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Differential Diagnosis of Abdominal Masses and Abdominal Hernias

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Differential Diagnosis of Abdominal Masses and Abdominal Hernias Differential diagnosis of abdominal masses and abdominal hernias Done By: Hanan Khushaim Reema AlRasheed Najla AlDraiweesh Reviewed by: Malak Al-Khathlan Abdulrahman Alkaff Color Index: -Surgery Recall -Browse’s / Davidson’s -Extra Correction File Email: [email protected] Introduction: In order to narrow your differentials, you must know the exact anatomical position of each organ: Layers of Anterior abdominal wall From external to internal : ❏ Skin ❏ Superficial fascia ( fatty layer is called Camper while membranous is called Scarpa ❏ Deep fascia ❏ Aponneuroses of muscle layers ❏ External oblique muscle ❏ Internal oblique muscle ❏ Transversus abdominis muscle ❏ Transversalis fascia ❏ Extrapertonieal fat ❏ Peritoneum Right upper quadrant masses Causes of hepatomegaly : -Infection -Congestion 1)Hepatic: -Bileduct obstruction (Hepatomegaly) -Cellular infiltration -Cellular proliferation -Space-occupying lesions Localized swellings: Generalised enlargement ● DDx: Smooth generalized ● Riedel’s lobe*. enlargement, without jaundice : ● Congestion from heart The physical signs of ● Secondary carcinoma. failure. an enlarged liver are ● Hydatid cyst. ● Cirrhosis. as follows: ● Liver abscess. ● Lymphoma. -It descends below ● Primary liver carcinoma. ● Hepatic vein obstruction the right costal Cholangiocarcinoma. (Budd–Chiari syndrome). margin. ● Benign liver adenoma. ● Amyloid disease. -You cannot feel its ● Kala-azar. upper limit. ● Gaucher’s disease. -It moves with respiration. -It is dull to Smooth generalized percussion up to the enlargement, with jaundice : level of the eighth rib ● Infective hepatitis. in the mid-axillary ● Biliary tract obstruction line. (gallstones, carcinoma of - It may have a sharp pancreas, atresia). or rounded edge with ● Cholangitis. a smooth or irregular ● Portal pyaemia. surface. ● Chronic active hepatitis. Knobbly generalized enlargement, without jaundice: ● Metastatic deposits. ● Cirrhosis. ● Polycystic disease. ● Primary liver carcinoma (hepatocellular and cholangiocarcinoma). Knobbly generalized enlargement, with jaundice : ● Metastatic deposits. ● Cirrhosis. 2) Gall bladder Causes of gallbladder The physical features enlargement: of an enlarged -Obstruction of the gallbladder are as cystic duct, usually by a follows: gallstone, and rarely by an ● It appears from intrinsic or extrinsic beneath the tip of the carcinoma – right ninth rib. No jaundice and the ● It is smooth and hemi ovoid. gallbladder often contains bile, mucus (a mucocele) ● It moves with or pus (an empyema) respiration. -Obstruction of the ● There is no space common bile duct, usually between the lump and by a stone or a carcinoma the edge of the liver. of the head of the ● It is dull to pancreas – the patient will percussion be jaundiced. *It is an extension of the right lobe of the liver below the costal margin, along the anterior axillary line. It is a normal anatomical variation.(note on previous page) Left upper quadrant masses: DDx Physical signs Infection -It appears from below the tip Bacterial :Typhoid of the left tenth rib and Splenomegaly Viral :Glandular fever. Epstein–Barr enlarges along the line of the rib virus. towards the umbilicus. Spirochaetal :Syphilis. ● Leptospirosis -It is firm, smooth and usually Protozoal : Malaria,Kala-azar spleen shaped; it often has a (leishmaniasis) ,Schistosomiasis. definite notch on its upper edge. - You cannot get above it. Cellular proliferation : -It moves with respiration. Myeloid and lymphatic leukaemia. ● -It is dull to percussion. Lymphomas. ● Pernicious anaemia. ● -it cannot be felt bimanually or Polycythaemia rubra vera. ● be balloted. Spherocytosis and other haemolytic anaemias, for example elliptocytosis, autoimmune haemolytic anaemia and thalassaemia. ● Thrombocytopenic purpura. ● Myelofibrosis. ● Sarcoidosis. Congestion : Portal hypertension (cirrhosis, portal vein thrombosis). , Hepatic vein obstruction. ● Congestive heart failure, Infarction and injury , Emboli from bacterial endocarditis. , Splenic artery or vein thrombosis caused by polycythaemia or sickle-cell disease. ● Haematoma. Cellular infiltration : Amyloidosis. ● Gaucher’s disease. Collagen diseases : Felty’s syndrome. ● Still’s disease. Space-occupying lesions : True solitary cysts. ● Polycystic disease. ● Hydatid cysts Kidney hydronephrosis; ● pyonephrosis; ● It is usually only possible to feel enlargement malignant disease: carcinoma of the lower pole, which is smooth the kidney and nephroblastoma; ● and hemi ovoid solitary cysts; ● polycystic . ● It moves with respiration. ● disease; ● perinephric abscess It is not dull to percussion because it is covered by the colon;. ● It can be felt bimanually and It can be balloted Epigastric masses Description Physical signs definition:a collection of The epigastrium contains a pancreatic juice and firm, sometimes tender, mass. inflammatory exudate, usually resonant to percussion Pancreatic pseudocysts associated with acute because it is covered by the pancreatitis, which forms on stomach. the surface of the pancreatic gland and may bulge forwards, ● It moves very slightly with filling the lesser sac. respiration -The patient is usually known to have had an attack of acute pancreatitis. -They may then develop epigastric fullness, pain, nausea and vomiting -The onset of indigestion or - They are difficult to feel epigastric pain, however because they are situated Carcinoma of the vague, in a patient over 40 high in the abdomen beneath stomach years of age should be the costal margin. treated very seriously -A palpable tumour is hard and irregular, disappearing - loss of appetite is a cardinal beneath the costal margin . symptom. The inevitable -It is rarely possible to feel consequence of a loss of its upper edge. appetite is loss of weight. The patient may lose 10–20kg in 1 ( Do not expect to feel a or 2 months. mass in a patient with carcinoma of the stomach) Umbilical region masses Description Physical signs Mesenteric cysts -They are cysts containing It forms a smooth, mobile, clear fluid that develop in the spherical swelling in the mesentery. centre of the abdomen. -They arise from the vestigial ● It moves freely at right remnants of reduplicated angles to the line of the root bowel and are usually found of the mesentery. by chance ● It is dull to percussion. -rarely cause recurrent ● Large cysts may be felt to colicky pain. fluctuate and have a fluid rarely, cause abdominal thrill. distension -It is difficult to discriminate between a very large cyst and tense ascites. Retroperitoneal tumors -Rare -abdominal distension; -The most common variety is -a smooth mass with an the liposarcoma indistinct edge -The patient complains of -soft to firm consistency; -resonance while they are distension, a vague abdominal covered with bowel, but when pain and sometimes anorexia they reach the anterior and weight loss. abdominal wall and push the bowel out to the flanks, they become dull to percussion . ● very little movement with respiration; ● possible transmission of aortic pulsation Hypogastric Masses DDx Physical Signs URINARY BLADDER Acute retention: the bladder is full and tender Arises out of the pelvis and so it has no Chronic retention: Painless lower edge o Not mobile and dull to History of prostatism percussiono Direct pressure often produces a desire to micturate PREGNANT UTERUS -The uterus enlarges to the xiphisternum by the 36th week of pregnancy, at this stage the fetus is palpable - A pregnant uterus is smooth, firm and dull FIBROIDS They cause irregular and heavy periods, disturbed Arises out of the pelvis and so the lower micturition, lower abdominal pain and backache. edge is not palpable Firm or hard, moves slightly in transverse direction and dull on percussion Right Iliac Fossa Masses DDx Physical Signs APPENDICULAR Central abdominal pain shifting to the right iliac fossa. Tender indistinct mass, dull to MASS Associated with nausea, vomiting and loss of appetite. percussion and fixed to the right iliac fossa posteriorly APPENDICULAR As for appendicitis with additional symptoms of an A tender mass which in its late stages ABSCESS abscess such as fever, rigors, sweating and increased may fluctuate and be associated with local pain edema and reddening of the overlying skin TUBERCULOSIS - inflamed ileocecal lymph nodes, parts of and the The mass is firm, distinct and hardo It terminal ileum and the cecum is not tender and does not resolve with - Vague chronic central pain for months observation - General ill health and weight loss - The pain eventually becomes intense and settles in the iliac fossa CROHN'S DISEASE Recurrent episodes of pain in the right iliac fossa, The elongated terminal ileum forms an malaise, loss of weight and episodes of diarrhea and elongated sausage-shaped melena mass which is rubbery and tender PSOAS ABSCESS General ill feeling for months, night sweats and weight - Soft, tender, dull and compressibleo loss There may be fullness in the lumbar region - The swelling extends below the groin and it may be possible to empty the swelling. OTHERS - Cecal carcinoma - Actinomycosis: rare infectious disease by actinomyces/complication of appendicitis. - Ruptured epigastric artery - Iliac lymphadenopathy - Iliac artery aneurysm - Kidney Transplant:The mass is situated beneath the transplant scar - Ovarian cyst/ tumor - Fibroids. Left Iliac Fossa Masses DDX Physical Signs DIVERTICULITIS -Recurrent lower abdominal pain and Tender indistinct mass, with signs -chronic constipation for years The acute episodes starts of general or local
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