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Abdominal Lump - Overview & Classification (Surgery Exam Guide)

Source: S. Das - A Manual on Clinical Surgery, 13th Ed.

1. Classification (The 6 Fs Mnemonic)

The causes of an abdominal lump/swelling can be remembered as:

F	Cause
Flatus	Intestinal gas - aerophagia, IBS, SIBO, FODMAP intolerance
Fat	Weight gain, Cushing's syndrome
Fluid	Ascites (hepatic, cardiac, malignant, TB)
Fetus	Pregnancy
Feces	Constipation, bowel obstruction
Fatal growth	Neoplasm, cyst, abscess, organomegaly, AAA

(Harrison's Principles of Internal Medicine, 22E)

2. Classification by Anatomical Origin

By Region (9 regions of abdomen)

Two horizontal lines (transpyloric + transtubercular) and two vertical lines divide the abdomen into:

Right hypochondrium
Epigastrium
Left hypochondrium
Right lumbar
Umbilical
Left lumbar
Right iliac
Hypogastrium
Left iliac

Position is the most important feature - it identifies the organ involved.

Common lumps by region

Region	Common Causes
Right hypochondrium	Liver (hepatomegaly, abscess, hydatid cyst), gallbladder (empyema, mucocele, Ca)
Epigastrium	Stomach (carcinoma, pyloric stenosis), pancreas (pseudocyst, carcinoma), aortic aneurysm
Left hypochondrium	Splenomegaly (malaria, kala-azar, portal hypertension, leukemia)
Right/Left lumbar	Kidney (hydronephrosis, polycystic, carcinoma), adrenal tumors
Umbilical	Umbilical hernia, lymph node metastases, small bowel tumor
Right iliac fossa	Appendicular mass/abscess, ileocecal TB, carcinoma cecum, ovarian cyst
Left iliac fossa	Carcinoma sigmoid colon, ovarian cyst, diverticular mass
Hypogastrium	Urinary bladder, uterine fibroids, ovarian cyst

3. Examination of an Abdominal Lump

A. INSPECTION

Skin over swelling - tense, red, shiny, pigmented? Engorged veins?
Position, size, shape - described in relation to the 9 regions
Movement with respiration:
- Moves well with respiration: liver, gallbladder, stomach, spleen
- Moves very little: kidney, suprarenal gland
Visible peristalsis - suggests obstruction
- Left to right = pyloric/gastric carcinoma
- Right to left = transverse colon carcinoma
Hernial sites - cough impulse test (positive = hernia)
Scrotum - always inspect; testicular malignancy metastasizes to para-aortic nodes which may be the first presenting lump
Left supraclavicular fossa (Virchow's/Troisier's node) - involvement suggests inoperable abdominal/breast/testicular malignancy

B. PALPATION (Deep)

Local temperature - raised = inflammatory
Tenderness - inflammatory swelling
Position, size, shape, surface - defines the organ and pathology
Margin:
- Well-defined = neoplasm
- Ill-defined = inflammatory or traumatic
Consistency - soft, cystic, firm, hard? Variable consistency? Fluctuation test, fluid thrill if cystic. Pitting = parietal abscess or feces-laden colon
Movement:
- Moves with respiration = liver, gallbladder, spleen, stomach origin
- Ballottable = renal swelling (bimanual palpation between loin and front)
- Mesenteric cyst = moves freely at right angles to mesentery attachment but restricted along it
Parietal vs. Intra-abdominal - Carnett's test:
- "Rising test" (raise shoulders with arms folded) or "leg lifting test"
- Parietal lump = becomes more prominent when muscles taut, freely movable over taut muscle
- Intra-abdominal lump = disappears or becomes smaller when muscles taut
Pulsatility:
- Transmitted pulsation = swelling lying in front of aorta (fingers don't separate)
- Expansile pulsation = aortic aneurysm (fingers are diverted apart with each beat)
- Knee-elbow test: pre-aortic lump becomes non-pulsatile; true aneurysm continues to pulsate
Hernial sites - cough impulse + reducibility
Insinuating fingers between lump and costal margin:
- Possible = renal swelling
- Not possible = hepatic or splenic swelling

C. PERCUSSION

Finding	Meaning
Dull on percussion	Solid superficial organ (liver, spleen)
Resonant on percussion	Renal swelling (coils of intestine overlie it), or intestinal lump
Shifting dullness	Ascites (flanks dull, shifts with position)
Central dullness, no shifting	Ovarian cyst
Hydatid thrill	Hydatid cyst (rarely positive)
Dull in loin (outside erector spinae)	Renal swelling (colon pushed aside)
Normal resonance in loin	Splenic swelling (colon not displaced)

D. AUSCULTATION

Absent bowel sounds / high-pitched localized = obstruction or ileus
Umbilical venous hum = portal hypertension
Hepatic bruit (rare) = hepatocellular carcinoma or alcoholic hepatitis

E. Always Perform

Rectal examination
Vaginal examination (in females)

4. Special Investigations by Organ

Organ	Key Investigations
Liver/Gallbladder	LFT, stool for E. histolytica, USG, ERCP, liver scan, angiography; hydatid cyst: eosinophilia + Casoni test + complement fixation
Spleen	CBC, platelet count, reticulocyte count, bleeding time
Pancreas	Barium meal (lateral view shows lump behind stomach in pseudocyst), stool fat, urine diastase, ERCP
Kidney	USG, IVU, cystoscopy, CT
Aorta	USG, CT angiography
Ovary/Uterus	USG pelvis, CA-125, CT

5. Key Differentials - Quick Reference Table

Feature	Liver	Spleen	Kidney	Ovarian Cyst	AAA
Respiratory movement	Yes	Yes	Slight	No	No
Ballottable	No	No	Yes	No	No
Pulsatile	No	No	No	No	Yes (expansile)
Percussion	Dull	Dull	Resonant	Central dull	Resonant
Fingers insinuated under costal margin	Difficult	Difficult	Yes	N/A	N/A
Loin percussion	Normal	Normal	Dull	N/A	N/A

Exam tip: Always remember the Troisier's sign (left supraclavicular node), Carnett's test (parietal vs. intra-abdominal), and the ballottability of renal swellings as high-yield exam points. The pulsation test (transmitted vs. expansile) for aortic aneurysm is another classic OSPE/viva question.

S. Das - A Manual on Clinical Surgery, 13th Ed., Ch. 35
Harrison's Principles of Internal Medicine, 22E

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