right hypochondriac mass

1. Right Hypochondrial Masses
Presenter: Dr. Mohammad Masoom Parwez
Moderator: Dr. M P Singh

2. Regions of Abdomen

3. Depending on origin
• Parietal
• Intra-Abdominal
• Retroperitoneal

4. Parietal swellings
• Arising from the skin and subcutaneous tissues
• Sebaceous cyst
• Lipoma
• Fibroma
• Neurofibroma
• Angioma
• Cold abscess-- caries rib >> caries spine, soft, cystic & fluctuant swelling, no
signs of inflammation. Irregularity of rib/deformity of spine ++
• Parietal abscess (hepatic/subphrenic/perigastric)

6. Intra abdominal swellings
• Liver
(1) Reidels lobe –
tongue shaped projection from lower
border of right lobe. Can be mistaken for
an enlarged gallbladder but it is more
wide and flat and lacks the spherical
outline
Incidence: 3.3-31%, more frequently in
women (1:3)

7. Intra abdominal swellings
(2)Amoebic hepatitis/abscess –
• pain in RHC referred to right shoulder with fever , past h/o amoebic dysentery
• Swelling indicates formation of an abscess
• Patient pale and icteric. Liver is palpable and very tender
• Intercostal tenderness + , upper limit of liver dullness is raised
• Subcutaneous edema which pits on pressure
• Xray– diaphragm is abnormally raised and immobile
• Entamoeba in stool– diagnostic
• Aspiration of anchovy sauce pus is confirmatory

9. Intra abdominal swellings
Hydatid cyst –
• When it occurs near the lower margin of the liver it gives rise to a
palpable spherical and smooth swelling, with hydatid thrill and
fluctuations.
• Diagnosis is made by the history of attack of urticaria, eosinophilia,
complement fixation test and Casoni’s intradermal reaction.
• X-ray and ultrasound are helpful when the cyst occurs at the upper
surface of the liver.
• If suppuration takes place the signs and symptoms of infection may
dominate

11. Intra abdominal swellings
Suppurative pylephlebitis –
• Infective thrombosis of portal vein
• usually a complication of intra abdominal
sepsis like: diverticulitis, perforated
appendicitis or peritonitis
• presents with fever, rigor + Liver palpable
and tender
• t/t: long course broad spectrum antibiotics
+ anticoagulants
• Can cause bowel ischaemia --- bowel
infarction

12. Intra abdominal swellings
Hepatic Carcinoma –
• Primary carcinoma is rare(hepatoma or cholangioma)
• Secondary carcinoma – more common.
• results from metastasis from carcinoma of the gastrointestinal tract via
portal vein or from organs like breast through lymphatics
• Liver is enlarged, irregular with nodules of varying size and shape and
becomes hard
• The nodules may show softening in the centre and may become
umbilicated
• The patient may be jaundiced sooner or later and ascites may be
associated with
• Primary focus should be searched

13. Hepatic carcinoma in 52yr old man with
cirrhosis
Late arterial phase- enhancing
nodule
Portal venous phase: washout
appearance with capsule

14. Intra abdominal swellings
Cirrhosis of the liver:
• In this condition the liver is not always enlarged; on the contrary it
may be shrunk
• In pre-cirrhotic stage the liver may be firm, irregular with small
nodules which are never umbilicated (cf. carcinoma)
• Portal hypertension will be present with enlargement of the spleen
• Ascites may be associated with but jaundice is never present
• These cases often come to the surgical clinic with haematemesis from
rupture of oesophageal varices

15. Intra abdominal swellings
Melanotic CA of liver:
• secondary to similar growth on the palm, foot or eye.
• An enlarged liver with malignant melanoma anywhere
in the body should clinch the diagnosis

16. Intra abdominal swellings
Suppurative cholangitis –
• h/o cholelithiasis,
• stone impacted in the CBD.
• High rise of temperature with tender liver. Jaundice +
Gumma of liver –
• very rare,
• resembles carcinoma, late presentation.
• Manifestation of 3rd stage of syphilis.
• Presence of other syphilitic signs are confirmatory

17. Intra abdominal swellings
• 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.

18. Intra abdominal swellings
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

19. Intra abdominal swellings
Gallbladder —
• oval smooth swelling which is tense and cystic
• lower border of the liver and moves freely up and down with
respiration along with liver
• The swelling may be tender depending on the amount of
inflammation present
• It can be moved sideways a little
• It is not ballottable as a kidney swelling

20. Intra abdominal swellings
• 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 periampullary carcinoma or growth in the CBD.
2. Hard gallbladder: Carcinoma gallbladder.
3. Tender gallbladder: Empyema GB

21. Subphrenic abscess
causes of accumulation of pus under the diaphragm:
• perforated peptic ulcer (commonest), following abdominal trauma,
following operations on biliary tract, following operation on the
stomach or colon and acute appendicitis
• The patient looks very much anxious. They may complain of anorexia
and nausea, associated with rise of temperature
• Rigor only occurs when there is concomitant pylephlebitis or a liver
abscess
• Tachycardia, tachypnoea are present

22. Subphrenic abscess
• Pain usually becomes localised to the site of lesion. Right hypochondrium
or epigastrium is the usual site of pain. Very occasionally it may be
complained of in the lower part of thorax, right lumbar region or even
referred to the right shoulder.
• Jaundice is not a sign of this condition but if present indicates obstruction
of the common bile duct with a stone or suppurative pylephlebitis
• Tenderness just below the costal margin or xiphoid process or more
precisely tenderness over the 11th intercostal space
• X-ray screening will show sluggish movement of the diaphragm. The
diaphragm becomes raised and gas may be found beneath it.
• Aspiration of pus from the subdiaphragmatic space leaves no doubt about
the diagnosis

23. Ca pylorus of stomach
• Carcinoma of this region usually gives rise to obstructive symptoms
• Barium meal X-ray will show 'filling-defect' which is very diagnostic

24. Subacute perforation of peptic ulcer
• forms a localized tender mass which is a rare condition
• The patient gives history suggestive of peptic ulcer and sudden
excruciating pain before formation of the mass
• It may lead to a subphrenic abscess

25. Intraabdominal swelling
• Hepatic flexure of colon:
• Intussusception: abdominal distension, pain, passage of red currant jelly
stools
• Hypertrophic TB: starts in the ileo-cecal junction and may move upto this
region
• CA hepatic flexure: may present with a lump only or with anaemia, anorexia
and occult blood in the stool. lump is irregular and hard with slight or no
movement. Barium enema X-ray reveals constant filling defect which is very
diagnostic

26. Colo-colic intussusception at hepatic flexure

27. Carcinoma hepatic flexure of colon

28. Intraabdominal swelling
Kidney: features of a kidney swelling are:
(i) It is a reniform swelling;
(ii) It moves very slightly with respiration as it comes down a little at
the height of inspiration;
(iii) It is ballottable;
(iv) A sickening sensation is often felt during manipulation; (v) A hand
can be easily insinuated between the upper pole of swelling and the
costal margin;
(vi) Percussion will reveal resonant note in front of a kidney swelling as
coils of intestine and colon will always be in front of the kidney

29. Intraabdominal swelling
• Kidney:
• Wilms tumor
• Renal cell cancer
• Hydronephrosis
• Pyonephrosis
• Polycystic kidney
• Adrenal mass:
• B/L Hyperplasia
• Adenoma/carcinoma
• Medulla: phaeochromocytoma, ganglioneuroma, neuroblastoma

30. Retroperitoneal swellings
Cyst:
• A cyst developing in the retroperitoneal tissue may attain very large
dimensions.
• Pyelography may be required to differentiate cyst from a
hydronephrosis.
• These cysts may be derived from remnants of the Wolfian ducts when
the containing fluid will be clear
• or the cyst may be a teratoma when it is filled with sebaceous
material

31. Retroperitoneal cyst

32. • Lymphoma: mainly affects women and will also require pyelography
for differential diagnosis
• Sarcoma: An indefinite abdominal pain or subacute intestinal
obstruction from pressure on the colon may be the presenting
symptom. On examination, a fixed smooth swelling may be
discovered which will require pyelography to rule out the possibility
of a renal swelling

33. 81yr old Asian male with abdominal pain
Imaging demonstrated a large left retroperitoneal soft tissue
mass

34. Thank you