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Clinical examination of abdominal lump

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Clinical examination of abdominal lump

  1. 1. EXAMINATION OF ABDOMINAL LUMP By - Dr. Waseem Ahmad Dept. of Surgery National Institute of Unani Medicine, Bangalore 14-12-2017
  2. 2. Contents 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Differential diagnosis
  3. 3. INSPECTION Position Position should be described according to the nine anatomical region of the abdomen. Skin overlying the swelling Tense, red, shiny, pigmented and engorged veins. Movements with respiration Swelling originating from liver, gall bladder, spleen and stomach move freely with respiration. Swellings arising from kidney and suprarenal gland move very little with respiration.
  4. 4. Visible peristalsis Conditions giving rise to visible peristalsis are intestinal obstruction and carcinoma of pylorus of stomach and transverse colon, •In case of obstruction In pyloric end of stomach: from left to right. In small intestine: ladder pattern peristalsis. In large intestine: from right to left in form of inverted U. INSPECTION
  5. 5. In case of carcinoma •Ca of pylorus of stomach: from left to right. •Ca of transverse colon: from right to left. Swelling on hernia sites If the swelling is situated over one of the hernia site, the patient is asked to cough, if cough impulse is present, it is a case of hernia. Lump on hernia site is not always a hernia. INSPECTION
  6. 6. The scrotum In case of abdominal lump, the scrotum is always examined. In case of malignancy of testes, the pre and para aortic lymph nodes are involved and metastasized. Left supraclavicular region Left supra clavicular lymph nodes are often secondarily involved and enlarged in case of malignancy of breast, stomach, colon, pancreas and testes. This is known as Troisier’s sign. INSPECTION
  7. 7. PALPATION Local temperature Local rise of temperature indicates inflammatory swelling. Tenderness Pain on pressure indicates inflammatory swelling. Position Position indicates the origin of the swelling. Size, shape and surface They indicate underlying pathology.
  8. 8. Margins Margins should be defined by getting all round the swelling. Well defined margins indicate neoplasm. Ill defined margins indicate inflammatory of traumatic swelling. Defining the margins may be difficult if the swelling is present under costal margin or pelvis. PALPATION
  9. 9. Consistency Define consistency like soft, cystic, firm, hard and stony hard. Same consistency throughout the swellig or different consistencies at different parts of swelling. Cystic swelling will show positive fluctuation and fluid thrill. If cystic swelling becomes tense then it may be difficult to elicit the fluid thrill. Does swelling pits on pressure? Like parietal abscess and colon loaded with faeces. PALPATION
  10. 10. Movement A: Movement with respiration Swelling associated with the liver, gall bladder, stomach and spleen move freely with respiration. This movement is up and down. One hand is placed on the lower border of the swelling and patient is asked to take deep breath, hand will move downwards with downward displacement of the swelling during inspiration. B: is the swelling movable in all direction? The swelling is held and tried to move in vertical and horizontal direction. A mesenteric cyst moves only at right angle to the line of attachment of cyst. PALPATION
  11. 11. C: is swelling ballottable? One hand behind the loin and other hand in front of abdomen and swelling is tried to move between two hands. Example: renal swelling. Is swelling Parietal or intra-abdominal? For differentiating this, following methods should be applied. A: leg raising test (Carnett’s test) B: shoulder raising test C: blow out air with mouth and nose shut In all the tests, abdominal muscles are taut and if the swelling is parietal, it will become prominent while it will disappear if it is an intra abdominal swelling. PALPATION
  12. 12. Is the swelling pulsatile? If it is pulsatile then differentiate between expansile pulsation and transmitted pulsation. Method 1: Index finger of each hand is put on the swelling. Two fingers will get diverted in case of expansile pulsation whereas fingers will not be diverted in transmitted pulsation. Method2: The patient is placed in knee-elbow position. Swelling in front of abdominal aorta will get separated from the aorta and will become non pulsatile whereas aortic aneurysm will continue to pulsate. Hernia orifices If the swelling is present over any of the hernia site, test for cough impulse and reducibility should be carried out. If cough impulse and reducibility are present then the case is one of the hernia. PALPATION
  13. 13. PERCUSSION Swelling arising from the solid organ will be dull on percussion. If coils of intestine overlie the swelling then percussion note will be resonant. That is why swellings arising from the liver and spleen are dull whereas renal swellings are resonant. Shifting dullness and fluid thrill should be looked for in case of fluid is suspected in peritoneal cavity. The dullness of ascites shifts with the change in position of the patient whereas the dullness of ovarian cyst does not shift with change in position. PALPATION
  14. 14. AUSCULTATION Peristaltic movement will be heard in hernia containing coils of intestine. Aortic pulsation can be heard in aortic aneurysm.
  16. 16. DIFFERENTIAL DIAGNOSIS Two things are remembered in this respect. First position of swelling or lump with respect to nine anatomical regions is confirmed then it is decided whether the swelling is parietal or intra abdominal. 1. D/D of lump in right hypochondrium. 2. D/D of lump in epigastrium. 3. D/D of lump in left hypochondrium. 4. D/D diagnosis of swelling in right and left lumbar regions. 5. D/D of swelling in umbilical region. 6. D/D of swelling in right iliac region. 7. D/D of swelling in hypogastrium. 8. D/D of swelling in left iliac region.
  17. 17. 1. D/D of lump in right hypochondrium. Parietal swelling Lipoma, fibroma, sebaceous cyst, angioma etc. Cold abscess It is arising from caries of ribs (common) and caries of spines (rare). Soft cystic and fluctuating swelling. No signs of inflammation. Irregularity of the affected rib and deformity of the spine in X-Ray clinches the diagnosis. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  18. 18. Intra abdominal swellings These swellings arise from following organs. I. Liver II. Gall bladder III. Subphrenic abscess IV. Pylorus of stomach and deudenum V. Hepatic flexure of colon VI. Right kidney VII.Right supra renal gland DIFFERENTIAL DIAGNOSIS right hypochondrium.
  19. 19. I. Liver Enlargement of liver swelling is determined by palpating its lower limit and percussing its upper border. Hepatic swellings are continuous with liver dullness. They move up and down with respirations Common causes of hepatic swelling are discussed below. Congenital Riedel’s lobe Tongue shaped projection from the lower border of right lobe of the liver. It is more wide and flat than the gall bladder. It lacks spherical outline like gall bladder. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  20. 20. Amoebic hepatitis and abscess Pt. complains of pain in right hypochondrium wich refers to right shoulder with rise of temperature. There is H/O dysentery months or years back. The patient looks pale and slightly icteric. The liver is palpable and tender. The upper limit of dullness is raised. Subcutaneous edema which pits on pressure is also found. X-ray chest: Diaphragm is raised and immobile. Stool(r/m): Presence of Entamoeba histolytica. Aspiration of anchovy sauce pus confirms diagnosis. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  21. 21. Suppurative pylephlebitis During the course of acute appendicitis and inflamed pile the patient suffers from high rise of temperature and rigors. The liver becomes palpable and tender. Suppurative cholangitis H/O cholelithiasis is received. The stone becomes impacted in CBD. High rise of temperature. Liver becomes tender. Jaundice is associated. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  22. 22. Hydatid cyst Occurs at lower margin of the liver. Palpable spherical and smooth swelling. Positive hydatid thrill and fluctuation. H/O attack of urticaria and oesinophilia. Positive complement fixation and Casoni’s intradermal reaction test. Melanotic Ca of liver It is an enlarged liver with malignant melanoma anywhere in the body. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  23. 23. Carcinoma of liver Primary carcinoma like hepatoma and cholangioma are rare. Secondary carcinoma from GIT via portal vein and other organs via lymphatics are common. Liver is enlarged and irregular with nodules of varying sizes. The nodules become soft at the centre and umbilicated. The patient may become jaundiced and ascitic. General condition of patient is severely ill. H/O weight loss. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  24. 24. Cirrhosis of liver The liver is firm, shrunk and irregular with small nodules. The nodules are never umbilicated. Portal hypertension with ascites. Hematemesis from ruptured esophageal varices. H/O alocohol consumption may be present. Patient may be jaundiced. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  25. 25. 2. Gall bladder It produces oval and smooth swelling which is tense and cystic. It comes out of the lower border of the liver and moves up and down with respiration. It is not a ballottable swelling. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  26. 26. 3. Subphrenic abscess There are multiple causes of pus collection under the diaphragm. Common causes are perforated peptic ulcer, following trauma of abdomen, following operation of biliary tract, following operation on stomach and colon and acute appendicitis. There is rise of temperature, rigors and rapid pulse. Pain in right hypochondrium. Presence of tachypnoea. Tenderness over the costal margin or xiphoid process or more precisely over the 11th intercostal space. X-ray chest: raised diaphragm with sluggish movement. Aspiration of pus from subdiaphragmatic space confirms the diagnosis. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  27. 27. 4. Pylorus of stomach and deudenum Carcinoma It gives rise to obstructive symptoms. Barium meal will show filling defect at pyloric end. Subacute perforation of peptic ulcer H/o symptoms of peptic ulcer. Localized tender mass. Sudden excruciating pain before formation of the mass. It may lead to subphrenic abscess. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  28. 28. 5. Hepatic flexure of colon I. Intussusception II. Hypertrophic tuberculosis III. Carcinoma DIFFERENTIAL DIAGNOSIS right hypochondrium.
  29. 29. Intussusceptions Colicky pain and lump in right hypochondrium, red currant jelly in stool. Pain comes in intervals. Pain disappears within few minutes and comes within 15 minutes. Facial pallor with each attack of pain In early stage normal stools are passed frequently. In later stage blood with mucus passes per rectum which is known as red currant jelly. On examination, palpation of lump which is curved and sausage shaped and concavity toward umbilicus. After six hours signs of dehydration appear. After 24 hours abdomen starts distending and vomiting becomes profuse. Barium enema reveals pincer like ending of the affected part. Emptiness in right iliac fossa (signe de dance) DIFFERENTIAL DIAGNOSIS right hypochondrium.
  30. 30. 6. Kidney The features of kidney swellings are Reniform in shape Moves very slightly with repiration Ballottable Hand can be easily insinuated between upper pole of kidney and costal margin. Percussion will reveal resonant notes as coils of intestine and colon will lie in front of the kidney. DIFFERENTIAL DIAGNOSIS right hypochondrium.
  31. 31. 2. D/D of lump in epigastrium. Parietal swelling Epigastric hernia The ususal sufferer is strong muscular labourer. It is a round swelling anywhere between the xiphisternum and umbilicus. At first stage: it is as herniation of extra peritoneal fat through the weak spot of linea alba. No symptoms at this stage. At second stage: a pouch of peritoneum is drawn after it. At the third stage: small tag of omentum gets into the sac and becomes adherent. Now the patient complains of dragging pain.
  32. 32. Intra abdominal swellings i. Liver ii. Subphrenic space iii. Stomach and deudenum iv. Transverse colon v. Omentum vi. Pancreas vii. Abdominal aorta viii.Lymph nodes ix. Retro peritoneal structure Liver, subphrenic abscess, stomach and deudenum have been described in previous section. DIFFERENTIAL DIAGNOSIS EPIGASTRIUM
  33. 33. Transverse colon Intussusceptions Colicky pain and lump in epigastrium, red currant jelly in stool. Pain comes in intervals. Pain disappears within few minutes and comes within 15 minutes. Facial pallor with each attack of pain In early stage normal stools are passed frequently. In later stage blood with mucus passes per rectum which is known as red currant jelly. On examination, palpation of lump which is curved and sausage shaped and concavity toward umbilicus. After six hours signs of dehydration appear. After 24 hours abdomen starts distending and vomiting becomes profuse. Barium enema reveals pincer like ending of the affected part. Emptiness in right iliac fossa (signe de dance) DIFFERENTIAL DIAGNOSIS EPIGASTRIUM
  34. 34. Diverticulitis A tender and inflamed mass is felt. In barium enema, saw tooth appearance will be seen. Carcinoma Main complaint is swelling Swelling is irregular and hard and may be mobile in up and down direction but very slight in sideways. Anemia anorexia and occult blood are features which help in diagnosis. Barium enema X-ray reveals filling defects in the affected part. DIFFERENTIAL DIAGNOSIS EPIGASTRIUM
  35. 35. Omentum Tubercular peritonitis In tubercular peritonitis the omentum is rolled up to form a transverse ridge in epigastrium. Enlarged lymph nodes and adherent coils of intestine. Pancreas Pseudo pancreatic cyst Most common lump of pancreas is pseudo pancreatic cyst. This is the collection of fluid in the lesser sac of the peritoneal cavity resulting from the acute pancreatitis or trauma. Smooth and rounded swelling with positive fluctuation. Barium meal X-ray will show the position of the swelling. DIFFERENTIAL DIAGNOSIS EPIGASTRIUM
  36. 36. Abdominal aorta Aneurysm Aneurysm of this part is not uncommon. Swelling in epigastrium with expansile pulsation. DIFFERENTIAL DIAGNOSIS EPIGASTRIUM
  37. 37. 3. D/D of lump in left hypochondrium. Parietal swelling Cold abscess as on right side described earlier. Intra abdominal swellings These swellings occur in connection with i. Spleen ii. Stomach iii. Left lobe of liver iv. Splenic flexure of colon v. Tail of the pancreas vi. Left subphrenic space vii. Left kidney viii.Left supra renal gland
  38. 38. Cause of splenic swelling are multiple. Common causes in India are kala azar and malaria but not much of surgical importance. Some conditions of surgical importance are described below. Haemolytic anaemia Hereditary spherocytosis Acquired haemolytic anaemia DIFFERENTIAL DIAGNOSIS LEFT HYPOCHONDRIUM
  39. 39. Spleen An enlarged spleen is differentiated from the renal swelling by following points The spleen enlarges toward the umbilicus i.e. downward, medially and forward whereas kidney enlarges downwards and anteriorly. An splenic swelling is smooth and uniform, its anterior border is sharp with one or more notches. On inspection, an splenic swelling move more freely with respiration. The spleen is palpated easily from anterior aspect whereas kidney from posterior aspect. The fingers can be easily insinuated between the swellings and costal margins in case of renal swelling. The loin lateral to erector spinea is dull in renal swelling whereas resonant in splenic swelling. DIFFERENTIAL DIAGNOSIS LEFT HYPOCHONDRIUM
  40. 40. Hereditary spherocytosis Patients presents with anaemia and jaundice. Family history positive 70% of untreated cases show pigmented stone in gall bladder. Decreased R.B.Cs count. The spleen is enlarged with palpable liver. Chronic ulcers on legs. Faecal urobilinogen is increased (as there is increased unconjugated bilirubin in blood) Fragility test will show increased fragility of R.B.Cs. DIFFERENTIAL DIAGNOSIS LEFT HYPOCHONDRIUM
  41. 41. Acquired haemolytic anaemia Auto antibodies are produced which destroys R.B.Cs. Middle aged or elderly patients. No family history of anaemia. Liver may be palpable and sometimes generalized enlargement of the lymph nodes. Coomb’s test is usually positive. DIFFERENTIAL DIAGNOSIS LEFT HYPOCHONDRIUM
  42. 42. Idiopathic thrombocytopenic purpura Disease menifasts by cutaneous purpura, bleeding from oral mucosa and epistaxis. This attacks tend to come in cyclic order. These lesions are mostly present on dependent area due to increased intravascular features. Tourniquet test is positive DIFFERENTIAL DIAGNOSIS LEFT HYPOCHONDRIUM
  43. 43. Porphyria Inborn error of catabolism in haemoglobin. The main surgical importance is association of abdominal crisis. The crisis is characterized by intestinal colic with constipation. The patient is anaemic with neurological and mental symptoms. Spleen is enlarged. Felty’s syndrome Rheumatoid arthritis, leucopenia and spleenomegaly. DIFFERENTIAL DIAGNOSIS LEFT HYPOCHONDRIUM
  44. 44. 5. D/D of swelling in umbilical region. Parietal swellings The swellings arising from umbilicus and rectus sheath are important. Umbilicus congenital polyp or adenoma – in association with patent umbilical end of the vitelline duct. Umbilical hernia There are three types i.e. congenital, infantile and para umbilical hernia. The para umbilical is being described. Patients are female, fat and multiparous above 40 years of age. The hernia is seen just above the umbilicus where the divarication of two recti muscle allows the hernia to come out. Expansile cough impulse and reducibility are present.
  45. 45. Rectus sheath Desmoids tumor This is a type of fibroma which is unencapsulated and hard. It arises from deeper part of rectus abdominis. Majority of the patients are female. Some type of trauma either stretching of muscle fibers during pregnancy or operational wound causes haematoma formation within muscle fibres. This haematoma may initiate tumor formation. This tumor often recurs after excision. So it requires wide excision. This is also known as recurrent fibroid of Paget. DIFFERENTIAL DIAGNOSIS UMBILICAL REGION
  46. 46. Intra abdominal swellings These swellings may arise from i. Small intestine ii. Mesentry Small intestine Matted coils of intestine with tuberculous mesenteric lymphadenitis Patient presents with a lump in abdomen. The patient is usually a child. Loss of appetite, loss of weight and evening pyrexia. Deep palpation reveals palpable lymph nodes. Each node is round with irregular outline. In X-ray calcified lymph nodes may be seen. DIFFERENTIAL DIAGNOSIS UMBILICAL REGION
  47. 47. Mesenteric cyst These patients present with painless abdominal swelling. Swelling is fluctuant and situated near umbilicus. These swellings move freely at right angle to the line of attachment of mesentery but less movable along the line of attachment. Cysts are dull on percussion but are surrounded by band of resonance. Temporary impaction of food bolus in a segment of the bowl narrowed by cyst may produce features of intestinal obstruction. Rupture and haemorrhage of the cyst are two main complications which may result in acute abdominal condition. DIFFERENTIAL DIAGNOSIS UMBILICAL REGION
  48. 48. 6. D/D of swelling in right iliac region. Parietal swelling Pyogenic iliac abscess Pain in RIF Fever Skin red, hyperaemic and swollen Local temperature raised with tenderness Fluctuation positive
  49. 49. Intra-abdominal swellings These swelling may occur in connection of the following organs i. Appendix ii. Caecum iii. Terminal part of ileum iv. Lymph nodes v. Iliac arteries vi. Iliopsoas sheath DIFFERENTIAL DIAGNOSIS RIGHT ILIAC FOSSA
  50. 50. Appendix Appendicular lump (Appendicular mass and appendicular abscess) Appendicular mass Most common lump in this region Appendicular mass develop on third day or after commencement of acute appendicitis. The coincides with the position of the appendix The rigidity of abdominal musculature and therefore sometimes it is hard to feel the appendicular mass. The mass consists of inflamed appendix, omentum, edematous caecal wall, coils of intestines matted together with lymph. With conservative treatment the mass may become smaller and disappear. The lump is irregular, firm, tender and fixed. DIFFERENTIAL DIAGNOSIS RIGHT ILIAC FOSSA
  51. 51. Appendicular abscess Invariable pyrexia. Increased total counts. Signs of inflammation over the skin. It contains pus whereas appendicular mass never contain pus. DIFFERENTIAL DIAGNOSIS RIGHT ILIAC FOSSA
  52. 52. Hyperplastic ileocaecal tuberculosis Infection starts in lymphoid follicles and travel to serosa, muscularis and mucosa of the caecum. The intestinal wall become thickened with narrowing of its lumen. A lump in RIF Involvement of regional lymph nodes which become matted Recurrent attacks of abdominal pain with diarrhea Features of blind loop syndrome i.e. anaemia, loss of weight and steatorrhoea. The patient is ill with evening rise of temperature. The lump is hard, irregular and fixed. Barium meal follow through X-ray: long narrow constricted ileum with caecum higher up in position. DIFFERENTIAL DIAGNOSIS RIGHT ILIAC FOSSA
  53. 53. Crohn’s disease or regional ileitis c/f can be categorized in four stages 1. Inflammatory stage: Tender mass in right iliac fossa Rise of temperature Diarhhoea instead of constipation (appendicitis) 2. The colitis stage: Diarrhea, anaemia, loss of weight and fever Occult blood in stool.steatorrhoea High incidence of fissure in ano, fistulae in ano and perianal abscess. 3. The Stenotic stage: When the picture of small intestine obstruction supervene 4. The Fistulae stage: Fistula may be either internal or external. It communicates internally with caecum, sigmoid colon and bladder. Barium meal X-ray reveals string sign of Kantor (loss of peristalsis, narrowing of lumen and cordlike appearance of intestine). DIFFERENTIAL DIAGNOSIS RIGHT ILIAC FOSSA
  54. 54. Carcinoma of caecum Usually age of patient is above 40. The is the first indication. Alternate constipation and diarrhea. Anaemia, anorexia and loss of weight. Occult blood in the stool. Barium enema X-ray reveals filling defect in the lumen of caecum. Impaction of round worms H/O passing of worms in stool. Iliac arteries Aneurysm of iliac artery is recognized by expansile pulsation. DIFFERENTIAL DIAGNOSIS RIGHT ILIAC FOSSA
  55. 55. Iliac abscess Results from infection of haematoma in traumatized iliac muscle. This is differentiated from appendicular abscess by two points A: There will be H/O trauma and pain is localized to this region only. B: There will be clear space between the abscess and the ileum. DIFFERENTIAL DIAGNOSIS RIGHT ILIAC FOSSA
  56. 56. Thank You