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Abdominal lump surgery practical mbbs neetpg universty R-1.pptx
- 1. Abdominal lump Dr. AshwiniJ Modi MS General Surgeon PDUMC, Rajkot
- 2. Abdominal lump :A vague mass in abdomen.
- 3. 4 Quadrantsof Abdomen.
- 4. 9 regionsof abdomen
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- 6. Clinical features: • 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.
- 7. Local examination • Inspectionof the mass: Anatomical location, margin, surface, movement with respiration. • Palpation of the mass: Site, extent, surface, tenderness, consistency, movement with respiration, mobility , borders, plane of the swelling (by leg raising test), presence of other masses. • Percussion is an important aspect of examination incase of an abdominal mass. Percussion over the mass is important to predict the anatomical location of the mass. If mass is dull, then it is in the anterior abdominal 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 secondaries in recto-vesical pouch, primary tumour or relation of lower abdomen masses (pelvic masses). • Pervaginal examination is done to assess pelvic masses.
- 8. MASS IN THERIGHT HYPOCHONDRIUM
- 9. Liver Palpable asMass in Right Hypochondrium It is horizontally placed. It usually moves with respiration. Upper border is not palpable. Dull on percussion. Fingers can’t be insinuated under Costal margin
- 10. Conditions where livergets 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: 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.
- 11. 3. Hard, smoothliver: 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. 4. Hard, multinodular liver: Multiple secondaries in liver: Here hard nodules show umbilication which is due to central necrosis. Macronodular cirrhotic liver.
- 12. Palpable Gallbladder inRight Hypochondrium It is smooth and soft (except in carcinoma gallbladder). It is mobile horizontally (side by side). It moves with respiration. It is located right of the rectus muscle. It is dull on percussion. Conditions where gallbladder is palpable. 1. Soft, non tender gallbladder: Mucocele of the gallbladder Enlarged gallbladder in obstructive jaundice due to carcinoma head of pancreas or peri ampullaray carcinoma or growth in CBD. 2. Hard gallbladder: Carcinoma gallbladder. 3. Tender gallbladder: Empyema GB.
- 13. Other masses inRHC Pericholecystic inflammatory mass: it is tender, smooth, firm, or soft, non mobile, intra abdominal mass often with guarding. Kidney masses arising from upper pole of kidney: It may be due to RCC or Hydronephrosis.
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- 15. PALPABLE LEFT LOBEOF LIVER Palpable Left lobe of Liver it is in epigastric region. Its upper border cannot be felt. It moves with respiration. It extends towards left hypochondrium. It is dull on percussion. Conditions where left lobe of liver is palpable: Hepatoma Amoebic liver abscess in left lobe Left lobe secondaries Hydrated cyst of the left lobe.
- 16. Features of stomachmass 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 obstruction. 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 O-G 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 commonest cause for stomach mass. Leiomyoma of stomach is smooth and firm.
- 17. It hasgot transmitted pulsation. It is confirmed 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.
- 18. Features of Pancreaticlesion 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. Cystadenocarcinoma of the Pancreas Mass is smooth, firm, does not move with respiration, Non mobile , resonant on percussion. Patient complaints of back pain.
- 19. Colonic mass Itis 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.
- 20. Para-aortic Lymph NodeMass Mass in the epigastric region which is deeply placed, Non mobile, not moving with respiration. It is vertically placed, above the level of the umbilicus and resonant on percussion. Causes for enlargement are: Secondaries, lymphomas or tuberculosis.
- 21. Aortic Aneurysm Itis 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, Non mobile , not moving with respiration resonant on percussion. More common infra renal but when it’s supra renal aneurysm; it presents in epigastric region.
- 22. MASS IN THELEFT HYPOCHONDRIUM
- 23. Enlarged spleen Spleenhas 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 can not be insinuated over the upper border. “Hook sign” is positive, i.e. one can not insinuate the fingers under the left costal margin. It is dull on percussion.
- 24. Left Sided ColonicMass It is mobile, nodular, resonant. It does not move with respiration. It is commonly due to carcinoma colon.
- 25. Left Renal Massfrom Upper Pole of any Cause Left Sided Adrenal Mass 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.
- 26. Mass Arising fromthe Tail of the Pancreas Clinical features are same as other pancreatic masses. Causes are pseudocyst in tail of the pancreas and cystadenomas.
- 27. MASS IN THELUMBAR REGION
- 28. 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.
- 29. Conditions Where Kidneygets Enlarged Hydronephrosis: It is smooth, soft, lobulated, nontender mass, non-mobile. Pyonephrosis: History of throbbing pain in the loin, pyuria and feverwith 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.
- 30. Adrenal Mass Itis nodular and hard. It does not move with respiration. It is not mobile and often crosses the midline. It is felt on deep palpation. It is resonant in front. It is not ballotable.
- 31. Mass from theAscending 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.
- 32. Retroperitoneal Tumours Theyare 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.
- 33. Retroperitoneal Cysts Theyare smooth and soft with the same features as retroperitoneal tumours.
- 34. Cystic lesions inthe abdomen Mucocele/empyema of gallbladder Pseudo-cyst of pancreas Hydatid cyst of liver Congenital nonparasitic cyst of liver Hydronephrosis Mesenteric cyst Ovarian cyst Omental cyst Aneurysm Retroperitoneal cyst Cystadeno carcinoma of ovary Loculated ascites
- 35. MASS IN THEUMBILICAL REGION
- 36. 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.
- 37. Omental Cyst Itis smooth, soft and nontender. It moves with respiration. It is mobile in all directions. It is dull on percussion.
- 38. Small Bowel Swellings Small bowel lymphomas. 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 fingers. 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.
- 40. MASS IN THERIGHT ILIAC FOSSA
- 41. Appendicular Mass Itis 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-localized mass with distinct borders.
- 42. Appendicular Abscess Itis smooth, soft, tender and dull mass in the right iliac fossa with indistinct borders.
- 43. Carcinoma Caecum Itis nodular, hard, mass in the right iliac fossa. It does not move with respiration. It is mobile but mobility may be restricted once it gets adherent to psoas muscle. Mass is resonant or there is impaired resonance on percussion. Often features of intestinal obstruction may be present.
- 44. Ileocaecal Tuberculosis Massin 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 fibrosis.
- 45. Amoeboma History ofdysentery with pain in the right iliac fossa. Smooth, hard, well-defined mass in the right iliac fossa which is nonmobile. It may or may not be tender.
- 46. Psoas Abscess Itis localized, smooth, soft, nonmobile mass in the right iliac fossa. Psoas spasm (flexion of the hip joint) is typical. Spine may show gibbus, tenderness, para spinal spasm. Spinal movements will be restricted.
- 47. MASS IN THELEFT ILIAC FOSSA
- 48. Carcinoma sigmoidor descending colon Bony masses Ovarian/uterine masses Psoas abscess Ectopic kidney Lymph node mass Undescended testis
- 49. MASS IN THEHYPOGASTRIUM
- 50. Bladder Mass Itis 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.
- 51. Uterine Mass Itis midline mass which is smooth, hard. Lower border is not felt which extends in to the pelvis. It is felt on pervaginal examination.
- 52. Ovarian Mass Pelvicsoft tissue mass.
- 53. Carnett’s Test Thepatient, in lying down position, is asked to lift both legs off the bed with knee extended. This puts the abdominal muscles into contraction. Intra-abdominal mass becomes less prominent, parietal mass persists as same, but becomes less mobile. In all lower abdomen masses P/R and or P/V is a must.
- 54. Investigations for MassAbdomen 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. Ascitic tap. Diagnostic laparoscopy. U/S guided/CT guided biopsy. IVU/RGP/Cystoscopy/Isotope renogram. Exploratory laparotomy.
- 55. Treatment According tocause.
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