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The Differential Diagnosis of Abdominal Masses Prof

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The Differential Diagnosis of Abdominal Masses Prof 1 The differential diagnosis of Abdominal masses Prof. Dr. Mohamed I. Kassem ILOs for DD of abdominal masses: To know the different divisions and compartments of the abdomen. To be oriented with the anatomical locations of the different abdominal organs. Describe the differential diagnosis of parietal swellings. To know the differential diagnosis of the intra-abdominal swellings in each compartment with their management. 2 Abdominal Examination Exposure Nipple to knee, If embarrassing cover the lower abdomen with sheet. Inspection Abdominal contour ⚫ Normal --- flat from xiphoid to pubis, ⚫ umbilicus is at the center of the abdomen. Abdominal contour ⚫ Generalized distension ⚫ fat, ⚫ fetus, ⚫ feces, ⚫ flatus, ⚫ fluid, ⚫ full-sized tumors. ⚫ Localized bulge ⚫ Mass, organomegaly, hernia. Palpation Superficial • Gain patient’s confidence • Temperature • Parietal mass • Tenderness • Hyperthesia 3 Deep • Liver • Spleen • Kidney • Abdominal Aorta • Masses If masses are felt, note: • Site, • size, • Shape • Surface • skin overlying • special character: • consistency • tenderness • pulsations • mobility with respiration or with hand. 4 Parietal versus intra-abdominal mass Rising up test Imaging 1. PARIETAL SWELLINGS • Extends over the costal margin 5 • Moves anterior and posterior with respiration • More prominent on rising up test 2. INTRA-ABDOMINAL SWELLINGS • Disappear beneath costal margin • Moves up and down with respiration • Less prominent on rising up test PARIETAL SWELLINGS (common for different quadrants) Skin: • Sebaceous cyst • Papilloma • Melanoma, SCC Subcutaneous tissue: • Lipoma: SC, intermuscular • Neurofibroma • Hamangioma, lymphangioma Muscles: • Rectus sheath haematoma • Desmoid tumour 6 ✓ Mid-clavicular lines are the vertical planes 7 In a patient presenting with mass abdomen, generally following clinical features should be assessed care fully. _ Pain: Site, nature, aggravating or relieving factors, duration of pain, referred pain. _ Vomiting: Type, content, haematemesis, relation to food, frequency. _ Jaundice: It is an important factor in relation to liver, gallbladder or pancreatic masses. _ Bowel habits: Constipation, diarrhoea, bloody diarrhoea, furious diarrhoea, tenesmus. _ Decreased appetite and weight. _ Inspection of the mass: Anatomical location, margin, surface, movement with respiration. _ Palpation of the mass: Site, extent, surface, tender ness, consistency, movement with respiration, mobility, borders, plane of the swelling (by leg raising test), presence of other masses. _ Often mass needs to be examined for change of position—in sitting, in standing, in side position, after a brisk walk, in knee elbow position for retroperitoneal mass and for puddle sign (but diffi cult to keep patient in this position). _ Percussion is an important aspect of examination in case of an abdominal mass. Percussion over the mass is important to predict the 8 anatomical location of the mass. If mass is dull, then it is in the anterior abdo minal wall or in front of the bowel intra-abdominally like liver, spleen, gallbladder. If the mass is with a impaired resonant note, then the mass is arising from the bowel like stomach, colon, small bowel. If the mass is resonant on percussion, then the mass is probably in the retroperitoneal region. Other than this, liver dullness, free fluid in the abdomen should be elicited during percussion. _ Per rectal examination: It is done to look for any secon daries in rectovesical pouch, primary tumour or relation of lower abdomen masses (pelvic masses). _ Pervaginal examination is done to assess pelvic masses. MASS IN THE RIGHT HYPOCHONDRIUM Liver Palpable Mass in Right Hypochondrium _ It is horizontally placed. _ 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. 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. 2. Soft, smooth, tender liver: 9 _ 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. Amoebic liver abscess _ It is due to entamoeba histolytica infestation _ It is more common in alcoholics and cirrhotics _ Single abscess is common—70%; common in right posterosuperior lobe—80% _ Chocolate colored Anchovy sauce pus is classical _ Secondary infection can occur—30%—life-threatening due to septicaemia _ It can be acute or chronic; both mimics hepatoma _ Rupture into lungs—most common site of rupture _ Most dangerous rupture is into pericardium—left lobe abscess _ Liver failure can develop in cirrhotic patient Features _ Common in males (20:1), fever, pain, intercostal tenderness, tender liver _ Mimics cholecystitis, subphrenic abscess, hepatoma _ Total count, LFT, prothrombin time, US abdomen are relevant investigations _ Chest X-ray may show left sided sympathetic pleural effusion _ CT scan to differentiate from hepatoma _ Treatment—drugs like metronidazole, injection dehydroemetine, chloroquine tablets, diloxanate furoate; U/S guided aspiration after controlling prothrombin time using inj vitamin K or FFP; if recurs percutaneous guided drainage using pigtail catheter, or open laparotomy and drainage with placement of Malecot’s catheter 3. Hard, smooth liver: _ Hepatoma (HCC): Here a large, single, hard nodule is palpable in the liver. But occasionally there can be multiple nodules when it is multicentric. Rapidly growing tumour can be soft also. Hepatoma often can also be 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. 10 Hepatoma/hepatocellular carcinoma/HCC _ Common aetiologies are afl atoxins, hepatitis B and hepatitis C virus infection, alcoholic cirrhosis, haemochromatosis, smoking, hepatic adenoma, clonorchis sinensis, polyvinyl chloride _ Unicentric and right lobe involvement is more common _ Fibrolamellar variant is common in left lobe, not related to hepatitis or cirrhosis without AFP level raise. There are increased serum vitamin B12 binding capacity and neurotensin levels. _ It can be multifocal/indeterminate/spreading/expanding— Okuda classifi cation _ Presents as large smooth hard liver mass—later jaundice, fever, pain and tenderness, ascites and bruit over mass _ Spreads to lymphatics, blood and direct spread _ Mimics amebic liver abscess, secondaries, hydatid cyst, polycystic liver disease _ LFT, CT scan, raised AFP, liver biopsy (only needed) are the investigations _ Hemihepatectomy in early operable growth is the treatment _ Hepatic artery ligation/intra-arterial chemotherapy/chemoembolisation/ percutaneous ethanol or acetic acid injection/ radiofrequency ablation/chemotherapy using adriamycin, carboplatin, gemcitabine—are palliative procedures 4. Hard, multinodular liver: _ Multiple secondaries in liver: Here hard nodules show umbilication which is due to central necrosis. _ Macronodular cirrhotic liver. 11 Palpable Gallbladder in Right Hypochondrium _ It is smooth and soft (except in carcinoma gallb ladder). _ It is mobile horizontally (side-to-side). _ It moves with respiration. _ It is located right of the right rectus muscle, below the right costal margin or below the lower margin of the palpable liver. _ It is dull on percussion. 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 peri ampullary carcinoma or growth in the CBD. 2. Hard gallbladder: _ Carcinoma gallbladder. 3. Tender gallbladder—empyema GB. Other Masses in the Right Hypochondrium _ Pericholecystic infl ammatory mass: It is tender, smooth, firm or soft, nonmobile, intra-abdominal mass often with guarding. _ Kidney mass arising from upper pole of the kidney: It may be due to renal cell carcinoma or hydronephrosis. MASS IN THE EPIGASTRIUM Palpable Left Lobe of the Liver _ It is in the epigastric region. 12 _ Its upper border cannot be felt. _ It moves with respiration. _ It extends towards left hypochondrium. _ It is dull on percussion. Features of Stomach Mass _ It is located in the epigastric region. _ It moves with respiration. It is intra-abdominal. _ It is resonant or impaired resonant on percussion. _ Mass may be better felt on standing or on walking. _ Mass is often mobile, unless it gets adherent posteriorly. _ In pylorus mass, all margins are well felt which is mobile with features of gastric outlet obs truction. _ Mass from the body of the stomach is horizontally placed without any features of obstruction. _ Mass from the upper part of the stomach near the OG junction causes dysphagia. _ Mass from the fundus of the stomach is in the upper part of the epigastric region towards left side. _ Carcinoma stomach is nodular and hard. It is the most common cause for stomach mass. _ Leiomyoma of stomach is smooth and firm. Management of gastric carcinoma _ Early growth—pylorus—lower radical gastrectomy with removal
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