Examination of Abdominal Lump: Differential Diagnosis

EXAMINATION OF ABDOMINAL
LUMP
By -
Dr. Waseem Ahmad
Dept. of Surgery
National Institute of Unani Medicine,
Bangalore
14-12-2017

Contents
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. Differential
diagnosis

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.

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

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

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

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.

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

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

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

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

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

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

AUSCULTATION
Peristaltic movement will be heard in hernia
containing coils of intestine.
Aortic pulsation can be heard in aortic aneurysm.

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.

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.
right hypochondrium.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

5. Hepatic flexure of colon
I. Intussusception
II. Hypertrophic tuberculosis
III. Carcinoma

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)

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.

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.

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.
EPIGASTRIUM

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)
EPIGASTRIUM

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.
EPIGASTRIUM

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.
EPIGASTRIUM

Abdominal aorta
Aneurysm
Aneurysm of this part is not uncommon.
Swelling in epigastrium with expansile pulsation.
EPIGASTRIUM

3. D/D of lump in left hypochondrium.
Parietal swelling
Cold abscess as on right side described earlier.
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

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
LEFT HYPOCHONDRIUM

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.
LEFT HYPOCHONDRIUM

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.
LEFT HYPOCHONDRIUM

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.
LEFT HYPOCHONDRIUM

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
LEFT HYPOCHONDRIUM

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.
LEFT HYPOCHONDRIUM

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.

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.
UMBILICAL REGION

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.
UMBILICAL REGION

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.
UMBILICAL REGION

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

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
RIGHT ILIAC FOSSA

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.
RIGHT ILIAC FOSSA

Appendicular abscess
Invariable pyrexia.
Increased total counts.
Signs of inflammation over the skin.
It contains pus whereas appendicular mass never
contain pus.
RIGHT ILIAC FOSSA

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.
RIGHT ILIAC FOSSA

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).
RIGHT ILIAC FOSSA

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.
RIGHT ILIAC FOSSA

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.
RIGHT ILIAC FOSSA

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