the differential diagnosis of abdominal masses

1

The differential diagnosis of Abdominal masses

Prof. Dr. Mohamed I. Kassem

ILOs for DD of abdominal masses:

To know the different divisions and compartments of the

abdomen.

To be oriented with the anatomical locations of the different

abdominal organs.

Describe the differential diagnosis of parietal swellings.

To know the differential diagnosis of the intra-abdominal

swellings in each compartment with their management.

2

Abdominal Examination

Exposure

Nipple to knee,

If embarrassing cover the lower abdomen with sheet.

Inspection

Abdominal contour

⚫ Normal --- flat from xiphoid to pubis,

⚫ umbilicus is at the center of the abdomen.

Abdominal contour

⚫ Generalized distension

⚫ fat,

⚫ fetus,

⚫ feces,

⚫ flatus,

⚫ fluid,

⚫ full-sized tumors.

⚫ Localized bulge

⚫ Mass, organomegaly, hernia.

Palpation

Superficial

• Gain patient’s confidence

• Temperature

• Parietal mass

• Tenderness

• Hyperthesia

3

Deep

• Liver

• Spleen

• Kidney

• Abdominal Aorta

• Masses

If masses are felt, note:

• Site,

• size,

• Shape

• Surface

• skin overlying

• special character:

• consistency

• tenderness

• pulsations

• mobility with respiration or with hand.

4

Parietal versus intra-abdominal mass

Rising up test

Imaging

1. PARIETAL SWELLINGS

• Extends over the costal margin

5

• Moves anterior and posterior with respiration

• More prominent on rising up test

2. INTRA-ABDOMINAL SWELLINGS

• Disappear beneath costal margin

• Moves up and down with respiration

• Less prominent on rising up test

PARIETAL SWELLINGS (common for different quadrants)

Skin:

• Sebaceous cyst

• Papilloma

• Melanoma, SCC

Subcutaneous tissue:

• Lipoma: SC, intermuscular

• Neurofibroma

• Hamangioma, lymphangioma

Muscles:

• Rectus sheath haematoma

• Desmoid tumour

6

✓ Mid-clavicular lines are the vertical planes

7

In a patient presenting with mass abdomen, generally following clinical

features should be assessed care fully.

_ Pain: Site, nature, aggravating or relieving factors, duration of pain,

referred pain.

_ Vomiting: Type, content, haematemesis, relation to food, frequency.

_ Jaundice: It is an important factor in relation to liver, gallbladder or

pancreatic masses.

_ Bowel habits: Constipation, diarrhoea, bloody diarrhoea, furious

diarrhoea, tenesmus.

_ Decreased appetite and weight.

_ Inspection of the mass: Anatomical location, margin, surface,

movement with respiration.

_ Palpation of the mass: Site, extent, surface, tender ness, consistency,

movement with respiration, mobility, borders, plane of the swelling (by

leg raising test), presence of other masses.

_ Often mass needs to be examined for change of position—in sitting, in

standing, in side position, after a brisk walk, in knee elbow position for

retroperitoneal mass and for puddle sign (but diffi cult to keep patient in

this position).

_ Percussion is an important aspect of examination in case of an

abdominal mass. Percussion over the mass is important to predict the

8

anatomical location of the mass. If mass is dull, then it is in the anterior

abdo minal wall or in front of the bowel intra-abdominally like liver,

spleen, gallbladder.

If the mass is with a impaired resonant note, then the mass is arising from

the bowel like stomach, colon, small bowel.

If the mass is resonant on percussion, then the mass is probably in the

retroperitoneal region. Other than this, liver dullness, free fluid in the

abdomen should be elicited during percussion.

_ Per rectal examination: It is done to look for any secon daries in

rectovesical pouch, primary tumour or relation of lower abdomen masses

(pelvic masses).

_ Pervaginal examination is done to assess pelvic masses.

MASS IN THE RIGHT HYPOCHONDRIUM

Liver Palpable Mass in Right Hypochondrium

_ It is horizontally placed.

_ It usually moves with respiration.

_ Upper border is not felt.

_ It is dull on percussion (This dullness continues over liver dullness

above).

_ Fingers can not be insinuated under right costal margin.

Conditions where liver gets enlarged:

1. Soft, smooth, nontender liver:

_ Hydrohepatosis: It is due to obstruction of CBD causing dilatation of

intrahepatic biliary radicles.

_ Congestive cardiac failure.

_ Hydatid cyst of the liver: Here mass is well-localised in the liver with

typical hydatid thrill. Three finger test: Three fingers are placed over the

mass widely. When central finger is tapped fluid movement is elicited in

lateral two fingers.

2. Soft, smooth, tender liver:

9

_ Amoebic liver abscess: Here liver often gets adherent to the anterior

abdominal wall and will not move with respiration. Intercostal

tenderness, right sided pleural effusion are common.

Amoebic liver abscess

_ It is due to entamoeba histolytica infestation

_ It is more common in alcoholics and cirrhotics

_ Single abscess is common—70%; common in right posterosuperior

lobe—80%

_ Chocolate colored Anchovy sauce pus is classical

_ Secondary infection can occur—30%—life-threatening due to

septicaemia

_ It can be acute or chronic; both mimics hepatoma

_ Rupture into lungs—most common site of rupture

_ Most dangerous rupture is into pericardium—left lobe abscess

_ Liver failure can develop in cirrhotic patient

Features

_ Common in males (20:1), fever, pain, intercostal tenderness, tender

liver

_ Mimics cholecystitis, subphrenic abscess, hepatoma

_ Total count, LFT, prothrombin time, US abdomen are relevant

investigations

_ Chest X-ray may show left sided sympathetic pleural effusion

_ CT scan to differentiate from hepatoma

_ Treatment—drugs like metronidazole, injection dehydroemetine,

chloroquine tablets, diloxanate furoate; U/S guided aspiration after

controlling prothrombin time using inj vitamin K or FFP; if recurs

percutaneous guided drainage using pigtail catheter, or open laparotomy

and drainage with placement of Malecot’s catheter

3. Hard, smooth liver:

_ Hepatoma (HCC): Here a large, single, hard nodule is palpable in the

liver. But occasionally there can be multiple nodules when it is

multicentric. Rapidly growing tumour can be soft also. Hepatoma often

can also be tender due to tumour necrosis or stretching of the liver

capsule. Vascular bruit may be heard over the liver during auscultation. It

mimics amoebic liver abscess in every respect.

_ Solitary secondary in liver.

10

Hepatoma/hepatocellular carcinoma/HCC

_ Common aetiologies are afl atoxins, hepatitis B and hepatitis C virus

infection, alcoholic cirrhosis, haemochromatosis, smoking, hepatic

adenoma, clonorchis sinensis, polyvinyl chloride

_ Unicentric and right lobe involvement is more common

_ Fibrolamellar variant is common in left lobe, not related to hepatitis or

cirrhosis without AFP level raise. There are increased serum vitamin B12

binding capacity and neurotensin levels.

_ It can be multifocal/indeterminate/spreading/expanding— Okuda

classifi cation

_ Presents as large smooth hard liver mass—later jaundice, fever, pain

and tenderness, ascites and bruit over mass

_ Spreads to lymphatics, blood and direct spread

_ Mimics amebic liver abscess, secondaries, hydatid cyst, polycystic liver

disease

_ LFT, CT scan, raised AFP, liver biopsy (only needed) are the

investigations

_ Hemihepatectomy in early operable growth is the treatment

_ Hepatic artery ligation/intra-arterial chemotherapy/chemoembolisation/

percutaneous ethanol or acetic acid injection/ radiofrequency

ablation/chemotherapy using adriamycin, carboplatin, gemcitabine—are

palliative procedures

4. Hard, multinodular liver:

_ Multiple secondaries in liver: Here hard nodules show umbilication

which is due to central necrosis.

_ Macronodular cirrhotic liver.

11

Palpable Gallbladder in Right Hypochondrium

_ It is smooth and soft (except in carcinoma gallb ladder).

_ It is mobile horizontally (side-to-side).

_ It moves with respiration.

_ It is located right of the right rectus muscle, below the right costal

margin or below the lower margin of the palpable liver.

_ It is dull on percussion.

Conditions where gallbladder is palpable:

1. Soft, nontender gallbladder:

_ Mucocele of the gallbladder.

_ Enlarged gallbladder in obstructive jaundice due to carcinoma head of

the pancreas or peri ampullary carcinoma or growth in the CBD.

2. Hard gallbladder:

_ Carcinoma gallbladder.

3. Tender gallbladder—empyema GB.

Other Masses in the Right Hypochondrium

_ Pericholecystic infl ammatory mass: It is tender, smooth, firm or soft,

nonmobile, intra-abdominal mass often with guarding.

_ Kidney mass arising from upper pole of the kidney: It may be due to

renal cell carcinoma or hydronephrosis.

MASS IN THE EPIGASTRIUM

Palpable Left Lobe of the Liver

_ It is in the epigastric region.

12

_ Its upper border cannot be felt.

_ It moves with respiration.

_ It extends towards left hypochondrium.


Features of Stomach Mass

_ It is located in the epigastric region.

_ It moves with respiration. It is intra-abdominal.

_ It is resonant or impaired resonant on percussion.

_ Mass may be better felt on standing or on walking.

_ Mass is often mobile, unless it gets adherent posteriorly.

_ In pylorus mass, all margins are well felt which is mobile with features

of gastric outlet obs truction.

_ Mass from the body of the stomach is horizontally placed without any

features of obstruction.

_ Mass from the upper part of the stomach near the OG junction causes

dysphagia.

_ Mass from the fundus of the stomach is in the upper part of the

epigastric region towards left side.

_ Carcinoma stomach is nodular and hard. It is the most common cause

for stomach mass.

_ Leiomyoma of stomach is smooth and firm.

Management of gastric carcinoma

_ Early growth—pylorus—lower radical gastrectomy with removal of

tumour, proximal 5 cm clearance, nodal clearance, greater and lesser

omentum, distal pancreas and spleen (now not regularly removed; it is

removed to clear splenic nodes—one of the node stations) and Billroth II

anastomosis or Roux-en-Y anastomosis is done. Postoperatively adjuvant

chemotherapy should be given—5 fl uorouracil, mitomycin, epirubicin,

cisplatin

_ Growth in body, proximal growth, diffuse carcinoma and generalised

linitis plastica are the indications for total radical gastrectomy with

oesophagojejunal anastomosis

_ Neoadjuvant chemotherapy in advanced gastric cancer prior to surgery

and later gastrectomy

13

_ Instillation of mitomycin C impregnated charcoal intraperitoneally to

control lymphatic disease (Japan)

_ Palliative procedures like palliative partial gastrectomy, anterior

gastrojejunostomy, Devine’s exclusion procedure, luminal stenting in

proximal inoperable growths, chemotherapy are used in inoperable cases

_ In early carcinoma proper lymph nodal clearance is important

14

Abdominal masses of pancreatic origin

Pancreatic cystic lesions (inflammatory cystic or cystic neoplasm)

WOPN (walled-off pancreatic necrosis)

Pseudocyst of the Pancreas

_ Mass in the epigastric region. It is smooth, soft. It can be tender if it is

infected.

_ It does not move with respiration.

_ It is not mobile.

_ It has got transmitted pulsation. It is confi rmed by placing the patient

in knee-elbow position.

_ Lower border is well felt. Upper border is not clear.

_ It is resonant on percussion.

_ Baid test: As the stomach is pushed in front, Ryle’s tube when passed,

can be felt per abdomen on palpation.

15

Investigations for pseudocyst of pancreas

• Ultrasound—commonly done procedure

• CT scan, ideal and choice

• LFT, serum amylase, prothrombin time

• ERCP to find out communications

• Barium meal—not done now— shows widened vertebrogastric angle

Indications of intervention:

Cyst size bigger than 6 cms

Mature thick wall cyst

Infected cyst

Complications

• Rupture—3%

• Infection—20%

• Bleeding—torrential 7%

• Cholangitis

Interventions

• Roux-en-Y cystojejunostomy is ideal

• Cystogastrostomy—Jurasz procedure— commonly done

cystoduodenostomy

• Cystogastrostomy with external drainage if infected—Smith operation

• Endoscopic stenting

• Laparoscopic cystogastrostomy— popular—safer

• Guided aspiration helps but high recurrence rate of 70%

16

Pancreatic cystic neoplasm (mucinous cystic, IPMN vs serous cystic)

Pancreatic cystadenocarcinoma

Mass is smooth, firm, does not move with respiration, nonmobile,

resonant on percussion. Patient complaints of back pain.

Serous cystadenomas (SCAs)

Have thick, fibrous walls and contain clear fluid. Almost all SCAs are

benign.

Intraductal Papillary Mucinous Neoplasms (IPMNs)

Start in the ducts that connect the pancreas to the intestine. They’re the

most common type of precancerous cyst. They produce large amounts of

proteins that form mucus (mucin) in the cyst lining and fluid.

It’s difficult to predict if and when an IPMN will become cancerous,

although research indicates that those that involve the main pancreatic

duct are at higher risk for this.

Mucinous Cystic Neoplasms (MCNs)

These cysts are precancerous growths that can start in the body and tail of

the pancreas. They almost always develop in women rather than men.

Large ones that contain tiny walls that divide the cyst into compartments,

called septations, may be more likely to become cancerous.

18

Pancreatic Cancer (Advanced cancer head pancreas, cancer body

pancreas)

It is the fourth leading cause of cancer deaths, being responsible for

8% of all cancer-related deaths.

Approximately 75% of all pancreatic carcinomas occur within the

head or neck of the pancreas, 15-20% occur in the body of the

pancreas, and 5-10% occur in the tail.

19

Palpable gallbladder (ie, Courvoisier sign)

Advanced intra-abdominal disease: Presence of ascites, a palpable

abdominal mass, hepatomegaly from liver metastases, or

splenomegaly from portal vein obstruction

Advanced disease: Paraumbilical subcutaneous metastases (or

Sister Mary Joseph nodule)

Possible presence of palpable metastatic mass in the rectal pouch

(Blumer shelf)

Possible presence of palpable metastatic cervical nodes: Nodes

may be palpable behind the medial end of the left clavicle

(Virchow node) and other areas in the cervical region

Colonic Mass

_ It is due to carcinoma of transverse colon.

_ It is mobile, horizontally placed, nodular, hard mass which does not

move with respiration. Caecum will be dilated and palpable.

_ It is resonant or impaired resonant on percussion.

_ Patient will be having bowel symptoms, loss of appetite and decreased

weight.

Para-aortic Lymph Node Mass

_ Mass in the epigastric region which is deeply placed, nonmobile, not

moving with respiration.

_ It is vertically placed, above the level of the umbilicus and resonant on

percussion.

20

_ Causes for enlargement are: Secondaries, lymphomas or tuberculosis.

Aortic Aneurysm

It is smooth, soft, pulsatile (expansile pulsation which is confirmed by

placing the patient in knee-elbow position).

It is vertically placed above the level of the umbilicus, nonmobile, not

moving with respiration and resonant on percussion.

MASS IN THE LEFT HYPOCHONDRIUM

Enlarged Spleen

_ Spleen has to enlarge three times to be palpable clinically.

_ It enlarges towards the right iliac fossa from left costal margin.

_ It moves with respiration, mobile, obliquely placed, smooth, soft or

firm, with a notch on the anterior edge which is directed downwards and

inwards. _ Fingers cannot be insinuated over the upper border.

_ “Hook sign” is positive, i.e. one cannot insinuate the fingers under the

left costal margin.


Causes of splenomegaly

Infectious:

Protozoa

Bilhariziasis, Malaria

Viral

CMV, EBV

Bacterial

Septicemia, TB, Typhoid

Cellular infiltration:

Amylodosis, sarcoidosis

Collagen disease:

Felty’s

Space occupying lesions:

Hydatid cyst

Cellular proliferative:

Leukemias

Lymphoma

21

Spherocytosis, hemolytic anemia

Myelofibrosis

sarcoidosis

Infarction, trauma:

Emoli BE

Splenic a., v. thrombosis

Splenic hematoma

Left Sided Colonic Mass

_ It is mobile, nodular, resonant.


_ It is commonly due to carcinoma colon.

Left Renal Mass from Upper Pole of any Cause

It has got features of renal mass.

Left Sided Adrenal Mass

22

_ It does not move with respiration. It is not mobile.

_ It is deeply placed mass. Often it crosses the midline.

_ It is resonant on percussion. It mimics kidney mass.

Mass Arising from the Tail of the Pancreas

Clinical features are same as other pancreatic masses. Causes are

pseudocyst in tail of the pancreas and cystadenomas.

MASS IN THE LUMBAR REGION

Palpable Kidney Mass

_ There is fullness in the loin which is better observed in sitting position.

_ Mass moves with respiration. It is vertically placed.

_ It is bimanually palpable. It is ballotable.

_ Renal angle is dull on percussion (normally it is resonant due to colon).

_ There is a band of resonance in front due to reflected colon.

_ It does not cross the midline.

Conditions Where Kidney Gets Enlarged

Hydronephrosis:

_ It is smooth, soft, lobulated, nontender mass, nonmobile.

Pyonephrosis:

_ History of throbbing pain in the loin, pyuria and fever with chills.

_ It is smooth, soft and tender kidney mass, nonmobile.

Polycystic kidney:

_ History of loin pain and haematuria.

_ Hypertension, anaemia and features of renal failure.

_ Usually bilateral. But one side can present early than on the other side.

_ Lobulated smooth surface.

Renal cell carcinoma:

_ History of mass in the loin, haematuria, fever and dull pain.

_ Mass is nodular and hard.

_ It does not cross the midline.

_ Initially mobile; eventually it infiltrates gets fixed and becomes

nonmobile.

23

Mass from the Ascending Colon on Right Side or Descending Colon

on Left Side

_ History of altered bowel habits with decreased appetite and weight.

_ Mass is nodular, hard which does not move with respiration and is not

ballotable.

_ It is resonant or there is impaired resonance on percussion.

_ Renal angle is resonant.

_ Proximal dilated bowel may be palpable.

Adrenal Mass

_ It is nodular and hard.


_ It is not mobile and often crosses the midline.

_ It is felt on deep palpation.

_ It is resonant in front.

_ It is not ballotable.

Retroperitoneal Tumours

_ They are not mobile, resonant and do not fall forward in knee-elbow

position.

_ They are deeply placed mass which are usually smooth and hard.

_ They may be retroperitoneal sarcomas or teratomas or lymph node

mass.

Retroperitoneal Cysts

They are smooth and soft with the same features as retroperitoneal

tumours.

✓ Cystic lesions in the abdomen

_ Mucocele/empyema of gallbladder

_ Pseudocyst of pancreas

_ Hydatid cyst of liver

_ Congenital nonparasitic cyst of liver

_ Hydronephrosis

_ Mesenteric cyst

_ Ovarian cyst

24

_ Omental cyst

_ Aneurysm

_ Retroperitoneal cyst

_ Cystadenocarcinoma of ovary

_ Loculated ascites

MASS IN THE UMBILICAL REGION

Usual masses are:

_ Mesenteric cyst

_ Omental cyst

_ Ovarian cyst (pedunculated)

_ Small bowel tumours

_ Extension of masses from other region

_ Transverse colon mass

_ Mass in the body of pancreas

_ Mesentery mass

_ Lymph node mass—secondaries (primary from GIT, testis, ovary,

melanoma)/lymphoma/tuberculosis

_ Retroperitoneal tumour

Mesenteric Cyst

_ Tillaux triad:

1. Soft intra-abdominal umbilical mass.

2. Mobile in the direction perpendicular to the attachment

of the mesentery.

3. Resonant mass.

_ May precipitate intestinal obstruction, volvulus.

Omental Cyst

_ It is smooth, soft and nontender.

_ It moves with respiration. It is mobile in all directions.


Small Bowel Swellings

_ Small bowel lymphomas.

25

_ Small bowel carcinomas.

_ Intussusception.

Intussusception

_ Mass in umbilical region usually towards left and above the umbilicus.

_ Occasionally towards right side.

_ Mass is intra-abdominal which is sausage shaped, with concavity

towards umbilicus, well-defined, smooth, firm and mobile.

_ Mass does not move with respiration.

_ Mass contracts under palpating fi ngers.

_ Often mass disappears and reappears.

_ Mass is resonant or there is impaired resonance on percussion.

_ “Red currant gelly” stool with features of intestinal obstruction may be

present.

MASS IN THE RIGHT ILIAC FOSSA

_ Appendicular mass or abscess

_ Carcinoma caecum

_ Ileocaecal tuberculosis

_ Amoeboma

_ Psoas abscess

_ Lymph node mass either mesenteric or external Iliac lymph nodes

_ Bony swellings

_ Ectopic kidney

_ Undescended testis (Abdominal)

_ Actinomycosis

_ Crohn’s disease

_ Iliac artery aneurysm

_ Ovarian swelling-ovarian cyst

_ Tubo—ovarian mass

_ Uterine mass like pedunculated fibroid

26

Appendicular Mass

_ It is smooth, firm, tender mass in the right iliac fossa.

_ It is not mobile. It does not move with respiration.

_ It is resonant on percussion. It is well-localised mass with distinct

borders

Appendicular Abscess

It is smooth, soft, tender and dull mass in the right iliac fossa with

indistinct borders.

Carcinoma Caecum

_ It is nodular, hard, mass in the right iliac fossa.


_ It is mobile but mobility may be restricted once it gets adherent to psoas

muscle.

_ Mass is resonant or there is impaired resonance on per cussion.

_ Often features of intestinal obstruction may be present.

Ileocaecal Tuberculosis

_ Mass in the right iliac fossa which is smooth, hard, resonant and

nontender.

_ It does not move with respiration and has restricted mobility.

_ Caecum may be pulled up to lumbar region due to fi brosis.

Amoeboma

_ History of dysentery with pain in the right iliac fossa.

_ Smooth, hard, well-defi ned mass in the right iliac fossa which is

nonmobile.

_ It may or may not be tender.

Psoas Abscess

_ It is localised, smooth, soft, nonmobile mass in the right iliac fossa.

_ Psoas spasm (fl exion of the hip joint) is typical.

_ Spine may show gibbus, tenderness, paraspinal spasm. Spinal

movements will be restricted.

27

MASS IN THE LEFT ILIAC FOSSA

_ Carcinoma sigmoid or descending colon

_ Bony masses

_ Ovarian/uterine masses

_ Psoas abscess

_ Ectopic kidney

_ Lymph node mass

_ Undescended testis

MASS IN THE HYPOGASTRIUM

Bladder Mass

_ It is in the midline. It is dull on percussion. Lower border is not felt.

_ It can be mobile in horizontal direction. Mass reduces in size after

emptying the bladder. It can be felt on per-rectal examination.

_ It is either carcinoma bladder (common) or leiomyoma or sarcoma

bladder.

Uterine Mass

_ It is midline mass which is smooth, hard.

_ Lower border is not felt which extends into the pelvis.

_ It is felt on pervaginal examination.

Ovarian Mass

Pelvic soft tissue mass.

In all lower abdomen masses P/R and or P/V is a must.

.

Investigations for Mass Abdomen

_ Haematocrit, liver function tests, renal function tests, stool/ urine

examination.

_ Ultrasound abdomen.

_ Endoscopies-gastroscopy-colonoscopy-ERCP-MRCP.

_ Barium studies-Barium meal-Barium enema-Barium meal - Follow

through.

_ CT scan-MRI.

_ Endosonography.

28

_ Ascitic tap.

_ Diagnostic laparoscopy.

_ U/S guided/CT guided biopsy.

_ IVU/RGP/Cystoscopy/Isotope renogram.

_ Exploratory laparotomy.

Important Notes:

_ Hard mass in the abdomen is commonly malignant

_ Firm mass may be tuberculous, lymphoma or many benign conditions

_ Soft masses are hydronephrosis, pseudocyst, mesenteric cyst, omental

cyst, and loculated ascites

_ In tuberculosis abdomen may be doughy due to thickened parietal

peritoneum or omentum

_ It is difficult to elicit fluctuation in the mass abdomen as mass cannot

be fixed properly

_ Plane of the swelling should be checked by leg raising/head raising

test/Valsalva manoeuvre/knee elbow test

_ Bimanual palpation, ballotability, renal angle inspection, palpation and

percussion should be done in case of renal mass

_ Intrinsic mobility should be checked. Different mobilities/ movements

are—gallbladder shows side to side; stomach lateral; ovarian mass—all

over; mesenteric cyst—right angle to line of mesentery; transverse colon

mass—vertical; small bowel mass all over; appendicular mass/pancreatic

mass/ nodal mass (para-aortic)/retroperitoneal mass do not show any

mobility; cystadenocarcinoma of pancreas may show

false mobility (tree top mobility)

Percussion is very important method of examination to find out the

anatomical plane of the mass. Mass in front of the bowel like

liver/spleen/gallbladder/parietal mass are dull on percussion. Mass from

the bowel is resonant on percussion like from stomach, small bowel and

colon. Retroperitoneal masses like cyst, sarcoma, nodal mass, aneurysm,

pancreatic mass are resonant on percussion

_ Succussion splash and auscultopercussion tests are done for gastric

outlet obstruction in pyloric stenosis

29

_ Digital examination of rectum (P/R) and left supraclavicular

examination for nodes is a must. PR is done to see Blumer shelf

secondaries in rectovesical pouch. Pervaginal examination should be

done in pelvic mass in females

_ Bladder should be emptied while examining pelvic mass

_ Bimanual examination is done often under general anaesthesia in case

of pelvic mass

_ Auscultation for bruit depends on condition and location of mass—over

epigastrium, over liver

_ Other relevant systemic examination is a must in examination of mass

abdomen—respiratory system, skeletal and neurological systems

Masses that may appear and disappear

_ Pseudocyst of pancreas (communicating)

_ Hydronephrosis (intermittent)

_ Choledochal cyst

_ Intussusception

the differential diagnosis of abdominal masses

Documents