Abdominal Mass Differential Presentation

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.

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 neonates 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.

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 lowgrade 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

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.
Left upper quadrant
Mid-line epigastric
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.
Left upper quadrant
Mid-line epigastric
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.
Left upper quadrant
Mid-line epigastric
Suprapubic
Right lower quadrant
Left lower quadrant
Appendix
Carcinoma of caecum
leocaecal tuberculosis
Crohns 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.
Left upper quadrant
Mid-line epigastric
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!

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ABDOMINAL MASS

Prof. Dr. Turgut IPEK

A Palpable abdominal mass must be

PALPABLE ABDOMINAL MASS

Normal abdominal masses

Status of the liver

Abdominal wall or intra-abdominal?

Movement with respiratory excursions

PALPABLE ABDOMINAL MASS

In abdominal wall (more prominent on tensing

Various skin and

Lumps of the anterior abdominal wall

The umbilicus is an obvious site of weakness, and two

PALPABLE ABDOMINAL MASS

Right upper quadrant

Liver (inferior edge)

Rihgt upper quadrant

Masses in the right upper quadrant that do

Left upper quadrant

Liver (inferior edge)

Left upper quadrant

Right lower quadrant

Left lower quadrant

Appendix mass is by far the best

patient empties bladder

Arising from pelvis

Not arising from pelvis

Dull, domed, pressure

An ovarian cyst may grow to such a large

The difficult case

Secondly, ultrasonography is the investigation

Finally, preliminary investigations should not be

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