Abdominal Mass (including organomegaly)

History

NB It is quite common for an abdominal mass to be a finding on examination not previously described by the patient in the history.

  • If a mass is part of the presenting complaint:
    • Ask about the location, size, onset, timing, progression of the lump.  E.g. did it come on suddenly after straining (? hernia); Has it been there a long time/since birth? (more likely to be benign); Has it been growing? (If so, how fast?); Can you point to its location? (Different locations- different causes- see below)
    • Are there any associated symptoms?
      • Pain
      • Nausea/vomiting
      • Change of bowel or urinary habit
      • Flatus/gas
      • Features of jaundice
      • Constitutional symptoms e.g. weight loss, sweats, fever, anorexia, pallor
      • Any blood in the faeces or urine?
      • Lower urinary tract symptoms
  • Ask about past medical history; drug history; family history; social history; travel history etc.

On examination

  • Carry out a full gastrointestinal examination with general examination:
    • General
      • Look at the hands and upper limbs for
        • Palmar erythema
        • Liver flap (asterixis)
        • Spider naevi
        • Dupuytren’s contracture
        • Leuconychia (hypoalbuminaemia)
        • Peripheral cyanosis
        • Bruising
      • Look at the eyes/sclera for jaundice (icterus); any xanthelasma; signs of anaemia e.g. pallor
      • Examine for any lymphadenopathy (in particular, look for Virchow’s node in the left supraclavicular fossa- sign of gastric cancer); gynaecomastia
    • Inspection
      • Lie the patient flat and inspect across the abdomen from eye level.
      • Look for scars; striae; dilated veins; rashes
      • Inspect the umbilicus- contour, location, any bulges
      • Inspect the contour of the abdomen- flat, rounded, hollowed/concave, any particular masses/bulges (asymmetrical)
      • Any signs of peristalsis (only really seen in very thin patients or those with suspected intestinal obstruction) or pulsations (e.g. AAA)
    • Palpation
      • Ask if the patient has any pain in a specific region.  Start away from the pain and finish examination with this region.
      • First, palpate ‘superficially’ (without much force) using the palmer aspect of your hands- pushing gently
        • Always look at the patient’s face to gauge any tenderness
        • Examine all 9 regions
      • Next, palpate deeply, pushing harder (you may want to use two hands on top of each other in an exam to emphasise this) into the abdomen, again looking at the patient’s face
        • Examine for any tenderness, guarding, rigidity, any masses
          • If present, describe the location, severity/size etc
    • Percussion
      • Percuss across the abdomen for the dullness of abnormal abdominal fluid (typically asicites)
        • NB this is usually more pronounced laterally (i.e. around a centre of resonance) when the patient is supine due to the effect of gravity on the fluid
      • Assess shifting dullness
        • Mark the border of resonance/dullness on one side with your finger and ask the patient to roll onto the opposite side (i.e. your finger is higher than the midline)
        • Percuss again to check if percussion is now resonant (positive result- suggests ascites)
          • You may also want to percuss down until dull again (whilst the patient is on their side) and repeat the process on the other side
      • Assess fluid wave/thrill
        • ask the patient to place the medial side of their hand down the midline (this will prevent wave transmission through fat)
        • With one hand on one side of the midline, use the other hand to flick/tap the fluid on the other side (i.e. to get it across the midline)
        • If the wave/thrill is felt across the midline, this suggest the presence of fluid
        • NB quite a lot of fluid usually has to be present for a positive test.
    • Examining organs
      • Liver
        • Palpate
          • Starting in the right iliac fossa, deeply palpate in this region and ask the patient to take a deep breath (this contracts the diaphragm, pushing the liver down)
          • Repeat this a little superiorly until the liver edge is felt (NB normally, the liver edge is not palpable below the rib cage.  On deep inspiration, the liver edge may be felt in a normal individual)
          • Examine/comment on size (cm or fingerbreadths) from costal margin; any tenderness
        • Percuss the lower and upper liver borders
          • By percussing from the thorax inferiorly and from the iliac fossa superiorly, the liver may be identified as dull (cf the resonant chest and less dull normal bowel)
      • Spleen
        • A similar approach is taken in examining the spleen
        • Percussion can be done in an identical fashion except on the left.  However, others prefer to percuss inferolaterally across Traube’s space
          • this is a crescent shaped area bordered superiorly by the left 6th rib; anteriorly by the left anterior axillary line and inferiorly by the left costal margin.  Normally, the stomach lies deep to Traube’s space and it is resonant to percuss.  In splenomegaly, it can be dull.  If resonant percussion is present at the left 6th rib, anterior axillary line, ask the patient to breathe in deeply and reassess.
        • Palpation is also done in a similar fashion except palpation usually begins at the right iliac fossa and makes its way diagonally across the abdomen.
          • Some also might reach over with their left hand to push forward the lower left rib cage and soft tissues with the right hand palpating below the costal margin on inspiration.
      • Kidneys
        • To ballotte the kidneys, reach around with your opposite hand to place under the patient (just under the 12th rib) and lifting the tissues anteriorly.  With your free hand, deeply palpate the upper quadrant, trying to feel the kidney between both hands.  This is also usually best done with deep inspiration.
        • To percuss the kidneys, ‘thump’ the costovertebral angles with the ulnar surface of a fist (enough to be forceful without trying to cause pain).  This may reveal kidney tenderness.
          • NB It is only really used when kidneys appear tender on ballotting.
      • Other structures
        • Bladder
          • A full or hyperinflated/distended bladder may be palpable as a tense suprapubic mass (usually resonant on percussion).  (Normally lies under the symphysis pubis so is not felt).
        • Aorta
          • Deep palpation, usually best using the finger pads of both hands simultaneously on either side of the midline, can be used to identify abdominal aortic pulsations (particularly in thin individuals; can be impossibly in larger individuals)
    • You would also auscultate the abdomen for bowel sounds.  Absent bowel sounds or tinkling bowel sounds could be a feature of intestinal obstruction.
  • Always consider performing a PR examination and examination of the inguinal orifices as part of the abdominal examination

Differential Diagnosis

kikikik

  • Causes of hepatomegaly
    • Using VINDICATE
      • Vascular
        • Congestive heart failure
        • Budd-Chiari malformation
      • Inflammatory/Infectious
        • Infective e.g. viral hepatitis, infectious mononucleosis; cytomegalovirus; malaria
        • Abscesses
          • Pyogenic/Amoebic abscesses
      • Neoplasia (+ infiltrative disease)
        • Secondaries
        • Primary hepatocellular carcinoma
        • Myeloma, leukaemia, lymphoma
        • Sarcoid/Amyloid
      • Degenerative/Deficiency/Drugs
        • Alcoholic liver disease
        • Drug induced hepatitis (statins, macrolides, amiodarone, paracetamol)
      • Idiopathic/Iatrogenic
        • Extrahepatic obstruction (stones or stricture)
      • Congenital
      • Autoimmune
        • Autoimmune hepatitis
        • Primary biliary cirrhosis
        • Primary sclerosing cholangitis
      • Traumatic
      • Endocrine/Metabolic
        • Haemochromatosis
        • Wilson’s disease
        • Glycogen storage disease
        • Porphyria
        • NASH
        • Diabetes associated liver disease
  • Causes of Splenomegaly
    • Haematological:
      • Haemolytic anaemias (eg thalassaemia, red cell defects, sickle cell anaemia).
      • Acute leukaemias, chronic leukaemias.
      • Polycythaemia rubra vera.
      • Macroglobulinaemia.
      • Lymphoma (Hodgkin’s disease and non-Hodgkin’s lymphoma).
      • Essential thrombocythaemia.
      • Myelofibrosis.
    • Infections:
      • Malaria.
      • Schistosomiasis.
      • Visceral leishmaniasis (Kala-azar).
      • Tuberculosisbrucellosis.
      • Glandular feverviral hepatitis.
      • Infective endocarditis.
    • Tumours and cysts:
      • Splenic abscesses.
      • Splenic metastases.
      • Cysts, eg hydatid, dermoid.
      • Tumours, eg haemangioma.
    • Congestive splenomegaly:
      • Liver cirrhosis.
      • Budd-Chiari syndrome
      • Portal or splenic vein obstruction.
      • Heart failure.
    • Connective tissue disorders:
      • Systemic lupus erythematosus.
      • Felty’s syndrome.
    • Other disorders:
      • Gaucher’s disease.
      • Niemann Pick disease.
      • Histiocytosis X.
      • Amyloidosis.

    Causes of massive splenomegaly

    • Chronic myeloid leukaemia.
    • Myelofibrosis, malaria (hyper-reactive malarial splenomegaly).
    • Leishmaniasis.
    • ‘Tropical splenomegaly’ (idiopathic; Africa, South-east Asia).
    • Gaucher’s syndrome

Investigations

  • Often Ultrasound is the first line imaging investigation used.  CT may be more appropriate in other cases (e.g. AAA)
  • FBC
    • Check Haemoglobin for signs of anaemia (?bleeding e.g. AAA, cancer)
    • WCC for any infection
  • LFTs
    • Abnormal liver function, especially in hepatomegaly
  • U&Es (kidney function)
    • Assess for abnormalities, particularly in those with any urinary symptoms or symptoms/signs suggestive of kidney pathology but also in those with ?GI pathology

Further management

  • May involve biopsy/sampling investigations with or without surgical investigation

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: