wall At umbilicus Intra-abdominal

In abdominal wall (more prominent on tensing abdominal wall muscles) At hernial orifice Cough impulse present

No cough impulse. Lump tense and tender Not at hernial orifice

Hernia:inguinal femoral mid-line incisional Spigelian lumbar (umbilical) Strangulated hernia

Various skin and subcutaneous lesions

Lumps of the anterior abdominal wall Lumps superficial to the muscles, i.e.in the skin and subcutaneous tissues, may be of the same nature as lesions occurring in the skin and subcutaneous 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-that is,places where the musculature of the abdominal wall is normally defective and the gap is closed only by fibrous tissue. The lateral border of the rectus musucle is also a point of potential weakness, especially in the lowver third of the abdomen where it has no posterior sheath, and a hernia coming through between the rectus and the lateral abdominal muscles is called a Spigelian hernia, a rare entity.

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

PALPABLE ABDOMINAL MASS Normal In abdominal wall At umbilicus Intra-abdominal

At umbilicus (NB hernias) Granuloma Foreign body Tumours, primary or secondary

Umbilical nodules Apart from hernias, umbilical nodules include a granuloma in the neonate resulting from low–grade infection of the stump of the umbilical cord, a primary tumour, 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 quadrant Moves with ventilation

Liver (inferior edge) Kidney (inferior rounded surface, palpable via lion) Gall bladder (inferior rounded surface, not palpable via lion) Does not move with ventilation Colon, duodenum, head of pancreas, small intestine and mesentary, lymp nodes,

Rihgt upper quadrant If the mass moves with ventilation, the likely possibilities are liver, kidney, and gall bladder. A mass in the region of the pylorus or the porta hepatis- 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 the under – surface of the liver to move.

Masses in the right upper quadrant that do not move with respiration may arise in the hepatic flexure and neighbouring segments of the large bowel, the duodenum or head of pancreas, the small bowel and its mesentery, or in structures such as lymph nodes on the posterior abdominal wall.

Liver A palpable solitary mass in the liver is either basically inflammatory, the inflammatory type of lesion includes pyogenic abscess and amoebic abscess, while the well patient group includes primary neoplasm (hepatoma), secondary neoplasm, a congenital cyst or a hydatid cyst.

Gall bladder If the patient is not jaundiced, the cystic duct is obstructed by a stone and cholecystectomy is indicated. If the patient shows the features of obstructive jaundice, 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 head of the pancreas.

Kidney Bilateral abnormalities suggest congenital anomalies such as polycystic kidneys or horseshoe kidney, or else obstruction of the lower urinary tract (bladder and below) where a single locus of obstruction produces backpressure in both upper renal tracts. If the abnormality is confined to one side, any obstructive 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 quadrant Moves with ventilation

Liver (inferior edge) Kidney (inferior rounded surface) Spleen (notch) Does not move with ventilation Colon, small intestine and mesentery, tail of pancreas, lymph nodes

Left upper quadrant In this quadrant a mass that moves with respiration arises from liver, kidney or spleen, while one that does not probably arises from colon, small bowel, mesentery, or lymph nodes, 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

Spleen Liver Stomach (pulsatile) aneurysm

Mid-line epigastric Masses in the mid-line of the epigastrium that move with respiration are either spleen, liver or, occasionally, a mass in the pyloric region of the stomach, and all these have received consideration. The dividing line between a normally palpable aorta and an aneurysm is usually set at a width of 5 cm, but the clinical 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

Left lower quadrant

Appendix Carcinoma of caecum İleocaecal tuberculosis Crohn’s disease Carcinoma of colon Diverticula

Appendix mass is by far the best contraindication to appendectomy; a mass palpable in the right lower quadrant of the abdomen. The conclusion that the mass is a zone of omentum and coils of small intestine wrapped around an inflamed appendix isnatural, and probably correct, but occasionally the diagnosis turns out to be some quite different condition such as carcinoma of the caecum or ileocaecal tuberculosis.

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

Not arising from pelvis

Dull, domed, pressure produces desire to urinate Bladder Moves with uterus=uterine fibroid(or neoplasm of uterus Moves separately from uterus=origin from ovaries or tubes Rarely, prostate or other

Suprapubic One situation relatively easy to assess is that the mass arises from the pubic bone. If the lump is not attached to bone, the next question to ask is, can one get below the swelling or does it arise from the pelvis? Masses emerging from the pelvis are likely to be the urinary bladder, an ovarian cyst, a uterine fibroid or, much less commonly, an enlargement of other pelvic structures such as the prostate or rectum.

An ovarian cyst may grow to such a large size, and be so soft in consistency, that its physical signs can be confused with the fluid thrill and shifting dullness of ascites. Ultrasound is also valuable here.

The difficult case Essentially this section comprises masses in the upper or mid-abdomen that do not move on respiration, and masses in the suprapubic region that do not arise from the pelvis. First, if the mass is mobile it is likely to arise from structures which normally possess a mesentery; i.e. the gastrointestinal tract, excluding the duodenum, the ascending and descending colon, and the hepatic and splenic flexures of the colon. If the mass is fixed, the possibilities are that it was originally mobile but has become secondarily attached by inflammation or tumour growth, or that it arises in retroperitoneal parts of the gastrointestinal tract, including the pancreas, or other structures fixed to the posterior abdominal wall such as lymph nodes.

Secondly, ultrasonography is the investigation statistically most likely to give diagnostic information if the nature of the swelling cannot be deduced from physical examination. Thirdly, it is difficult to get a view of the whole of both kidneys during the laparotomy, and therefore an exploratory laparotomy should always be preceded by an ultrasound examination and if necessary an intravenous pyelogram to exonerate the kidneys. Fourthly, ultrasonography and CT-scanning of such organs as the pancreas are very helpful, but angiograms of the major abdominal visceral arteries such as the hepatic, coeliac, and superior and inferior mesenteric may yield valuable clues in expert hands.

Finally, preliminary investigations should not be prolonged indefinitely; an undiagnosed intraabdominal swelling must be subjected to diagnostic laparotomy at some time, and preferably while it is still amenable to treatment!