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Abdominal Mass


Abdominal Mass, Generalized

As the physician examines the abdomen, how can he or she recall all of the causes of a mass or swelling? The physician should consider the possibilities for the composition of the mass. It may be air, in which case the physician would think of air in the peritoneum with rupture of a viscus, particularly a peptic ulcer, or it may be air in the intestinal tract from focal or generalized distention, in which case the physician would recall gastric dilatation, intestinal obstruction related to numerous causes (see page 30), or paralytic ileus. The mass may be fluid, in which case the physician would recall fluid in the abdominal wall (anasarca), the peritoneum (ascites, page 28) and its various causes, and fluid (urine) accumulation in the bladder or intestine or cysts of other abdominal organs. The latter brings to mind ovarian, pancreatic, and omental cysts. The mass may be blood in the peritoneal wall, the peritoneum, or any of the organ systems of the abdomen. The mass may be a solid inorganic substance, such as the fecal accumulation in celiac disease and Hirschsprung disease. Finally, the mass may be a hypertrophy, swelling, or neoplasm of any one of the organs or tissues in the abdomen.

This is where anatomy comes in. In the abdominal wall, there may be an accumulation of fat (obesity). The liver may be enlarged by neoplasm or obstruction of its vascular supply (e.g., Budd–Chiari syndrome or cardiac cirrhosis) or by obstruction of the biliary tree with neoplasms or biliary cirrhosis. The spleen may become massively enlarged by hypertrophy, hyperplasia in Gaucher disease, infiltration of cells in chronic myelogenous leukemia and myeloid metaplasia, or by inflammation in kala azar. The kidney rarely enlarges to the point at which it causes a generalized abdominal swelling in hydronephrosis, but a Wilms tumor or carcinoma may occasionally become extremely large.

The bladder, as mentioned above, may be enlarged sufficiently to present a generalized abdominal swelling when it becomes obstructed, but a neoplasm of the bladder will not present as a huge mass. The uterus presents as a generalized abdominal mass in late stages of pregnancy, but ovarian cysts should be first considered in huge masses arising from the female genital tract. Pancreatic cysts and pseudocysts are possible causes of a generalized abdominal swelling, although they are usually localized to the right upper quadrant (RUQ) or epigastrium. It would be unusual for an aortic aneurysm to grow to a size sufficient to cause a generalized abdominal mass, but it is frequently mentioned in differential diagnosis texts.

The above method is one method of developing a differential diagnosis of generalized abdominal swelling or mass. Relying solely on anatomy and cross-indexing the various structures with the mnemonic MINT is another. This mnemonic is suggested as an exercise for the reader. Take each organ system as a tract. Thus, the gastrointestinal (GI) tract presents most commonly with a diffuse swelling in intestinal obstruction and paralytic ileus; the biliary tract and pancreas with hepatitis, neoplasms, and pancreatic pseudocysts. The urinary tract presents with a diffuse “mass” in bladder neck obstruction. The female genital tract may be the cause of a huge abdominal mass in ovarian cysts, neoplasms, and pregnancy. Apply the same technique to the spleen and abdominal wall to complete the picture.

There are, in addition, certain conditions that cause abdominal swelling that is more apparent than real. Lumbar lordosis causes abdominal protuberance, as does visceroptosis. A huge ventral hernia or diastasis recti may mimic an abdominal swelling. Psychogenic protrusion of the belly by straining is another cause.


Approach to the Diagnosis

What can be done to work up a diffuse abdominal swelling? It is important to catheterize the bladder if there is any question that this may be the cause. A flat plate of the abdomen and lateral decubitus and upright films will help in diagnosing intestinal obstruction, a ruptured viscus, or peritoneal fluid. A pregnancy test must be done in women of childbearing age. If pregnancy or ovarian cysts can be definitively excluded by ultrasonography, then a computed tomography (CT) scan or diagnostic peritoneal tap may be helpful in the diagnosis.


Other Useful Tests



  • Complete blood count (CBC)


  • Amylase and lipase levels (pancreatic pseudocyst)


  • Liver profile (ascites)


  • Laparoscopy (ovarian cysts, metastatic carcinoma, tuberculous peritonitis)


  • Lymphangiogram (retroperitoneal sarcoma)


  • Surgery consult


  • Gynecology consult


  • Exploratory laparotomy


  • Alpha-fetoprotein (hepatoma)


Right Upper Quadrant Mass

When the clinician lays his or her hand on the RUQ and feels a mass, he or she should visualize the anatomy and the differential diagnosis should become clear. Proceeding from the skin, the physician encounters the subcutaneous tissue, fascia, muscle, peritoneum, liver, hepatic flexure of the colon, gallbladder, duodenum, pancreas, kidney, and adrenal gland. The blood vessels and lymphatics to these organs and the bile and pancreatic ducts should be
considered. Then, because masses are caused by a limited number of etiologies, apply the mnemonic MINT to each organ. The differential using these methods is developed in Table 1.






Abdominal mass, generalized.

Skin malformations do not usually cause a mass, but inflammation of the skin is manifested by cellulitis and carbuncles, and neoplasms are manifested as carcinomas, both primary and metastatic. Trauma of the skin is usually manifested by obvious contusions or lacerations. A mass of the subcutaneous tissue may be a lipoma, fibroma, metastatic carcinoma, cellulitis, or contusion. A mass disease of the fascia is usually the result of a hernia. The causes of hepatomegaly are reviewed on page 220, but if the mass is in the liver, it is usually hepatitis, amebic or
septic abscess, carcinoma (primary or metastatic), contusion, or laceration. A Riedel lobe should not be mistaken for a large gallbladder. The hepatic flexure of the colon may be enlarged by diverticulitis, carcinoma, granulomatous colitis, contusion, or volvulus. Malrotation may cause a mass in infants. A retrocecal appendix should not be forgotten here either.








Table 1 Right Upper Quadrant Mass










































































  M
Malformation
I
Inflammation
N
Neoplasm
T
Trauma
Skin Sebaceous cyst Abscess Carcinomas (primary or metastatic) Contusion
Subcutaneous Tissue and Fascia Hernia Cellulitis Metastatic carcinoma
Lipoma
Contusion
Muscle   Myositis   Contusion
Liver Cyst
Riedel lobe
Abscess
Hepatitis
Carcinoma (primary and metastatic) Contusion
Laceration
Hepatic Flexure of Colon Diverticulum
Malrotation
Diverticulitis
Retrocecal appendix
Carcinoma of the colon Contusion
Perforation
Gallbladder and Ducts Hydrops Cholecystitis
Cholelithiasis
Pancreatic carcinoma
Cholangioma
Choledochal carcinoma
Contusion
Duodenum   Perforation of ulcer with subphrenic abscess    
Pancreas Pancreatic cyst Acute and chronic pancreatitis Carcinoma of the head of the pancreas Traumatic pseudocyst
Kidney Renal cyst
Hydronephrosis
Polycystic kidney
Hydronephrosis
Pyonephrosis
Perinephric abscess
Wilms tumor
Hypernephroma
Contusion
Laceration
Adrenal Gland     Neuroblastoma
Pheochromocytoma
Adrenal carcinoma
 
Lymph Nodes     Hodgkin lymphoma
Metastatic carcinoma
 

An enlarged gallbladder accounts for the mass in the RUQ in many cases. The enlargement may be caused by cholecystitis, obstruction of the neck of the cystic duct by a stone causing gallbladder hydrops, Courvoisier–Terrier syndrome caused by obstruction of the bile duct by carcinoma of the head of the pancreas, or cholangiocarcinoma.

The pancreas may be enlarged in M—Malformations by congenital or acquired pancreatic cysts, I—Inflammation of an acute or chronic pancreatitis, N—Neoplasm, and T—Traumatic pseudocysts.

A duodenal diverticulum is not usually felt as a mass, but a perforated duodenal ulcer may manifest itself by a palpable subphrenic abscess in the right anterior intraperitoneal pouch. Malformations of the kidney often cause hydronephrosis, whereas inflammation may cause a perinephric abscess and thus an RUQ mass. Carcinoma or Wilms tumor of the kidney is frequently responsible for a large kidney.

Carcinoma of the adrenal gland is not usually palpable until late in the disease process, but a neuroblastoma is palpable early. Other lesions of the adrenal gland are not usually associated with a mass.

Aneurysms, emboli, and thromboses of the vessels supplying these organs usually do not produce a mass, but a thrombosis of the hepatic vein (the well-known Budd–Chiari syndrome) causes hepatomegaly, and emboli and thrombi of the mesenteric vessels of the colon may cause focal enlargement from obstruction and infarction. Visualizing the lymphatics should recall Hodgkin lymphoma in the portal area.


Approach to the Diagnosis

Acute onset of the RUQ mass with a history of trauma is no doubt a laceration or contusion of the liver or kidney: A surgeon should be consulted immediately. Order a CT scan with and without contrast as well as a CT angiogram.
When an RUQ mass is discovered unexpectedly or during a routine physical examination, one may proceed more deliberately. Ultrasonography will help determine if the mass is a gallbladder, liver, or pancreatic cyst. A CBC, chemistry profile, and liver panel will help determine if the mass is hepatic in origin. An intravenous pyelogram (IVP), urinalysis, or urine culture will help determine if it is renal in origin. However, a CT scan can resolve the dilemma quickly in most cases so it may be the most cost-effective approach. Then, one can determine which specialist to refer the patient to without hesitation. It is important to remember that whereas most masses will require referral to a specialist, fecal impactions and abdominal wall hematomas can be handled by the primary care physician.






Abdominal mass, generalized.


Other Useful Tests



  • Amylase and lipase levels (pancreatic carcinoma, pancreatic cysts)


  • Barium enema (colon carcinoma)


  • Cholecystogram (gallstones)


  • Gallium scan (subphrenic abscess)


  • Aortogram (aortic aneurysm)


  • Small-bowel series (tumor)


  • Gastroenterology consult


  • Exploratory laparoscopy



Left Upper Quadrant Mass

The differential diagnosis for left upper quadrant (LUQ) masses is not a great deal different from that of the RUQ. The anatomy is similar: Just replace the liver with the spleen and the gallbladder with the stomach. The presence of the aorta on the side of the abdomen should not be forgotten. Again, anatomy is the key, as shown in Table 2. Cross-index the various organs and tissues with the etiologies using MINT as the mnemonic.







Abdominal mass, right upper quadrant.



  • M—Malformations of the skin, subcutaneous tissue, fascia, and muscle are usually hernias; for the spleen, they are aneurysms; for the splenic flexure of the colon, they are mainly volvulus, intussusceptions, and diverticula. Gastric dilatation of the stomach is caused by obstruction or pneumonia. Cysts are common for the pancreas, just as polycystic disease, single cysts, and hydronephrosis are common for the kidney. There is no common malformation for the adrenal gland.


  • I—Inflammatory conditions of the skin, subcutaneous tissue, muscle, and fascia are usually abscesses and cellulitis. In the spleen, a host of systemic inflammatory lesions can cause enlargement (see page 392), but primary infections of the spleen are unusual. The colon may be inflamed by diverticulitis, granulomatous colitis, and, occasionally, by tuberculosis. Inflammatory disease of the stomach does not usually produce a mass, but if an ulcer perforates or if a diverticulum ruptures, a subphrenic abscess may form in the left hypochondrium. Inflammatory pseudocysts may form in the tail of the pancreas. A palpable perinephric abscess and an enlarged kidney from acute pyelonephritis or tuberculosis may be felt, but inflammatory lesions of the adrenal gland are rarely palpable.


  • N—Neoplasms of the organs mentioned above account for most of the masses in the LUQ. Carcinoma of the stomach or colon, Hodgkin lymphoma, chronic leukemias involving the spleen, Wilms tumor, carcinoma of the kidney, and neuroblastoma must be considered. A retroperitoneal sarcoma is occasionally responsible for an LUQ mass.


  • T—Trauma to the spleen or kidney will produce a tender mass in the LUQ. Less common traumatic lesions here include contusion of the muscle and perforation of the stomach or colon. It should be noted that the left lobe of the liver may project into the LUQ; therefore, tumor and abscess of the liver must be considered.


Approach to the Diagnosis

The presence or absence of other symptoms and signs is the key to the clinical diagnosis of an LUQ mass. A history of trauma would be a clear indication for a surgical consult, CT scan, and possibly CT angiography. The presence of jaundice would suggest that the mass is a large spleen. The presence of blood in the stool would suggest carcinoma of the colon. The presence of hematuria would suggest that the mass is renal in origin. An enema should be done to exclude fecal impaction before an extensive workup is performed.

A conservative workup will include a CBC, sedimentation rate, urinalysis, chemistry panel, platelet count, stool for occult blood, coagulation profile, and a flat plate of the
abdomen. On the basis of these results, the clinician can determine whether to do an upper GI series, barium enema, IVP, or CT scan of the abdomen. Another approach would be to do the CT scan immediately. In the long run, the latter approach may be more cost-effective. It is usually prudent to get a surgical or gastroenterologic consult to help decide between the two approaches.








Table 2 Left Upper Quadrant Mass










































































  M
Malformation
I
Inflammation
N
Neoplasm
T
Trauma
Skin Sebaceous cyst Abscess Carcinoma (primary or metastatic) Contusion
Subcutaneous Tissue and Fascia Hernia Cellulitis Metastatic tumor
Lipoma
Contusion
Muscle   Myositis   Contusion
Spleen Aneurysm
Accessory spleen
Tuberculosis
Systemic disease
Malaria
Hodgkin lymphoma
Chronic leukemia
Contusion
Laceration
Stomach Gastric dilatation Perforated ulcer with subphrenic abscess Carcinoma of the stomach Perforation
Splenic Flexure of the Colon Diverticulum
Volvulus
Intussusception
Diverticulitis Carcinoma of the colon Contusion
Perforation
Pancreas Pancreatic cyst Pseudocyst from pancreatitis Carcinoma of the pancreas Traumatic pseudocyst
Kidney Hydronephrosis
Polycystic kidney
Renal cyst
Hydronephrosis
Pyonephrosis
Perinephric abscess
Wilms tumor
Hypernephroma
Contusion
Laceration
Adrenal Gland     Neuroblastoma
Pheochromocytoma
Adrenal carcinoma
 
Lymph Nodes     Hodgkin lymphoma
Retroperitoneal lymphosarcoma
 
Blood Vessels Aortic aneurysm      


Other Useful Tests



  • Amylase and lipase levels (pancreatic pseudocyst or tumor)


  • Bone marrow examination (splenomegaly)


  • Liver–spleen scan (splenomegaly)


  • Sonogram (renal cyst, pancreatic cyst)


  • Colonoscopy (colon carcinoma)


  • Laparoscopy


  • Biopsy of mass (neoplasm)


  • Gallium scan (abscess)


Right Lower Quadrant Mass

Anatomy is once again the key to developing a differential diagnosis of a right lower quadrant (RLQ) mass. Underneath the skin, subcutaneous tissue, fascia, and muscle lie the cecum, appendix, terminal ileum, iliac artery and vein, and ileum. In the female, the fallopian tube and ovary should be included. Occasionally a ptosed kidney also will be felt here. Now, apply the etiologic mnemonic MINT to each organ, and you should have a reliable differential diagnosis, like that in Table 3. The important lesions to remember here are the following:



  • M—Malformations such as inguinal and femoral hernias may be present.


  • I—Inflammations include acute appendicitis with abscess, tubo-ovarian abscesses, and regional ileitis.


  • N—Neoplasms to be considered in this area are carcinoma of the cecum and ovarian tumors.


  • T—Traumatic lesions include fracture or contusion of the ileum and perforation of the bowel from a stab wound.

The lymph nodes may be involved with tuberculosis or actinomycosis. The cecum may also be enlarged by accumulation of Ascaris or other parasites. The omentum can contribute to adhesions of the bowel to form a mass, or it may develop cysts.







Abdominal mass, left upper quadrant.


Approach to the Diagnosis

As with other abdominal masses, it is important to look for other symptoms and signs that will help determine the origin of the mass. If there are fever and chills, an appendiceal or diverticular abscess is possible. Blood in the stool suggests a diagnosis of colon carcinoma or intussusception. If there is amenorrhea or vaginal bleeding in a woman of childbearing age, an ectopic pregnancy must be considered. A long history of chronic diarrhea with or without blood in the stools suggests Crohn disease.

The initial workup will include a CBC, sedimentation rate, chemistry panel, stool for occult blood, pregnancy test, and flat plate of the abdomen. If appendicitis is strongly suspected, ultrasonography should be performed without delay. If there is fever and an acute presentation, consultation with a general surgeon to consider an immediate exploratory laparotomy is indicated.

With a more insidious onset of the RLQ mass, the clinician has a choice of ordering a CT scan of the abdomen and pelvis after performing the initial diagnostic studies or proceeding systematically with a barium enema, IVP, or small-bowel series to determine the origin of the mass. A gastroenterology or gynecology consult may be the best way to resolve this dilemma.


Other Useful Tests



  • Sonogram (ectopic pregnancy)


  • Peritoneal tap (ruptured ectopic, peritoneal abscess)


  • Colonoscopy (colonic neoplasm)


  • Serum protein electrophoresis (plasmacytoma)


  • Indium scan (peritoneal abscess)


  • Aortogram (aortic aneurysm)


  • Lymphangiogram (retroperitoneal tumor)


  • Laparoscopy (neoplasm, ectopic pregnancy)







Abdominal mass, right lower quadrant.



Left Lower Quadrant Mass

To quickly develop a list of etiologies of a left lower quadrant (LLQ) mass, visualize the anatomy of the area. Compared to the RUQ, the number of organs there is few. Beneath the skin, subcutaneous tissue, fascia, and muscle are the sigmoid colon, the iliac artery and veins, the aorta, and the ileum. In the female, one must remember the fallopian tube and ovary. Occasionally, the kidney drops into this region (nephroptosis) and the omentum may cause adhesion. Now apply the mnemonic MINT to each organ and the list of possibilities in Table 4 is completed without any difficulty.

Lesions of the skin and fascia are similar to those in upper quadrants with one exception: Because of the inguinal and femoral canals, hernias (especially indirect inguinal hernias) are much more frequent. In the sigmoid colon the following conditions should be considered:



  • M—Malformations include diverticula and volvulus.


  • I—Inflammatory conditions include diverticulitis, abscesses, and granulomatous and ulcerative colitis.


  • N—Neoplasms such as polyps and carcinomas may be present.


  • T—Trauma to this area may involve perforations and contusions.

This list excludes an important consideration, that of fecal impaction. If the patient is given an enema, the mass will often disappear. Less common causes of masses in the
sigmoid colon are tuberculosis and amebiasis and other parasites.








Table 3 Right Lower Quadrant Mass






























































  M
Malformation
I
Inflammation
N
Neoplasm
T
Trauma
Skin Sebaceous cyst Abscess Primary or metastatic carcinoma Contusion
Subcutaneous Tissue and Fascia Hernia Cellulitis Metastatic carcinoma
Lipoma
Contusion
Cecum Intussusception
Diverticulum
Intestinal obstruction
Diverticulitis
Granulomatous colitis
Parasites
Amebiasis
Ulcerative colitis
Carcinoma of the cecum Perforation
Contusion
Muscle   Psoas abscess
Myositis
  Contusion
Appendix Fecalith Appendicitis
Appendiceal abscess
Carcinoid Perforation
Terminal Ileum Intussusception
Meckel diverticulum
Intestinal obstruction
Regional ileitis
Typhoid
Tuberculosis
Polyp
Carcinoid
Sarcoma
Perforation
Contusion
Iliac Blood Vessels Aneurysm Thrombophlebitis    
Lymph Nodes   Tuberculous adenitis Metastatic tumor  
Ilium   Osteomyelitis Sarcoma Fracture or contusion

There may be aneurysms of the iliac artery or aorta and thrombosis of the iliac vein, although the latter is not usually palpable. The iliac lymph nodes may enlarge from Hodgkin lymphoma, metastatic carcinoma, or tuberculosis. Tubal and ovarian lesions that should come to mind are malignant and benign ovarian cysts, tubo-ovarian abscesses, ectopic pregnancy, and endometriosis. A sarcoma or other tumor of the ileum may be palpable, but abscesses of the sacroiliac joint are rarely palpable.


Approach to the Diagnosis

The approach to this diagnosis includes a careful pelvic and rectal examination; a search for the presence of blood in the stool; a history of weight loss; tenderness of the mass, fever, and other symptoms; and a laboratory workup. As mentioned above, an enema may diagnose and treat a fecal impaction. A surgical consult is wise at this point. Stool examination (for blood, ova, and parasites), sigmoidoscopy, and barium enemas are the most useful diagnostic procedures other than a colonoscopy. Arteriography and gallium scans (for diverticular and other abscesses) and the CT scan have become useful additions to the diagnostic armamentarium. Peritoneoscopy and exploratory laparotomy are still necessary in many cases.


Other Useful Tests



  • Sonogram (ovarian cyst, ectopic pregnancy)


  • Peritoneal tap (ruptured ectopic, peritoneal abscess)


  • IVP (pelvic kidney)


  • Pregnancy test (ectopic pregnancy)


  • CBC (infection, anemia)


  • Sedimentation rate (abscess, pelvic inflammatory disease [PID])


  • Gastroenterology consult


Epigastric Mass

In developing the differential diagnosis of an epigastric mass, one merely needs to visualize the anatomy of the epigastrium from skin to spine. The conditions are presented in outline form in Table 5, but the important conditions are emphasized in the following discussion.



  • Abdominal wall: Here the physician must consider ventral hernias, contusions in the wall, the xiphoid cartilage (which occasionally fools the novice), and lipomas or sebaceous cysts.


  • Diaphragm: A subphrenic abscess may be felt here.


  • Liver: The liver extends into the epigastrium and occasionally into the LUQ; thus, any cause of hepatomegaly (see page 220) may present as an epigastric mass.


  • Omentum: This may be enlarged by a cyst, a mass of adhesions, tuberculoma, or metastatic carcinoma.


  • Stomach: The acute dilatation in pneumonia or pyloric stenosis needs to be recalled. However, one usually thinks of carcinoma of the stomach or a perforated ulcer when this organ is visualized.



  • Colon: Carcinoma, toxic megacolon, or diverticulitis may cause a mass in this organ, but a hard chunk of feces also may do so.


  • Pancreas: Important conditions that must be considered here are carcinoma of the pancreas and pancreatic cysts. Occasionally, chronic pancreatitis may present as a mass.


  • Retroperitoneal lymph nodes: Lymphoma, retroperitoneal sarcoma, and metastatic tumor may make these nodes palpable.


  • Aorta: An aortic aneurysm may be felt, but more often the examiner is fooled by a normal or slightly enlarged aorta.


  • Spine: Deformities of the spine (e.g., lordosis) may make it especially prominent, but a fracture, metastatic neoplasm, myeloma, or arthritis may do the same.








Table 4 Left Lower Quadrant Mass
























































  M
Malformation
I
Inflammation
N
Neoplasm
T
Trauma
Skin Sebaceous cyst Abscess Primary and metastatic carcinomas Contusion
Subcutaneous Tissue and Fascia Hernia Cellulitis Metastatic carcinoma
Lipoma
Contusion
Muscle   Myositis   Contusion
Sigmoid Colon Intestinal obstruction Diverticulum
Volvulus
Diverticulitis and abscess
Tuberculosis
Granulomatous and ulcerative colitis
Carcinoma and polyp Perforation
Contusion
Foreign body
Tube and Ovary Hydatid cyst of Morgagni
Ectopic pregnancy
Tubo-ovarian abscess Ovarian cyst and carcinoma  
Iliac Artery and Veins and Aorta Aneurysm Thrombophlebitis    
Lymph Nodes   Tuberculous and acute infectious adenitis Metastatic tumor  
Ilium   Osteomyelitis Sarcoma Fracture or contusion


Approach to the Diagnosis

The association of other symptoms and signs are very helpful in determining the origin of an epigastric mass. If there is jaundice, the mass is probably an enlarged liver. Fever and chills suggests a subphrenic abscess displacing the liver downward or an abscessed gallbladder. A mass associated with a history of anorexia and wasting suggests pancreatic or gastric carcinoma. A history of alcoholism suggests that the mass is an enlarged liver or pancreatic pseudocyst. Blood in the stool suggests carcinoma of the stomach or colon. A history of constipation would warrant a cleansing enema to rule out a fecal impaction before ordering an expensive workup. If the mass pulsates, one would consider an aortic aneurysm in the differential diagnosis.

The initial workup should include a CBC, urinalysis, chemistry panel, amylase and lipase levels, stool for occult blood, and flat and upright x-rays of the abdomen. If a presentation is acute, a general surgeon should be consulted to consider immediate exploratory laparotomy. If the development was more insidious and the patient is in no acute distress, a more systematic workup can be done at this point. Based on the results of the initial workup, one can proceed with an upper GI series, a barium enema, or ultrasonography of the gallbladder and pancreas. However, a more expeditious route to the diagnosis would be to order a CT scan of the abdomen. MRCP or ERCP may be ordered to diagnose pancreatic CA. It is wise to consult a surgeon or gastroenterologist to help decide what method would be the most cost-effective and prudent.


Other Useful Tests



  • Liver function tests (cirrhosis or carcinoma of the liver)


  • Hepatitis profile (hepatitis)


  • Gastroscopy (gastric carcinoma)


  • Colonoscopy (colon carcinoma)


  • Peritoneal tap (metastatic neoplasm, peritonitis)


  • Laparoscopy (metastatic neoplasm)


  • Aortogram (aortic aneurysm)


  • Gallium scan (subphrenic abscess)



  • Liver biopsy (cirrhosis, neoplasm)


  • Liver–spleen scan (hepatomegaly)


  • Exploratory laparotomy


  • Bentiromide excretion test (chronic pancreatitis)






Abdominal mass, left lower quadrant.



Hypogastric Mass

More physicians have been fooled by a hypogastric mass than by a mass in any other area. How many times can you recall the mass disappearing on the operating table after catheterization of the bladder? More often than not, the mass is more apparent than real because of a lumbar lordosis or a diastasis recti.

Anatomy is the key to the differential diagnosis. There are not many organs here normally. Under the skin, subcutaneous tissue, fascia, and rectus abdominis muscles, the bladder, terminal aorta, and lumbosacral spine may be palpated in a thin male. In the female, the uterus may be palpated on bimanual pelvic examination. When there is visceroptosis, the transverse colon will be palpated.

Under pathologic conditions, however, the lymph nodes, sigmoid colon, fallopian tube and ovary, and small intestines may be palpated as well as a pelvic kidney. Applying the mnemonic MINT to these organs results in the extensive differential diagnosis in Table 6. The discussion that follows mentions only the most significant causes of a hypogastric mass.







Abdominal mass, epigastric.

Lipomas of the skin, ventral hernias, and diastasis recti form the most frequently encountered disorders in the covering of the hypogastrium. The bladder may be obstructed by strictures and prostatism (see page 351), but bladder carcinoma and stones may also be palpable. Bladder rupture should be considered in trauma to the perineum. The uterus may be enlarged by pregnancy, endometritis, fibroid, choriocarcinoma, or endometrial carcinoma. An ovarian or tubal mass may be caused by a benign or malignant ovarian cyst, an ectopic pregnancy, or a tubo-ovarian abscess. The aorta may present as a mass in aneurysms or thrombosis and severe arteriosclerosis of the terminal aorta. Finally, the lumbosacral spine may present as a hypogastric mass in the severe lordosis of Pott disease, spondylolisthesis, metastatic carcinoma, and lumbar spondylosis. The preaortic lymph nodes may greatly enlarge in tuberculosis, Hodgkin lymphoma, and metastatic carcinoma. If the transverse colon drops to the hypogastrium, a carcinoma or inflamed and abscessed diverticulum may be felt. Volvulus may present a mass here.

Ascites from cirrhosis of the liver, ruptured abdominal viscus, or bacterial or tuberculous peritonitis is often encountered and is difficult to differentiate from an ovarian cyst and a distended bladder. Careful percussion or ultrasonic evaluation will be extremely helpful, but a peritoneoscopy or a peritoneal tap in the lateral quadrants may be necessary.


Approach to the Diagnosis

Before the clinician can evaluate a hypogastric mass, it is important to have the patient empty his or her bladder. If the mass is still present, catheterization for residual urine or ultrasonography can determine if the mass is a distended bladder due to a neurogenic bladder or bladder neck obstruction. If there are objective neurologic findings, there may be a neurogenic bladder and the patient should be referred to a neurologist. If the clinician suspects bladder neck obstruction, a referral to an urologist is in order.

After the possibility that the mass is a distended bladder has been excluded, one should consider ruling out pregnancy
in women of childbearing age. A pregnancy test is done: If the test is positive, ultrasonography may be done, particularly if an ectopic pregnancy is suspected or the patient denies that she could be pregnant.








Table 5 Epigastric Mass




































































  M
Malformation
I
Inflammation
N
Neoplasm
T
Trauma
Abdominal Wall Hernia Cellulitis
Carbuncles
Lipoma
Sebaceous cyst
Contusion
Diaphragm Hiatal hernia Subphrenic abscess    
Liver Cyst
Hemangioma
Abscess
Hepatitis
Hepatoma
Metastatic carcinoma
Contusion
Laceration
Omentum Adhesion
Cyst
Peritonitis
Tuberculoma
Metastatic carcinoma Traumatic fat necrosis
Hemorrhage
Stomach Hypertrophic pyloric stenosis Gastric ulcer
Gastric dilatation
Gastric syphilis
Gastric carcinoma Hemorrhage
Stab wound
Colon Hirschsprung disease
Intussusception
Volvulus
Diverticulitis
Toxic megacolon
Colon carcinoma
Polyp
Contusion
Laceration
Pancreas Cyst
Pseudocyst
Pancreatitis Carcinoma of pancreas Contusion
Retroperitoneal Lymph Nodes   Tuberculosis Lymphoma
Sarcoma
Metastatic carcinoma
 
Aorta Aneurysm      
Spine Lordosis
Scoliosis
Tuberculosis
Arthritis
Osteomyelitis
Metastatic carcinoma
Myeloma
Hodgkin lymphoma
Fracture
Herniated disc
Hematoma

After a distended bladder and pregnancy have been removed from consideration, the next step would be a CT scan of the abdomen and pelvis. It is probably wise to consult a gynecologist, general surgeon, or urologist before ordering this expensive test. Their wisdom may make the test unnecessary.


Other Useful Tests



  • Stool for occult blood (rectal carcinoma)


  • CBC


  • Urinalysis (bladder neoplasm or stone)


  • Urine culture (cystitis, bladder diverticulum)


  • IVP (malformation neoplasm, pelvic kidney)


  • Barium enema (rectal or sigmoid carcinoma)


  • Colonoscopy (sigmoid or colon carcinoma)


  • Culdoscopy (ectopic pregnancy, ovarian cyst)


  • Laparoscopy (ovarian cyst, ectopic pregnancy, other pelvic mass)


  • Exploratory laparotomy


  • Aortogram (aortic aneurysm)


  • X-ray of the lumbosacral spine (deformities of the spine)


  • Lymphangiogram (retroperitoneal lymph nodes)


  • CA-125 (Ovarian carcinoma)


Abdominal Pain


Abdominal Pain, Generalized

The GI tract is the only “organ” that really covers the abdomen from one end to the other. Anything that causes an irritation of all or a large portion of this “tube” may cause generalized abdominal pain. Thus, gastritis, viral and bacterial gastroenteritis, irritable bowel syndrome, ulcerative colitis, and amebic colitis fall into this category. The remainder of the causes of generalized abdominal pain can be developed by using the mnemonic ROS with the anatomy of the entire abdomen.

When faced with a patient with diffuse abdominal pain, think of R for ruptured viscus. Now take each organ and consider the possibility of its having ruptured. Thus, the stomach and duodenum suggest a ruptured peptic ulcer; the pancreas, an acute hemorrhagic pancreatitis; the gallbladder, a ruptured cholecystitis. The liver and spleen usually rupture from trauma, whereas the fallopian tube may rupture from an ectopic pregnancy. The colon ruptures from diverticulitis, ulcerative colitis, or carcinoma. What is the one thing that should make the physician suspect a ruptured viscus? Rebound tenderness is the answer. In addition, one
or both testicles may be drawn up (Collins sign). If only the right testicle is drawn up, suspect a ruptured appendix or peptic ulcer. If only the left is drawn up, suspect a ruptured diverticulum. If both are drawn up, suspect pancreatitis or a generalized peritonitis.






Abdominal mass, hypogastric.

Now take the letter O. This signifies intestinal obstruction. Think of adhesion hernia, volvulus, paralytic ileus, intussusception, fecal impaction, carcinoma, mesenteric infarction, regional ileitis, and malrotation. The best way to recall all these is with the mnemonic VINDICATE.

Next take the letter S. This signifies the systemic diseases that may irritate the intestines, the peritoneum, or both. Once again the mnemonic VINDICATE will remind one to recall the important offenders.



  • V—Vascular suggests the anemias, congestive heart failure (CHF), coagulation disorders, and mesenteric artery occlusion, embolism, or thrombosis.


  • I—Inflammatory includes tuberculous, gonococcal and pneumococcal peritonitis, and trichinosis.


  • N—Neoplasms should suggest leukemia and metastatic carcinoma.


  • D—Deficiency might suggest the gastroenteritis of pellagra.


  • I—Intoxication reminds one of lead colic, uremia, and the venom of a black widow spider bite.


  • C—Congenital suggests porphyria and sickle cell disease.


  • A—Autoimmune brings to mind periarteritis nodosa, rheumatic fever, Henoch–Schönlein purpura, and dermatomyositis.


  • T—Trauma would suggest the paralytic ileus of trauma anywhere, the crush syndrome, and hemoperitoneum.


  • E—Endocrine disease suggests diabetic ketoacidosis, addisonian crisis, and hypocalcemia.


Approach to the Diagnosis

If the onset is acute, a general surgeon should be consulted at the outset. Ominous signs include boardlike rigidity, rebound tenderness, and shock with nausea and vomiting. With a history of trauma and hypotension, ultrasonography or peritoneal lavage may diagnose a ruptured spleen. Hyperactive bowel sounds of a high-pitched tinkling character with distention and obstipation suggest intestinal obstruction. In contrast, normal bowel sounds, little distention, good vital signs, and minimal tenderness suggest gastroenteritis or other diffuse irritation of the bowel.

It is wise to pass a nasogastric tube and attach to suction and proceed with a CBC, urinalysis, an immediate CT scan of the abdomen and pelvis, chest x-ray, serum amylase and lipase levels, and chemistry panel. Sometimes, lateral decubitus films are necessary to reveal the stepladder pattern of intestinal obstruction. A pregnancy test should be ordered if age and gender dictates it.

If these tests fail to confirm the clinical diagnosis and the patient’s condition is deteriorating, it is probably wise to proceed immediately with an exploratory laparotomy. If the patient’s condition is stable, one may
order more diagnostic tests depending on the location of the pain and other symptoms and signs. For example, if the pain seems more localized to the RUQ, a gallbladder ultrasound or nuclear scan may be ordered. Monitoring vital signs and doing repeated CBCs, serum amylase levels, and flat plates of the abdomen are useful in borderline cases.








Table 6 Mass in the Hypogastrium










































































  M
Acquired or Congenital Malformation
I
Inflammation
N
Neoplasm
T
Trauma
Skin Sebaceous cyst Abscess Primary and metastatic tumors
Lipoma
Contusion
Subcutaneous Tissue and Fascia Ventral hernia Cellulitis Primary and metastatic tumors
Lipoma
Neurofibroma
Contusion
Muscle Diastasis recti Myositis   Contusion
Bladder Diverticulum
Obstruction
Stone
  Carcinoma of bladder or prostate
Prostatic hypertrophy
Ruptured bladder
Transverse Colon Diverticulum
Volvulus
Intussusception
Diverticular abscess
Granulomatous colitis
Toxic megacolon
Carcinoma of colon Contusion Perforation
Uterus Pregnancy
Endometriosis
Endometritis
Parametritis
Fibroids
Endometrial carcinoma
Cervical carcinoma
Choriocarcinoma
Perforation
Contusion
Tube and Ovary Ectopic pregnancy Tubo-ovarian abscess Ovarian cyst (benign and malignant) Perforation
Rupture
Aorta Aneurysm
Leriche syndrome
Arteriosclerosis
    Perforation
Lumbosacral Spine Spondylolisthesis
Lordosis
Pott disease
Osteomyelitis
Metastatic tumor Herniated disc
Preaortic Lymph Nodes   Tuberculous adenitis Metastatic carcinoma
Hodgkin lymphoma
Herniated disc
Peritoneum Obstruction of portal vein with ascites Ascites from tuberculosis or gonorrhea Metastatic carcinoma with ascites Bloody ascites from perforation of viscus


Other Useful Tests



  • Quantitative urine amylase level


  • Four-quadrant peritoneal tap (peritonitis, pancreatitis, ruptured ectopic pregnancy)


  • Urine porphobilinogen (porphyria)


  • IVP (renal calculus)


  • Serial cardiac enzymes (myocardial infarct)


  • Serial electrocardiograms (ECGs)


  • Double enema (intestinal obstruction)


  • Esophagoscopy (reflux esophagitis)


  • Gastroscopy (peptic ulcer)


  • Colonoscopy (diverticulitis, carcinoma)


  • Laparoscopy (ruptured viscus, PID)


  • Culdocentesis (ruptured ectopic pregnancy)


  • Pelvic sonogram (ruptured ectopic pregnancy)


  • CT angiography or a conventional angiogram (mesenteric thrombosis)


  • Breath test, serologic tests, or stool tests for Helicobacter pylori (peptic ulcer)


  • Lipid profile (hypertriglyceridemia and chylomicronemia syndrome)


  • Gastric emptying studies(chronic dyspepsia)


Right Upper Quadrant Pain

The patient is complaining of RUQ pain and you cannot just give him or her a bag of pills and send him or her home.







Abdominal pain, generalized.

The patient’s condition may be serious. However, you are in a hurry to get out of the office because you have another important appointment. What do you do? The key is to visualize the anatomy. Imagine the liver, gallbladder, bile ducts, hepatic flexure of the colon, duodenum, and head of the pancreas. Surrounding these are the skin, fascia, ribs, and thoracic and lumbar spine, with the intercostal nerves and arteries and abdominal muscle.

Pain is usually from inflammation, trauma, or infarction. The patient gives no history of trauma, but he or she could have a contusion of the muscle from coughing hard.
That is not likely, however, unless the patient has other symptoms of the respiratory tract.

The possible sources of inflammation should be narrowed down first. The liver can be inflamed from hepatitis (most likely viral), the gallbladder from cholecystitis (most likely induced by stones and bacteria), or the bile ducts from cholangitis. The colon may be involved with diverticulitis, a segment of granulomatous colitis, or perhaps there is a retrocecal appendix. The duodenum, of course, would most likely have a peptic ulcer which could cause an obstruction or a perforation if the patient is vomiting, or pallor and shock if the patient is bleeding. The pancreas could be inflamed with pancreatitis, especially if the patient drinks alcohol.

These are the most important intra-abdominal considerations, but if the mnemonic VINDICATE in Table 7 were applied one might not forget the Budd–Chiari syndrome (thrombosis of the hepatic veins), portal vein thrombosis, or pylephlebitis; these are rare. In addition, toxic hepatitis from isoniazid, thorazine, and erythromycin estolate (Ilosone), for example, can be painful. Collagen diseases affecting the liver are another possibility.

Now let us round out the differential diagnosis with extra-abdominal disorders. The skin may be involved with herpes zoster or cellulitis. A fascial rent may cause a hernia, particularly if there was previous upper abdominal surgery. Compression of the nerve roots by a herniated disc, thoracic spondylosis, or a spinal cord tumor is possible, but unlikely. Systemic conditions, such as lead colic and porphyria, and involvement of another organ, such as the kidney, must be considered (pyelonephritis or renal colic).


Approach to the Diagnosis

As in the case of generalized abdominal pain, an immediate CBC, urinalysis, chemistry profile, serum amylase and lipase levels, and flat plate and upright films of the abdomen are ordered. If cholecystitis is suspected, ultrasonography or nuclear scanning of the gallbladder (hepatoiminodiacetic acid [HIDA] scan) is ordered. If there is jaundice, a common duct stone can be ruled out by an MRCP or endoscopic retrograde cholangiopancreatography (ERCP).


Other Useful Tests



  • Surgery consult


  • CT scan of the abdomen


  • Quantitative urine amylase


  • Urine porphobilinogen (porphyria)


  • Gallium scan (subphrenic abscess)


  • IVP (renal stone)


  • Liver function studies (common duct stone)


  • Blood lead level


  • Pregnancy test (ruptured ectopic pregnancy)


  • X-ray of thoracolumbar spine (radiculopathy)


  • Laparoscopy (ruptured viscus)


  • Aortogram (dissecting aneurysm)


  • Lymphangiogram (Hodgkin lymphoma)


  • Exploratory laparotomy


  • MRI


  • Endoscopic ultrasonography

Sep 23, 2018 | Posted by in CRITICAL CARE | Comments Off on A
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