Abdominal lump

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Abdominal Lump

An abdominal lump (swelling/mass) is a palpable abnormality felt on the abdominal wall or within the abdominal cavity. The clinical approach involves systematically determining the site, character, and origin of the swelling, then building a differential diagnosis based on the anatomy of each region.

1. General Clinical Approach

History

Onset & duration - sudden (e.g. torsion, haematoma) vs. gradual (neoplasm, hernia)
Pain - site, radiation, colicky vs. constant
Associated symptoms - weight loss, anorexia, vomiting, jaundice, bowel/bladder changes, blood loss, fever
Reducibility - lump that disappears on lying down suggests hernia
Obstetric/menstrual history in females (ovarian, uterine pathology)
Family history - colorectal cancer, polyposis

Classic presentations to remember:

Right colon cancer - anaemia (iron deficiency)
Gastric cancer - anorexia and weight loss
Ovarian cancer - abdominal distension
Metastatic liver disease - weight loss + hepatomegaly

Examination of Any Lump (SEDUCTIVE mnemonic)

Feature	What to assess
Site	Which abdominal region?
Size	Approximate dimensions
Shape	Round, oval, irregular
Surface	Smooth, nodular, bosselated
Edge	Well-defined vs. indistinct
Consistency	Soft, firm, hard, fluctuant, cystic
Tenderness	Suggests inflammation or rapid expansion
Pulsatility	Expansile pulsation = aneurysm; transmitted = overlying structure
Mobility	Moves with respiration (liver, spleen, kidney, gallbladder); moves freely = mesenteric; fixed = retroperitoneal/malignant
Reducibility	Can it be pushed back? (hernia)
Resonance	Resonant = gas-containing (bowel within hernia); dull = solid/fluid
Transillumination	Bright = fluid-filled cyst
Auscultation	Bowel sounds over hernia; bruit over vascular tumour/aneurysm

2. Parietal vs. Intra-Abdominal

The first distinction is whether the lump is in the abdominal wall (parietal) or inside the peritoneal cavity.

Test: Ask the patient to raise their head and tense the abdominal muscles.

If the lump becomes more prominent - it is parietal (wall)
If the lump disappears or becomes less palpable - it is intra-abdominal

3. Differential Diagnosis by Region

The abdomen is divided into 9 regions (or 4 quadrants). Key causes per region:

Right Hypochondrium (RHC)

Liver enlargement (hepatomegaly, hepatoma, hydatid cyst, liver abscess)
Gallbladder swelling (mucocele, empyema, carcinoma)
Hepatic flexure of colon (carcinoma, intussusception, hypertrophic tuberculosis)
Subphrenic abscess (follows perforated peptic ulcer, abdominal trauma, biliary surgery)

Epigastrium

Stomach (carcinoma, pyloric stenosis, hourglass stomach)
Pancreas (pseudocyst, carcinoma - hard, fixed, does not move with respiration)
Left lobe of liver
Aortic aneurysm (expansile, pulsatile midline mass)
Subacute perforation of peptic ulcer (localized tender mass)

Left Hypochondrium (LHC)

Splenomegaly (malaria, kala-azar, portal hypertension, lymphoma, leukaemia)
Stomach/splenic flexure lesions
Pancreatic tail mass

Umbilical Region

Transverse colon (carcinoma, intussusception)
Mesenteric cyst (smooth, rounded, fluctuant, moves perpendicular to mesenteric root - from left of L2 to right iliac fossa; resonant with a band of resonance around it)
Aortic aneurysm
Retroperitoneal structures (lymphoma, sarcoma, cysts from Wolffian duct remnants)
Small bowel loop (tuberculosis, Crohn's disease)

Right Iliac Fossa (RIF)

Most common swellings from structures normally present here:

Appendicular lump - develops ~day 3 of acute appendicitis; consists of inflamed appendix + omentum + small bowel; tender, fixed, with overlying muscular rigidity
Appendicular abscess - fluctuant, very tender, with fever and toxicity
Caecal carcinoma - hard, irregular, poorly mobile
Ileocaecal tuberculosis - firm, matted; may mimic Crohn's
Ileo-caecal intussusception
Lymph node mass (mesenteric adenitis, lymphoma)

Swellings invading the RIF from elsewhere:

Unascended (ectopic) kidney
Grossly enlarged gallbladder (hydrops)
Ovarian cyst / tubo-ovarian mass / broad ligament cyst
Fibroid uterus
Undescended testis (within inguinal canal - "testicular feel")
Pelvic abscess overflowing upward
Iliac bone lesion

Left Iliac Fossa (LIF)

Carcinoma of sigmoid colon (most common)
Diverticular mass/abscess (pericolic inflammation)
Ovarian cyst / fibroid uterus
Iliac lymphadenopathy

Lumbar Regions (Flanks)

Renal swelling - ballottable, resonant in front (bowel overlies), moves with respiration, fingers can get between it and costal margin
Retroperitoneal mass

Hypogastrium (Suprapubic)

Always empty the bladder first before examining.

Urinary bladder (retention - smooth, dull, midline, reducible with catheterization)
Uterus (pregnancy, fibroids)
Ovarian cyst
Urachal cyst (rare midline parietal swelling between umbilicus and pubis)

4. Characteristics That Suggest Origin

Feature	Organ
Moves with respiration	Liver, spleen, kidney, gallbladder, stomach
Ballottable (can be flicked between two hands)	Kidney, floating masses
Notch on medial border	Spleen
Can get above it (fingers between mass and costal margin)	NOT kidney, NOT spleen
Cannot get above it	Liver or spleen
Resonant percussion + band of resonance surrounding	Mesenteric cyst
Expansile pulsation	Aortic aneurysm
Reducible / impulse on cough	Hernia
Transilluminates brightly	Cyst (simple fluid-filled)

5. Key Investigations

Ultrasound abdomen - first-line; differentiates cystic vs. solid, organ of origin
CT abdomen/pelvis with contrast - gold standard for characterization, staging, surgical planning
MRI - soft tissue detail (pelvic masses, liver lesions, retroperitoneal pathology)
Blood tests - FBC, LFTs, tumour markers (AFP for HCC/hepatoblastoma, CA-125 for ovarian, CEA for colorectal, beta-HCG for trophoblastic)
IVP/CT urogram - renal and retroperitoneal masses
Barium studies - bowel displacement/narrowing by mesenteric cysts or colonic masses
Biopsy (image-guided) - tissue diagnosis for suspected malignancy

6. Summary: Red Flags Suggesting Malignancy

Hard, irregular, fixed, non-tender mass
Associated weight loss, night sweats, anorexia
Hepatomegaly or lymphadenopathy
Ascites
Elevated tumour markers

Sources: S. Das - A Manual on Clinical Surgery, 13th Ed. | Bailey and Love's Short Practice of Surgery, 28th Ed.

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