approach to a patient presenting with lump abdomen. a guide for medical students.

1. Approach to a patient with lump
in abdomen
Dr.Ankita Singh
Department Of Surgical Disciplines
AIIMS Delhi

2. Objectives
Adopt sequential approach to a patient
complaining about abdominal lump by
• Extracting relevant history
• Thorough clinical examination
• Clue to right diagnosis by conducting
investigations guided by above history &
examination
• Offering adequate treatment

3. history
Demography:
• age
• gender
• occupation
• address
• socio economic status

4. History…
Presenting complaints:
• abdominal lump: appearance, duration, site,
approx size, progression/regression, any
association with
meals/posture/straining/trauma/*pain,
disappears spontaneously
• pain: site, onset, duration, character,
radiation/migration/reffered, any relieving
/aggrevating factors

5. History …
other associated complaints-
• nausea/vomiting: character, amount,
frequency, content (hemetemesis),
relieving/aggrevating factors,
• altered bowel habit: diarrhea, constipation,
obstipation, flatulent dyspepsia etc
• melaena/hematochezia
• jaundice: onset, duration,progression etc.

6. History…
• associated fever episodes
• appetite
• weight loss
• any other relevant history

7. History…
Past & personal history:
• comorbidity/ treatments- medical or
surgical
• Sleep-wake cycle/ eating habits/ appetite/
bladder & bowel habits/ substance abuse
Family/ menstrual & obstetric history:
• some diseases run in family (peptic ulcers/
crohn’s/ulcerative colitis/diverticulitis/ some
CA

8. Physical examination
Prerequisites: Consent,environment,chaperon
General survey:
• built, nutrition, mentation
• vitals
• signs-pallor, icterus, cyanosis, pedal edema,
lymphadenopathy, clubbing.
Systemic examination:
• CNS/Respiratory/Cardiovascular
examination

9. Physical examination
• Abdominal examination:
Inspection:
1. Contour (normal/scaphoid/obese/distension),
symmetric/asymmetric
2. Skin- scars, pigmentation, signs of inflammation,
wounds/ulcer, engorged veins etc
3. Umbilicus- position
4. Visible abnormal protuberance/lump
5. Movement-with respiration/peristalsis/pulsations
6. Hernial orifices

10. Right
hypochondrium
Epigastrium Left
hypochondrium
Right lumbar Left lumbarumbilical
Right iliac fossa left iliac fossaHypogastrium
Right upper quadrant Left upper quadrant
Right lower quadrant Left lower quadrant

11. Physical examination
Palpation:
1. Soft/tense/distention
2. Temperature
3. tenderness
4. Palpable organomegaly & its description
5. Palpable lump: site, tenderness, size, surface,
shape, consistency, margins,
movement(respiration/all directions/ballotable),
pulsatile(transmitted/expansile), *intraperitonial
vs parietal wall vs retroperitonial.
6. Hernial sites

12. Physical Examination…
*The abdominal muscles made taut by asking
patient
(i) to raise his shoulders from the bed with
the arms folded over the chest —
the 'rising-test' or
(ii) to raise both the extended legs from the
bed — the 'leg lifting test’(Carnett's test) or
(iii) to try to blow out with his nose and
mouth shut.

13. Physical examination
• If the swelling is parietal the swelling will be more
prominent when the abdominal muscles are
made taut and will be freely movable over the
taut muscle.
• If the swelling is parietal but fixed to the
abdominal muscle the swelling will not be
movable when the muscles are made taut
• Another differentiating point is that if the
swelling moves vertically with
• respiration it is obviously an intra-abdominal
swelling.

14. Physical examination
Percussion:
1. Technique for lump
2. Technique for evaluation of ascites
3. Span of organomegaly
*solid lump-dull(superficial),resonant(coils of
bowel overlying)
#Band of colonic resonance
~Hydatid thrill

15. Auscultation:
1.Bowel sounds
2.Abnormal sounds (bruit, hums)

16. Physical examination…
• Scrotal examination
• Left supraclavicular lymph nodes examination
• Rectal & vaginal examination

18. Investigations
To confirm diagnosis, based on site:
1. USG abdomen- origin of lump, nature,
invovement of adjacent structures, other
findings
2. Organ specific: Stomach, duodenum,
Hepatobiliary, spleen, pancreas, small bowel
vs large bowel, urinary organs, adenexa etc.
3. Supporting blood investigations and imaging

19. Differential diagnosis of abdominal
lumps

20. Right
hypochondrium

21. Lump in Right hypochondrium
a. PARIETAL SWELLINGS:
skin & subcutaneous tissue-sebaceous cyst,
lipoma, fibroma, neurofibroma, angioma, etc.
cold abscess
b. INTRA ABDOMINAL:
1. liver- hepatomegaly(fatty liver, infections,
malignancy), isolated palpable liver
lesion(hydatid)

22. Lump in Right hypochondrium
(a) congenital riedel’s lobe
(b) amoebic hepatitis & abscess
(c) suppurative pylephlebitis
(d) suppurative cholangitis
(e) gumma of liver
(f) hydatid cyst
(g) liver carcinoma- primary vs secondary
(h) cirrhosis

23. Lump in Right hypochondrium
2. Gall bladder: benign- smooth globular lump,
upper margin not defined, movement with
respiration +.
(a) Mucocele
(b)Empyema with stone impaction neck
(c) Porceliene gall bladder
(d)Carcinoma gall bladder

24. Lump in Right hypochondrium
3. Subdiaphragmatic abscess
4. Pylorus stomach & duodenum:
(a) Carcinoma
(b)Subacute perforation of peptic ulcer
5. Hepatic flexure of colon:
(a) Intussusseption
(b)Hypertrophic tuberculosis- ileo-caecal
(c) Colonic ca

25. Lump in Right hypochondrium
6. kidney: bean shaped firm lump, slight
movement with respiration, ballotable,
bimanual palpable
(a) Hydropehrosis/ pyonephrosis
(b)Renal cell carcinoma
(c) Lymphoma
7. suprarenal/ adrenal:
(a) adrenal hyperplasia

26. Lump in Right hypochondrium
(b) Pheochromocytoma
(c) Benign ganglioneuroma
(d) Malignant neuroblastoma

27. Epigastriu
m Right upper quadrant Left upper quadrant

28. Lump in epigastrium
a. PARIETAL LUMP:
Skin & subcutaneous tissue lumps
Cold/liver/subphrenic/perigastric abscess
Epigastric hernia
b. INTRA ABDOMINAL LUMP:
1.Liver & subphrenic space: discussed previously
2.Stomach & duodenum:
(a) Congenital pyloric stenosis

29. Lump in epigastrium
(b) Subacute perforation of peptic ulcer
(c) Carcinoma stomach
3. Transverse colon:
(a) Intussusception
(b)Diverticulitis
(c) Hyperplastic TB
(d)Neoplasm

30. Lump in epigastrium
4. omentum: tuberculosis, pancreatitis
5. pancreas: pseudocyst, tumour
6. Abdominal aorta: aneurysm
7. Lymph nodes: tabes mesentrica,
lymphosarcoma, secondary
8. Retroperitonium: sarcoma, teratoma

31. Left
hypochondrium
Left upper quadrant

32. Lump in left hypochondrium
PARIETAL LUMPS:as discussed previously
INTRA ABDOMINAL LUMPS:
1. spleen: palpation and characteristics
(a) infections- malaria, kala azar, schistosomiasis et
(b) Hemolytic anemias- congenital & acquired
(c) ITP
(d) Porphyria
(e) Felty’s syndrome
(f) Leukemia
(g) Tumours & cysts

33. Right lumbar Left lumbar
Right upper quadrant Left upper quadrant
Right lower quadrant Left lower quadrant

34. Lump in left & right lumbar region
PARIETAL SWELLINGS: as previously discussed
Lumbar cold abscess (pott’s disease)
Lumbar hernia
INTRA ABDOMINAL LUMP:
1. Ascending & descending colon
2. b/l kidney & adrenals
3. Extension of swellings of liver, GB, spleen

35. umbilical
Right upper quadrant Left upper quadrant
Right lower quadrant Left lower quadrant

36. Lump in umbilical region
PARIETAL LUMP: previously discussed
1. umbilicus: hernia (congenital, aquired,
incisional), caput medusae, sister joseph mary
nodule
2. Rectus sheath: hematoma, abscess, desmoid
tumour
INTRA ABDOMINAL LUMP:
1.stomach & duodenum 2.transverse colon
3. omentum: as discused

37. Lump in umbilical region
4. small bowel & mesentry: TB, tumour-adenoma,
submucous lipoma, leiomyoma, sarcoma, mesentric
cyst
5. Retroperitonial tissue: cyst, lymphoma, sarcoma
6. LN, pancreas, aorta: as disscused

38. Right iliac fossa Right lower quadrant

39. Lump in Right iliac fossa
PARIETAL LUMP:
Appendicular abscess may rupture into parietal
INTRA ABDOMINAL:
1. appendix: abscess, appendicular mass
2. Ileo caecal region- hyperplastic TB, amoebic
typhilitis, crohn’s (inflammatory stage),
caecal cancer, actinomycosis caecum, round
worm inpaction.

40. Lump in Right iliac fossa
3, lymph nodes, retroperitonium: as discussed
4. Iliopsoas sheath: abscess (TB & pyogenic)
5.Iliac hematoma/abscess
6. Iliac bone swelling
7. Unascended kidney/ dropped or moveable
kidney
8. Gall bladder: hydrops wit hepatomegaly
9. Uterus & its appendages: tubo ovarian mass,
pyosalpinx, cyst, abscess of broad ligament, fibroid,
ovarian cyst

41. Lump in Right iliac fossa
10. Urinary bladder: diverticulum
11. retained/ undescended testis
12. Inguinal: hernia, lymph node, abscess
13. Pelvic abscess

42. Hypogastrium Right lower quadrant Left lower quadrant

43. Lump in hypogastrium
*Urinary bladder must be emptied prior
PARIETAL LUMP: urachal cyst, rectal hematoma
/abscess
INTRA ABDOMINAL LUMP:
1. Urinary bladder: urinary retension, bladder
mass
2. Uterus & adenexa: gravid, large fibroid, tubo
ovarian mass, ruptured tubal ectopic, cysts,
tumours

44. left iliac fossa Left lower quadrant

45. Lump in left iliac fossa
PARIETAL LUMP: iliac abscess(pyogenic/ TB)
INTRA ABDOMINAL LUMP: same as RIF except
ileo caecal, appendix.
1. Sigmoid & descending colon: diverticulitis,
carcinoma.