Abdominal lump
Reading File
Asking for Preferences
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Reading File
Finding Sources
Reading File
Finding Sources
Reading File
Reading File
Reading File
Finding Sources
Reading File
I now have solid content from Harrison's and Pye's Surgical Handicraft. Let me compile a comprehensive, well-structured answer.
Abdominal Lump: Clinical Overview
Definition and Initial Approach
An abdominal lump is any palpable mass arising within or on the abdominal wall or cavity. The clinical approach follows a systematic pattern: history → examination → investigations.
Causes: The "Six Fs" (Abdominal Swelling)
A useful mnemonic for the broad causes of abdominal swelling and masses (Harrison's Principles, 22nd Ed.):
| "F" | Cause | Examples |
|---|---|---|
| Flatus | Intestinal gas | Aerophagia, IBS, SIBO, lactose intolerance |
| Fat | Adiposity | Obesity, Cushing's syndrome |
| Fluid | Ascites | Cirrhosis, heart failure, malignancy, TB |
| Fetus | Pregnancy | Uterus rising from pelvis at ~12 weeks |
| Feces | Constipation/obstruction | Bowel obstruction, severe constipation |
| Fatal Growth | Neoplasm/mass | Carcinoma, abscess, cyst, organomegaly, AAA |
Regional Differential Diagnosis
| Region | Common Causes |
|---|---|
| Right hypochondrium | Hepatomegaly, Riedel's lobe (normal variant), distended gallbladder, hepatic metastases |
| Epigastrium | Gastric carcinoma, pancreatic pseudocyst/tumor, aortic aneurysm (pulsatile) |
| Left hypochondrium | Splenomegaly (lymphoma, portal hypertension, haematological malignancy) |
| Umbilical/periumbilical | Small bowel mass, lymph nodes, aortic aneurysm |
| Right iliac fossa | Appendix mass/abscess, Crohn's disease (doughy mass), caecal carcinoma, iliopsoas abscess, ovarian cyst (female) |
| Left iliac fossa | Sigmoid carcinoma, diverticular mass, ovarian cyst (female) |
| Flanks | Renal mass (descends on inspiration), polycystic kidneys |
| Suprapubic/hypogastric | Bladder distension, uterine fibroid/carcinoma, ovarian mass |
| Diffuse | Ascites, gross organomegaly, mesenteric cyst |
History Taking
Key questions (Harrison's, 22nd Ed.):
- Onset and timing: Sudden vs. gradual; related to meals or bowel habit
- Associated symptoms: Weight loss, night sweats, anorexia (suggest malignancy); jaundice, alcohol use (suggest liver disease); inability to pass stool/flatus (obstruction)
- Prior surgery: Adhesions, recurrent pathology
- Risk factors: Alcohol, viral hepatitis (cirrhosis); family history of malignancy
Physical Examination
Positioning
Patient supine, hands by sides, single pillow under head (Pye's Surgical Handicraft, p. 265-266).
Inspection
- Visible mass, asymmetric distension
- Visible peristalsis (intestinal obstruction)
- Epigastric pulsation (aortic aneurysm)
- Caput medusae (dilated periumbilical veins): portal hypertension / portal vein thrombosis
- Dilated flank veins: IVC obstruction
- Spider angiomas, palmar erythema, gynecomastia: liver disease
- Surgical scars: adhesions or recurrent pathology
Auscultation (before palpation)
- High-pitched localized bowel sounds: intestinal obstruction
- Absent bowel sounds: peritonitis / paralytic ileus
- Umbilical venous hum: portal hypertension
- Hepatic bruit (rare): hepatocellular carcinoma or alcoholic hepatitis
Percussion
- Tympanic: gas-filled bowel (flatus)
- Dull: solid mass or fluid (ascites)
- Shifting dullness / fluid thrill: ascites (needs >1500 mL to detect clinically)
- Splenomegaly: dull to percussion below left costal margin
Palpation
- Begin gently, away from the painful area
- Renal masses arise in the flanks and descend on inspiration (bimanually palpable - ballotable)
- Splenomegaly: descends on deep inspiration toward right iliac fossa, has a notch, cannot get above it
- Hepatomegaly: descends on inspiration, dull to percussion, cannot get above it
- Non-tender mass: likely neoplastic
- Tender mass: likely inflammatory (e.g., Crohn's disease, abscess)
- Assess: size, shape, surface, consistency, mobility, movement with respiration, pulsatility, reducibility (hernia)
Always Complete With
- Rectal examination (rectal carcinoma, extrinsic pelvic mass)
- Lymph nodes - especially Virchow's node (left supraclavicular fossa): suggests metastatic abdominal malignancy
Investigations
Imaging
| Test | Use |
|---|---|
| Abdominal X-ray | Dilated bowel loops (obstruction/ileus), calcification (stones, AAA), fecal loading |
| Ultrasound | First-line: detects ascites (as little as 100 mL), hepatosplenomegaly, gallstones, renal masses, abdominal aortic aneurysm |
| CT abdomen/pelvis | Definitive characterization; retroperitoneal nodes, pancreatic lesions, staging malignancy |
| MRI | Liver lesions, soft tissue characterization |
Laboratory
- FBC: Anaemia (blood loss/malignancy), leukocytosis (infection), cytopenias (hypersplenism)
- LFTs + albumin + PT/INR: Hepatic function (cirrhosis, malignancy)
- Amylase/lipase: Pancreatitis
- Urea & electrolytes: Renal function
- Tumour markers: CEA (colorectal), CA-125 (ovarian), AFP (hepatocellular), CA 19-9 (pancreatic) - as clinically indicated
- Urine protein: Nephrotic syndrome
Interventional
- Diagnostic paracentesis: Ascites - serum-ascites albumin gradient (SAAG) differentiates portal hypertension (SAAG ≥1.1) from other causes
- Biopsy: Tissue diagnosis for solid masses
Key Clinical Clues at a Glance
| Finding | Think of |
|---|---|
| Pulsatile expansile epigastric mass | Abdominal aortic aneurysm |
| Non-tender RUQ mass + jaundice | Courvoisier's sign (pancreatic/biliary carcinoma) |
| Doughy RIF mass + diarrhoea | Crohn's disease |
| Ballotable flank mass | Renal cell carcinoma / hydronephrosis |
| Left supraclavicular node (Virchow's) | Gastric/GI metastasis |
| Umbilical nodule | Sister Mary Joseph nodule (metastatic intra-abdominal carcinoma) |
| Shifting dullness + fluid thrill | Ascites |
Sources:
- Harrison's Principles of Internal Medicine, 22nd Ed., Ch. 53 - Abdominal Swelling and Ascites
- Pye's Surgical Handicraft, 22nd Ed., pp. 265-266 - Abdominal Signs
This is a shared conversation. Sign in to Orris to start your own chat.